Gall Bladder Case Study

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" colspan=2 height=90 BGCOLOR="#006699" TEXT="#080000" background="14afd5a3.jpg"> <div> <FONT SIZE="5" COLOR="#000000" FACE="Arial" ><B>SUSAN HATHAWAY TCM</B></FONT><B>    </B><B> |     </B><A HREF="index.htm" TARGET="_top" TITLE="SUSAN HATHAWAY TCM"><U><B>home</B></U></A></div> <div> <A HREF="id9.htm" TARGET="_top" TITLE="Case Studies"><U>Case Studies</U></A></div> <div> </div> </td> </tr><tr> <td valign="top" width=210 BGCOLOR="#FFCC66" TEXT="#080000" background="14bd2043.jpg"> <bR> </td> <td valign="top" height=390 BGCOLOR="#FFFFFF" TEXT="#080000"> <div> <I>Gall Bladder Case Study</I></div> <bR> <div> <I>Shang Han Lun Theory Used to Treat Acute Gallbladder Meridian Pain in Postcholecystectomy Patients</I></div> <div> <I>ABSTRACT</I></div> <div> <U>Background</U>: Patients who have had cholecystectomies will sometimes present with similar precholecystectomy symptoms, such as upper right quadrant pain and tenderness, bloating, belching and referred pain to the jaw and shoulder area. These symptoms are generally associated with cholecystitis, but without a gallbladder, these patients cannot be viewed as typical cholecystitis patients. TCM treatment can still follow the meridian and symptoms.</div> <bR> <div> <U>Objective</U>: TCM treatment following the theory of six levels of cold invasion as described in the Shang Han Lun (Treatises on Cold Induced Febrile Diseases) was used to treat Gallbladder meridian pain.</div> <bR> <div> <U>Methods, Setting, Patients</U>: Five patients ranging in age from 54 to 89 were treated in private practice with acupuncture and/or Chinese Herbal formulas for pain on the Gallbladder and San Jiao Meridian. All presented with positive Ashi reactions on or around Yang Ling Qian, GB 34.</div> <div> Outcome measures: Treatment was judged to be successful if the GB 34 Ashi point was no longer tender. In addition, symptom relief, in epigastric or hypochondriac pain, bloating, gas, and neck and shoulder pain was also considered a factor of success.</div> <bR> <div> <U>Results</U>: All patients received some degree of relief of symptomatic pain in the neck and shoulder, reduction of tenderness at GB 34 and a feeling of bloating or fullness under the hypochondrium.</div> <bR> <div> Conclusions: Patients without a gallbladder were treated following a theory from the Shang Han Lun (Treatises on Cold Induced Febrile Diseases) for symptoms generally associated with cholecystitis. By following the treatment principles for the Shaoyang Level of Cold Invasion, patients received relief from their symptoms. Further study is suggested to confirm these results.</div> <bR> <div> <B>INTRODUCTION</B></div> <div> Cholecystitis is an inflammation of the Gallbladder. The most common cause is gallstones and it is estimated that 10 to 15% of the population in industrialized societies have gallstones. <FONT SIZE="1" COLOR="#000000" FACE="TTE1B50530t00" >(1) </FONT>If fever is involved with or without gallstones being present, infection of the gallbladder may be the cause of the cholecystitis. The symptoms associated with cholecystitis are generally sudden severe pain in the upper right quadrant (URQ) or epigastric area. <FONT SIZE="1" COLOR="#000000" FACE="TTE1B50530t00" >(2) </FONT>Murphy's sign (tenderness over the intercostal rib during inspiration upon palpation) is also a symptom of gallbladder involvement. <FONT SIZE="1" COLOR="#000000" FACE="TTE1B50530t00" >(3) </FONT>Occasionally, the gallbladder is palpable. If jaundice occurs, stone blockage of the bile duct may have occurred. <FONT SIZE="1" COLOR="#000000" FACE="TTE1B50530t00" >(2) </FONT>Referred pain to the jaw and shoulder can also occur as can pain in the middle of the back. <FONT SIZE="1" COLOR="#000000" FACE="TTE1B50530t00" >(4) </FONT>Acute attacks are usually brought on by consumption of a meal heavy on fats and the attacks usually subside within days with minor intervention and dietary alterations. Chronic cholecystitis can occur if there are repeated acute attacks. Treatment for cholecystitis when gallstones are present, if gangrene of the gallbladder is suspected or chronic attacks do not respond to conservative treatment of dietary changes and antibiotics is surgical intervention to either remove the gallbladder or the stones. <FONT SIZE="1" COLOR="#000000" FACE="TTE1B50530t00" >(2) </FONT>The laparoscopic cholescystectomy, the conventional procedure for removal of the gallbladder or stone, allows for faster recovery and fewer complications. However, injury to the bile duct can occur. In addition, it is estimated that 20% of Postcholecystectomy patients continue to experience the same symptoms. <FONT SIZE="1" COLOR="#000000" FACE="TTE1B50530t00" >(1) </FONT>One possible explanation is that the original diagnosis was not correct and that the problem had not been present in the gallbladder but was possibly gastritis or pancreatitis.</div> <bR> <bR> <div> <B>WESTERN SCIENCE PERSPECTIVE</B></div> <div> Pain in the URQ is one of the major reasons that convince patients to seek treatment for gallbladder problems. Acute or chronic attacks can be extremely painful; fever, nausea and vomiting can also occur. However, it is accepted that these symptomatic patients make up only about 20% of the Gallstone patients. <FONT SIZE="1" COLOR="#000000" FACE="TTE1B50530t00" >(1) </FONT>Not all patients with gallstone symptoms are suitable candidates for cholecystectomies. <FONT SIZE="1" COLOR="#000000" FACE="TTE1B50530t00" >(5) </FONT>Alternative techniques involving diet modifications, chemical dissolutions and mechanical lithotripsy have been shown to reduce the need for surgery. <FONT SIZE="1" COLOR="#000000" FACE="TTE1B50530t00" >(1,5) </FONT>When surgical intervention is deemed appropriate, as in cases where gangrene of the gallbladder has occurred, laparoscopic procedures appear to have the lowest rate of complications. <FONT SIZE="1" COLOR="#000000" FACE="TTE1B50530t00" >(1) </FONT>Sometimes patients, who otherwise would need emergency surgery, can delay or avoid more invasive surgical techniques by use of laparoscopic techniques to drain the gallbladder. </div> <bR> <div> Problems with the gallbladder producing pain in the URQ, positive Murphy's sign, nausea or vomiting and/or referred pain can be caused by gallstones, changes in the wall of the gallbladder or even spasms of the sphincter of Oddi (SO). <FONT SIZE="1" COLOR="#000000" FACE="TTE1B50530t00" >(2) </FONT>85% of Gallstones are cholesterol based. Formation of gallstones usually occurs when there is insufficient emptying of the gallbladder, which allows for a build-up of billiary cholesterol. The increased levels of cholesterol can then form crystals of cholesterol. Bile salts can dissolve cholesterol gallstones and can be used in place of surgery to remove gallstones, but there are side effects such as diarrhea, liver toxicity and interference with digestion. Recent studies have looked at bioactive substances that can increase activity of the SO. Even if the stones are dissolved, without addressing the question as to why the stones formed in the first place, new stones can form. <FONT SIZE="1" COLOR="#000000" FACE="TTE1B50530t00" >(1)</FONT></div> <div> If more complete emptying of the gallbladder occurs, this can decrease the chance of reformation of stones. <FONT SIZE="1" COLOR="#000000" FACE="TTE1B50530t00" >(6) </FONT>Usually in order for surgery or laparoscopic procedures to be carried out, confirmation of gallstones through diagnostic imaging needs to have been done. Sometimes engorged gallbladders will manifest on plain radiographs. Though usually contrast films or abdominal ultrasounds are made. If the stones are small or if the patient is obese, imaging may not show evidence of stones. Tests can be done to determine if the SO is emptying properly.</div> <bR> <div> Laboratory tests may show elevation in white blood cells, liver enzymes or serum amylase. <FONT SIZE="1" COLOR="#000000" FACE="TTE1B50530t00" >(2) </FONT>The lab tests may not be elevated if the patient is experiencing an acute attack. Even when surgical intervention is carried out and a gallbladder is removed from a patient experiencing acute or chronic symptom, sometimes the pain will still return or never leave. Postcholecystectomy pain is present in some patients following surgery. If the gallbladder is left in place, the recurrence rate is about 10% annually for up to 5 years post-surgery. <FONT SIZE="1" COLOR="#000000" FACE="TTE1B50530t00" >(1) </FONT>If the gallbladder has been removed and the pain returns, there is some thought that the original diagnosis of gallstones may have been incorrect and the patient's pain is due to inflammation in another part of the digestive system, i.e. gastritis, pancreatitis or radiculopathy. <FONT SIZE="1" COLOR="#000000" FACE="TTE1B50530t00" >(2) </FONT>However, a study done over a 2 year period on 400 consecutive patients with gallstones that had the stones removed by laparoscopy, showed that 54 patients had to have two procedures and 22 patients had to have 3 or more procedures to remove stones <FONT SIZE="1" COLOR="#000000" FACE="TTE1B50530t00" >(5) </FONT>This study suggests pain could continue or return in gallbladder patients following surgical intervention. Even if the gallbladder has been removed, stone formation could continue and result in similar symptoms or even more intense symptoms especially if stones are present in the bile duct or pancreas. Formation of stones could be preceded by bile sludge, which if the patient still has a slow or incomplete SO function, could form into stones. Dietary intervention is recommended to help reduce crystallization of cholesterol. Besides bile salts, cyclic monoterpernes, a bioactive ingredient in Olive Oil has been shown to reduce crystal formation and actually was able to dissolve gallstones in humans and rats and hamsters. <FONT SIZE="1" COLOR="#000000" FACE="TTE1B50530t00" >(1)</FONT></div> <bR> <div> <B>TCM PERSPECTIVE</B></div> <div> Pain in the URQ, especially hypochondriac pain, distension, bloating or belching can be associated with Liver Qi stagnation. <FONT SIZE="1" COLOR="#000000" FACE="TTE1B50530t00" >(7) </FONT>In addition to physical symptoms, emotional symptoms associated with Liver Qi Stagnation can also occur, including irritability, flashes of anger, depression, sighing and sleep disturbances. <FONT SIZE="1" COLOR="#000000" FACE="TTE1B50530t00" >(8) </FONT>A study was carried out to determine if blood levels of neurohumoral compounds would change in those patients diagnosed with Liver Qi</div> <div> Stagnation. The patient was diagnosed with Liver Qi Stagnation if they had 3 or more of the following six criteria: hypochondriac, breast or lower abdominal pain, depression, restless or easily irritated, period irregularities, throat obstruction or tense pulse. One group of patients meeting the Liver Qi Stagnation criteria had been diagnosed with chronic cholecystitis. <FONT SIZE="1" COLOR="#000000" FACE="TTE1B50530t00" >(9)</FONT></div> <bR> <div> According to Maciocia, pain in the URQ can be from Liver Qi Stagnation or Damp-Heat in the Gallbladder. The major difference between these diagnoses is the appearance of the tongue and pulse. Liver Qi Stagnation usually presents with a tense or wiry pulse, while one would expect a slippery, full pulse with Damp-Heat syndromes. The tongue appears with little coating in Liver Qi Stagnation but with yellow greasy coating with Damp-Heat. <FONT SIZE="1" COLOR="#000000" FACE="TTE1B50530t00" >(7) </FONT>However, the Gallbladder is the Foot Shaoyang Meridian and according to the Shang Han Lun (Treatises on Cold Induced Febrile Diseases), pulses of those who are suffering at the Shaoyang level can range from tight to floating, especially if the condition lingers. Another section on Shaoyang disease indicates that the pulse can be sinking and tight. </div> <bR> <div> All the sections agree that the conformation is one that is best treated with Xiao Chai Hu Tang formula (Minor Bupleurum Decoction). <FONT SIZE="1" COLOR="#000000" FACE="TTE1B50530t00" >(10) </FONT>The Huang Di Nei Jing (Yellow Emperor Classic) also discusses conditions related to the Shaoyang. In Chapter 21, excess conditions of the Shaoyang can produce a slippery and perhaps weak pulse and respond to acupuncture at Zu Ling Qi, GB 41. Headaches associated with Shaoyang level are usually centered on the temporal region and Ren Ying, ST 9. In Chapter 40, Shaoyang channel disturbances will have a pulse at St 9, which is twice that at the radial pulses. <FONT SIZE="1" COLOR="#000000" FACE="TTE1B50530t00" >(11,12) </FONT>This would be consistent with headache descriptions of throbbing pain in this area. Cholecystitis is usually associated with infection or obstruction in the gallbladder and belongs to the categories of `xie tong' (hypochondriac pain), `dan zhang' (billiary distention) or `huang dan' (jaundice). </div> <bR> <div> The common differentiations of syndromes are in the categories of Qi stagnation, Qi stagnation leading to blood stagnation or Damp -Heat. Qi stagnation is usually responsible for the distending pain under the ribs, pain up the neck and shoulder, taut or wiry and large pulse with white greasy coating. Damp-Heat syndromes usually involve jaundice, fever, nausea and vomiting along with pain in the URQ. Pathogenesis of syndromes usually starts with damp invasion from over consumption of fried, greasy foods or Qi stagnation from strong emotions, or cold invasion to the Shaoyang level. Damp heat invasion can lead to gallstone formation by blocking normal gallbladder function. The gallbladder is important in Qi movement, impairment of which can lead to Qi Stagnation which can lead to blood stagnation, which can then block the meridians, causing pain. <FONT SIZE="1" COLOR="#000000" FACE="TTE1B50530t00" >(13) </FONT>Table 1 summarizes the common signs and symptoms associated with the differentiation of syndromes involving the gallbladder.</div> <bR> <bR> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="609" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 38 WIDTH="146"><div> Conformation </div> <bR> </tD> <tD VALIGN=TOP WIDTH="146"><div> Pulse</div> </tD> <tD VALIGN=TOP WIDTH="146"><div> Tongue</div> </tD> <tD VALIGN=TOP WIDTH="146"><div> Symptoms</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 57 WIDTH="146"><div> Liver Qi/GB Qi stagnation</div> <bR> </tD> <tD VALIGN=TOP WIDTH="146"><div> Wiry, large</div> </tD> <tD VALIGN=TOP><NOBR><div> White and greasy </div> <bR> </NOBR></tD> <tD VALIGN=TOP WIDTH="146"><div> Reflux, Pain URQ, belching foul odor     </div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 57 ><NOBR><div> Qi stagnation/Blood</div> <div> Stasis</div> </NOBR></tD> <tD VALIGN=TOP><NOBR><div> Wiry, thready, rough</div> </NOBR></tD> <tD VALIGN=TOP WIDTH="146"><div> Dark purple, red spots</div> </tD> <tD VALIGN=TOP WIDTH="146"><div> Severe pain URQ, dry mouth, bitter taste</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 96 WIDTH="146"><div> Damp Heat</div> </tD> <tD VALIGN=TOP WIDTH="146"><div> Wiry rapid</div> </tD> <tD VALIGN=TOP WIDTH="146"><div> Yellow greasy</div> </tD> <tD VALIGN=TOP WIDTH="146"><div> URQ distension, vomiting, nausea, jaundice, poor appetite, irritable restlessness,</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 76 ><NOBR><div> Def Kidney Yang</div> </NOBR></tD> <tD VALIGN=TOP WIDTH="146"><div> Wiry, weak</div> </tD> <tD VALIGN=TOP><NOBR><div> Pale, white greasy</div> </NOBR></tD> <tD VALIGN=TOP WIDTH="146"><div> URQ distension, Distension in abdomen, cold aversion, cold limbs</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 76 WIDTH="146"><div> Shaoyang level of cold invasion</div> </tD> <tD VALIGN=TOP WIDTH="146"><div> Wiry, floating, small, sinking, tight</div> </tD> <tD VALIGN=TOP WIDTH="146"><div> ??????</div> </tD> <tD VALIGN=TOP WIDTH="146"><div> Bitter taste, swelling around ear, tidal fever distension in URQ</div> </tD> </tR> </TABLE></div> <div> Table 1. Summary of major signs and symptoms of different TCM syndromes of Cholecystitis. <FONT SIZE="1" COLOR="#000000" FACE="TTE1B51C50t00" >(7,8,10,13) </FONT></div> <bR> <div> <B>RATIONALE OF CASE SERIES</B></div> <div> In my practice, I have seen multiple cases of patients presenting with URQ pain, neck and shoulder pain and digestive upsets ranging from belching and bloating to acid reflux symptoms.</div> <div> During the initial work-up I would routinely palpate the Yuan ling quan, GB 34 point for patients that present any of the above symptoms. If the point demonstrated a positive reaction I would discuss with them how their symptoms could be related to their gallbladder. I started noticing that some of these patients were postcholecystectomy, some as many of 20 or 30 years post surgery.</div> <div> My treatment would be essentially the same for those patients with or without a gallbladder. Upon reading of the literature, I found that the current Western Science viewpoint is that if the symptoms were the same pre- and post-cholescystectomy then an error had probably been made in the original diagnosis. I decided to review my case files of recent or current postcholecystectomy patients seen at my Office and determine if treatment of these symptoms followed protocol for treatment of Shao Yang (Gallbladder) level of Cold Invasion. I chose five patients that presented with clear symptoms related to the Shao Yang level. All patients had signed consent forms allowing their information to be used in a case series study. </div> <bR> <div> <B>CASE STUDY</B></div> <div> Five patients were treated in the office suffering from URQ (Upper Right Quadrant) pain. All the patients had cholecystectomies. One patient had surgery as recent as 1 month prior to treatment, while the other patients had their gallbladders removed more than twenty years prior to seeking treatment. All patients remembered the symptoms that had lead them to have the surgery. The patient's current symptoms had certain components similar to the original symptoms but most had new symptoms separate from what they remembered. All patients had a positive Ashi point on or around Yang ling quan, GB 34 prior to treatment. All had decreased or absent Ashi after treatments. Ashi would return if symptoms returned. Table 2 summarizes the signs and symptoms of the 5 patients treated for postcholecystectomy pain. </div> <bR> <bR> <div> GB 34 ashi  (+/-)</div> <bR> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="805" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 57 WIDTH="55"><div> Name</div> <bR> </tD> <tD VALIGN=TOP WIDTH="40"><div> # Of Txs</div> <bR> </tD> <tD VALIGN=TOP><NOBR><div> Yrs From </div> <div> Surgery</div> <bR> </NOBR></tD> <tD VALIGN=TOP WIDTH="42"><div> Age</div> </tD> <tD VALIGN=TOP WIDTH="41"><div> Sex</div> </tD> <tD VALIGN=TOP WIDTH="62"><div> Pulse</div> </tD> <tD VALIGN=TOP WIDTH="115"><div> Tongue</div> </tD> <tD VALIGN=TOP><NOBR><div> Chief complaint</div> </NOBR></tD> <tD VALIGN=TOP WIDTH="100"><div> Treatment</div> </tD> <tD VALIGN=TOP WIDTH="59"><div> Before Tx</div> </tD> <tD VALIGN=TOP WIDTH="47"><div> After Tx.</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 76 WIDTH="55"><div> E.G</div> </tD> <tD VALIGN=TOP WIDTH="40"><div> 2 </div> </tD> <tD VALIGN=TOP WIDTH="68"><div> >20</div> </tD> <tD VALIGN=TOP WIDTH="42"><div> 79</div> </tD> <tD VALIGN=TOP WIDTH="41"><div> F</div> </tD> <tD VALIGN=TOP WIDTH="62"><div> Liver full,</div> <div> Heart empty</div> <bR> </tD> <tD VALIGN=TOP WIDTH="115"><div> Slight yellow/greasy</div> </tD> <tD VALIGN=TOP WIDTH="116"><div> Hip, leg, back pain; edema, depressed</div> <bR> </tD> <tD VALIGN=TOP WIDTH="100"><div> Herbal formula</div> <bR> </tD> <tD VALIGN=TOP WIDTH="59"><div> +</div> </tD> <tD VALIGN=TOP WIDTH="47"><div> -</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 57 WIDTH="55"><div> C.J.</div> </tD> <tD VALIGN=TOP WIDTH="40"><div> 2</div> </tD> <tD VALIGN=TOP WIDTH="68"><div> 1 mo</div> </tD> <tD VALIGN=TOP WIDTH="42"><div> 57</div> </tD> <tD VALIGN=TOP WIDTH="41"><div> F</div> </tD> <tD VALIGN=TOP WIDTH="62"><div> Liver full</div> <div> Spleen deep</div> </tD> <tD VALIGN=TOP WIDTH="115"><div> Pale</div> </tD> <tD VALIGN=TOP WIDTH="116"><div> Pale Shoulder/neck pain</div> </tD> <tD VALIGN=TOP WIDTH="100"><div> Acupuncture</div> <div> Herbal Formula</div> </tD> <tD VALIGN=TOP WIDTH="59"><div> +</div> </tD> <tD VALIGN=TOP WIDTH="47"><div> -</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 95 WIDTH="55"><div> Y. G. </div> </tD> <tD VALIGN=TOP WIDTH="40"><div> 2</div> </tD> <tD VALIGN=TOP WIDTH="68"><div> >20</div> </tD> <tD VALIGN=TOP WIDTH="42"><div> 63</div> </tD> <tD VALIGN=TOP WIDTH="41"><div> F</div> </tD> <tD VALIGN=TOP WIDTH="62"><div> Deep</div> </tD> <tD VALIGN=TOP><NOBR><div> Peeled/Greasy</div> </NOBR></tD> <tD VALIGN=TOP WIDTH="116"><div> Neck pain,</div> <div> HA, hypochondriac pain</div> <bR> </tD> <tD VALIGN=TOP WIDTH="100"><div> Herbal Formula</div> </tD> <tD VALIGN=TOP WIDTH="59"><div> +</div> </tD> <tD VALIGN=TOP WIDTH="47"><div> -</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 76 WIDTH="55"><div> J. H. </div> </tD> <tD VALIGN=TOP WIDTH="40"><div> >10</div> </tD> <tD VALIGN=TOP WIDTH="68"><div> >20</div> </tD> <tD VALIGN=TOP WIDTH="42"><div> 87</div> </tD> <tD VALIGN=TOP WIDTH="41"><div> F</div> </tD> <tD VALIGN=TOP WIDTH="62"><div> Liver full</div> <div> Heart empty</div> <bR> </tD> <tD VALIGN=TOP><NOBR><div> Yellow Greasy</div> </NOBR></tD> <tD VALIGN=TOP WIDTH="116"><div> Hypochondriac pain, bloating, neck pain</div> <div>  </div> </tD> <tD VALIGN=TOP WIDTH="100"><div> Herbal Formula</div> </tD> <tD VALIGN=TOP WIDTH="59"><div> +</div> </tD> <tD VALIGN=TOP WIDTH="47"><div> +*</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 76 WIDTH="55"><div> C. Y. </div> </tD> <tD VALIGN=TOP WIDTH="40"><div> >10</div> </tD> <tD VALIGN=TOP WIDTH="68"><div> 35</div> </tD> <tD VALIGN=TOP WIDTH="42"><div> 54</div> </tD> <tD VALIGN=TOP WIDTH="41"><div> F</div> </tD> <tD VALIGN=TOP WIDTH="62"><div> Liver full, spleen wiry</div> <bR> </tD> <tD VALIGN=TOP><NOBR><div> Yellow Greasy</div> </NOBR></tD> <tD VALIGN=TOP WIDTH="116"><div> Hypochondriac pain, fullness around ears</div> <bR> </tD> <tD VALIGN=TOP WIDTH="100"><div> Herbal formula</div> <div> Acupuncture</div> <bR> </tD> <tD VALIGN=TOP WIDTH="59"><div> +</div> </tD> <tD VALIGN=TOP WIDTH="47"><div> -</div> </tD> </tR> </TABLE></div> <bR> <div> *Ashi would decrease then return.</div> <div> Table 2. Information on initial visit signs and symptoms of 5 patients presenting with pain associated with the Gallbladder Meridian as suggested by a positive Ashi response on Yang ling quan GB 34 left side. All 5 patients are post-cholescystectomy.</div> <bR> <div> <B>DIAGNOSES</B></div> <div> All patients had some degree of pain or distension in the URQ. For some the pain went through to their mid-back and for others it stayed in one spot under the ribs. All patients had normal bowel movements, appetite, thirst and urination. All patients suffered from some sort of sleep disorder, either trouble falling asleep during Gallbladder time 11-1 am or waking during Liver time (1- 3 am). All the patients were menopausal and not taking hormone replacement. The pain reported if other than hypochondriac, followed the Gallbladder meridian. All patients had some degree of neck and shoulder pain and some degree of indigestion from belching and reflux to mild stomach upset. All the patients except for Y.G. presented with pulses consistent with Qi Stagnation. Y.G.'s pulse could indicate Shaoyang level of cold invasion or Yang deficiency. The tongue appearances except for C.J. suggest Phlegm-Heat. C.J.`s tongue and pulse diagnosis is more consistent with Qi stagnation leading to a deficiency syndrome. As mentioned earlier, a sign of Shaoyang excess can be a pulse that is both slippery (excess) and weak. <FONT SIZE="1" COLOR="#000000" FACE="TTE1B50530t00" >(10,11) </FONT>If one translates the pulse to be `full' on the Liver/GB pulse and `weak' at another position, then the patients presenting above have more classic Shaoyang patterns. We don't have the tongue appearance mentioned in either the Shang Han Lun (Treatises on Cold Induced Febrile Diseases) or the Huang Di Nei Jing (Yellow Emperor Classics), but the tongue appearances of the five patients are consistent with slippery excess pulses or even the classic thin, sinking or small pulse mentioned in the Shang Han Lun. All the patients have some degree of symptoms mentioned for Shaoyang Level. <FONT SIZE="1" COLOR="#000000" FACE="TTE1B50530t00" >(10,11,12)</FONT> The Diagnoses for the 5 patients are Liver and Gallbladder Qi Stagnation, phlegm-Heat and Shaoyang Level of cold invasion.</div> <bR> <div> <B>TREATMENT</B></div> <div> The treatment plan for the five patients was to move Qi, soothe the Liver, regulate the Shaoyang and remove phlegm. All patients received the herbal formula Xiao Chai Hu Tang (san) (Minor Bupleurum decoction in powder form) plus Bai Shao, Paeonia radix, Hai Jin Sha, Lygodii Japonici spores and Wu Bei Zi, Galla Rhois Chinensis. * The 40 grams of powdered herbal formula were placed in 100 capsules and patients were advised to take 4 capsules twice a day before lunch and before bed. Eight capsules could be taken if pain returned. Xiao Chai Hu Tang is the primary formula to regulate the Shao Yang. The ingredients within the formula move Qi and harmonize the middle, Ban Xia, Pinellia removes phlegm, Bai Shao, Paeonia stops pain, Hai Jin Sha, Lygodum spores, dissolves stones. Wu Bei Zi (gallnut) is used because of its similarity to gallstones (principle of like to treat like) and it is used to detoxify. Acupuncture treatment was needling of the ashi point on or around Yang Ling Qian GB 34 (left side only) to a depth sufficient to produce strong deqi reaction. Yang Ling Qian GB 34 regulates the Gallbladder, relaxes tendons and removes damp heat. Patients were asked to take a deep breath and then exhale, the needle being inserted on exhalation to intensify the Qi response. San Yin Jiao, SP 6 and Yin Ling Qian, SP 9 were needled bilaterally for abdominal pain, remove damp and support the Yin organs of the leg. After insertion, the needle was strongly twirled once to the right. Zu Lin Qi GB 41 was needled bilaterally to decrease excess in the Shaoyang Channel. After insertion, the needle was lightly twirled ½ turn to the right. A second manipulation might be done if neck pain was still present. Tai Chong LV 3 was needled bilaterally to soothe the Liver, move Qi and stop pain. Zhong Zhu SJ 3 was needled bilaterally to use the Hand Shaoyang to treat Foot Shaoyang; the needles inserted into these two points were not additionally stimulated. All patients were advised to refrain from eating rich, greasy or fried foods and were advised to drink warm or hot drinks with meals and after eating. All patients were advised to start an exercise program involving deep breathing like Tai Chi, Qi Gong or Yoga to aid in the movement of Qi throughout their body. </div> <bR> <div> <B>RESULTS</B></div> <div> All patients receiving acupuncture had no pain after treatment and returned for additional treatments as needed. Patients receiving only the herbal formula had a reduction in URQ by the second day of herbs and were able to reduce their dosage to as needed when they felt their URQ or neck/shoulder pain return. Table 3 summarizes the results of treatment of the five patients.</div> <div> One patient, J.H, is noncompliant in exercise or diet modifications and uses the herbs on a frequent basis whenever the pain returns. </div> <bR> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="614" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="82"><div> Name</div> </tD> <tD VALIGN=TOP WIDTH="83"><div> Pulse</div> </tD> <tD VALIGN=TOP WIDTH="94"><div> Tongue</div> </tD> <tD VALIGN=TOP><NOBR><div> Symptoms</div> </NOBR></tD> <tD VALIGN=TOP><NOBR><div> Recommendation</div> </NOBR></tD> <tD VALIGN=TOP WIDTH="112"><div> Comments</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 115 WIDTH="82"><div> E.G.</div> </tD> <tD VALIGN=TOP><NOBR><div> Liver wiry</div> <div> Heart thin</div> </NOBR></tD> <tD VALIGN=TOP><NOBR><div> Greasy</div> <div> Decreased</div> </NOBR></tD> <tD VALIGN=TOP WIDTH="91"><div> Edema gone, pain came back when stopped herbs</div> </tD> <tD VALIGN=TOP WIDTH="117"><div> Decrease cold foods and drink, continue herbs as needed, return as needed</div> </tD> <tD VALIGN=TOP WIDTH="112"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="115" ALIGN="bottom" WIDTH="112" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 76 WIDTH="82"><div> C.J.</div> </tD> <tD VALIGN=TOP><NOBR><div> Liver wiry</div> </NOBR></tD> <tD VALIGN=TOP WIDTH="94"><div> Tongue unremarkable</div> </tD> <tD VALIGN=TOP><NOBR><div> Pain gone </div> <bR> </NOBR></tD> <tD VALIGN=TOP WIDTH="117"><div> Continue herbs as needed, stop sodas</div> </tD> <tD VALIGN=TOP WIDTH="112"><div> 7 months passed until next visit, pain still gone</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 57 WIDTH="82"><div> Y.G.</div> </tD> <tD VALIGN=TOP><NOBR><div> Liver wiry</div> </NOBR></tD> <tD VALIGN=TOP WIDTH="94"><div> Less geographic</div> </tD> <tD VALIGN=TOP WIDTH="91"><div> Main GB symptoms gone</div> </tD> <tD VALIGN=TOP WIDTH="117"><div> Hot drinks, Olive oil, decrease cold & raw foods</div> </tD> <tD VALIGN=TOP WIDTH="112"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="57" ALIGN="bottom" WIDTH="112" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 96 WIDTH="82"><div> J.H.</div> </tD> <tD VALIGN=TOP WIDTH="83"><div> Liver full</div> </tD> <tD VALIGN=TOP WIDTH="94"><div> Greasy </div> <bR> </tD> <tD VALIGN=TOP WIDTH="91"><div> Symptoms decrease with herbs and acupuncture</div> </tD> <tD VALIGN=TOP WIDTH="117"><div> Decrease cold; decrease fried greasy foods, rich foods</div> </tD> <tD VALIGN=TOP WIDTH="112"><div> Patient noncompliant on diet recommendation</div> <bR> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 76 WIDTH="82"><div> C.Y.</div> </tD> <tD VALIGN=TOP WIDTH="83"><div> Liver sinking</div> <bR> </tD> <tD VALIGN=TOP WIDTH="94"><div> Yellow </div> <bR> </tD> <tD VALIGN=TOP WIDTH="91"><div> Symptoms improved</div> </tD> <tD VALIGN=TOP WIDTH="117"><div> Decrease fried, greasy foods, protect from wind</div> </tD> <tD VALIGN=TOP WIDTH="112"><div> Pain returns when drinks alcohol</div> <bR> </tD> </tR> </TABLE></div> <div> Table 3. Summary of results of the five patients treated with the same herbal formula for symptoms associated with the Gallbladder Meridian. Some of the patients received acupuncture. Some of the patients received other formulas for additional symptoms.</div> <bR> <div> <B>DISCUSSION</B></div> <div> Patients presenting with pain or fullness under the ribs, irritability, belching, and bloating are usually diagnosed with Liver Qi Stagnation, especially if the patient has a wiry pulse and purple tongue. Since these symptoms can also be present in patients with a history of gallbladder problems, Liver/Gallbladder Qi Stagnation can be an appropriate diagnosis. If the tongue is coated with yellow grease and the pulse is slippery. Damp Heat in the Gallbladder can also be an appropriate diagnosis. <FONT SIZE="1" COLOR="#000000" FACE="TTE1B50530t00" >(7,8) </FONT>However, Cold invasion into the Shao Yang Level can also produce symptoms associated with Gallbladder. <FONT SIZE="1" COLOR="#000000" FACE="TTE1B50530t00" >(10) </FONT>Some of the difficulties in diagnosing the Shao Yang Level are the absence of tongue description and the fact that multiple pulse descriptions are listed for Shao Yang both in the Shang Han Lun (Treatises on Cold Induced Febrile Diseases) and</div> <div> Huang Di Nei Jing (Yellow Emperor Classic). <FONT SIZE="1" COLOR="#000000" FACE="TTE1B50530t00" >(10,11,12) </FONT>However, sufficient clues are present in-patient symptoms to suggest that Shao Yang level is appropriate for diagnosing and treatment.</div> <bR> <div> As mentioned, the Shang Han Lun describes Shao Yang level patients as having fullness under the ribs (distension, bloating), tidal fever, alternating hot and cold, which is due in part to the fact that the pathogen has been trapped between Interior and Exterior (between Tai Yang and Yang</div> <div> Ming). <FONT SIZE="1" COLOR="#000000" FACE="TTE1B50530t00" >(10) </FONT>I think that pulse has such a wide variation because of the Cold moving between those two levels. The basic treatment therapy, no matter which pulse is present, would be to harmonize the Shao Yang, for which the best formula is the Xiao Chai Hu Tang (Minor Bupleurum decoction), if bowel movement is normal. I think that these symptoms can be very frustrating for patients because they all assumed that after their surgery to remove their gallbladder that they would not have pain or digestive upsets again. Most of the patients admitted that while the post-cholesectomy pain was not as severe as the pain that lead to the surgery, the pain they were experiencing was severe enough to seek treatment. Most patients denied being told any dietary restrictions following cholesectomy, however, except for occasional lapses, suggestions involving restrictions of fried food, greasy or rich foods and drinking hot drinks with or after meals were met with compliance. Patients started noticing a cause and effect of lapses of diet restrictions and return of symptoms, which increased compliance. All patients found that their primary symptoms for seeking treatment had reduced or were eliminated following acupuncture or herbal formulas. All patients were advised to take the herbal formula as needed whenever their original symptoms returned.</div> <bR> <div> <B>CONCLUSION</B></div> <div> In conclusion, the treatment of five patients all presenting with symptoms that were consistent with gallbladder problems following removal of the gallbladder was shown to be successful following the principles suggested in the Shang Han Lun for treatment of the Shao Yang Level of</div> <div> Cold invasion. While all patients received the same herbal formula based on Xiao Chai Hu Tang</div> <div> (Minor Bupleurum decoction), some patients also had acupuncture. The acupuncture helped reduce immediate symptoms such as pain along the Gall Bladder and/or San Jiao meridian, bloating and distension. The herbal formula was also able to reduce the pain as well. The results of this study suggest the validity of using the Shang Han Lun formula with appropriate modifications to treat symptoms related to the Level of invasion. Further study is needed to verify whether this treatment is valid for post-cholesectomy pain that follows the Shao Yang meridians.</div> <div> *The formula used is a modification of Xiao Chai Hu Tang (Minor Bupleurum decoction) from the Shang Hun Lun <FONT SIZE="1" COLOR="#000000" FACE="TTE1B50530t00" >(15)</FONT> All the herbs Sheng Jiang are powdered raw, either prepared in the office or brought commercially.</div> <div> 5 parts Chai Hu, Bupleurum radix</div> <div> 3 parts Huang Qin, Scutellaria radix</div> <div> 3 parts Xi Yang Shen, Panax</div> <div> 3 parts Gan Cao, Glycyrrhia radix</div> <div> 4 parts Ban Xia, Pinellia</div> <div> 3 parts Sheng Jiang (commercial 5:1 extract) Zingiber</div> <div> 2 parts Da Zao, Ziziphus</div> <div> 4 parts Bai Shao, Paeonia radix</div> <div> This formula is used intact and modified with:</div> <div> 6 parts of modified Xiao Chai Hu Tang (san)</div> <div> 1 part Wu bei Zi Galla Rhous Chinensis</div> <div> 1 part Hai Jin Sha, Lygodii Spora</div> <div> (Example: for 100 capsules, 40 grams of formula is used, 5 grams of Wu Bei Zi, 5 grams of Hai Jin Sha and 30 grams of Xiao Chai Hu Tang (san)</div> <bR> <div> <B>REFERENCES</B></div> <div> 1. <FONT SIZE="3" COLOR="#000000" FACE="TTE1B50530t00" >Konifoff, F. 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