The Treatment of Digestive Problems with Acupuncture and Herbs

Giovanni Maciocia FEELING OF DISTENSION, OPPRESSION, FULLNESS, STUFFINESS

A feeling of DISTENSION (zhang 胀) indicates stagnation of Qi. This type of sensation will be seldom referred to as "distension" by Western patients: more often than not patients will call it a feeling of “bloating”, "bursting", "being blown-up", etc.

A feeling of distension is both subjective and objective. The patient feel bloated subjectively, and distension is also objective in that it can be seen and palpated. On palpation it feel like an over-inflated balloon, it resists on palpation and “rebounds”.

Subjective Can be seen Objective Can be palpated (like balloon) A feeling of distension indicates Qi stagnation: it is the cardinal symptom of Qi stagnation which usually affects the Liver.

Remember, however, that it affects also other organs: in the context of digestive disorders, it affects the Stomach, Intestines and Spleen.

Note that Qi stagnation does not always derive from anger (whether repressed or not) but it frequently derives from worry or guilt.

Please note that English-speaking patients would not say “distension” but most probably “bloating”. - Liver-Qi stagnation: abdominal and/or epigastric bloating, related to emotional state. Pulse all Wiry or Wiry on left.

- Stomach-Qi stagnation: epigastric bloating, not much related to emotional state. Alleviated by burping. Pulse Wiry on right Guan.

- Spleen-Qi stagnation: lower abdominal bloating, loose stools. Alleviated by passing gas and by rest. Pulse slightly Wiry on left and Weak on right. Wiry Weak

- Intestines Qi stagnation: abdominal distension and pain, borborygmi, constipation. Alleviated by passing gas. Pulse Wiry on both Chi position. Distension of epigastrium: Ren-10 Xiawan, Ren-12 Zhongwan, ST- 21 Liangmen, ST-34 Liangqiu, ST-40 Fenglong, GB-34 Yanglingquan.

Distension of lower abdomen: ST-25 Tianshu, SP-15 Daheng, GB-34 Yanglingquan, Ren-6 Qihai. A feeling of FULLNESS (man 满 ) indicates retention of food or Dampness. A feeling of fullness is different than a feeling of distension. One literally feels full and slightly nauseous. It may affect the epigastriun or abdomen.

The feeling of fullness is subjective and objective. Subjectively, the patient feels full. It is felt objectively on palpation but not seen on observation. On palpation, the abdomen feels hard and not elastic as in the feeling of distension.

A feeling of an actual mass (on palpation) indicates stasis of Blood.

Subjective

Objective Can be palpated (feels hard)

Epigastric fullness: ST-19 Burong, ST-21 Liangmen, Ren-10 Xiawan, SP-4 Gongsun/P-6 Neiguan (Chong Mai), ST-34 Liangqiu.

Abdominal fullness: ST-25 Tianshu, ST-27 Daju, SP-4 Gongsun/P-6 Neiguan (Chong Mai), ST-37 Shangjuxu, ST-39 Xiajuxu. A feeling of OPPRESSION (men 闷 ) denotes Phlegm or also more severe stagnation of Qi. The translation of this term cannot adequately convey the image evoked by its Chinese character: this depicts a heart constrained by a door and, besides the physical sensation, it also implies a certain mental anguish associated with this feeling. 闷门心 Men Door Heart

A feeling of oppression is purely subjective and it is experienced mostly in the chest. Some patients would describe it as a “weight” on the chest.

In Western patients too, a feeling of oppression of the chest reflects emotional stress especially to do with sadness, grief, worry, shame and guilt.

Feeling of oppression of the chest: Ren-17 Shanzhong, P-6 Neiguan, LU-7 Lieque, ST-40 Fenglong. A feeling of STUFFINESS (pi 痞) usually indicates Stomach-Qi deficiency with Stomach-Heat. Contrary to the previous two sensations which can be felt objectively on palpation (e.g. a distended or full abdomen feels so on touch), the sensation of stuffiness is only subjective and the abdomen feels soft on touch.

The feeling of stuffiness is usually in the epigastrium. DISTENSION FULLNESS OPPRESSION STUFFINESS

Subjective/objective Both Both Subjective Subjective

Symptoms Bloating Full, nausea Weight Mildly full

Chinese Zhang 张 Man 满 Men 闷 Pi 痞

Objective on what Visually and On palpation Soft on palpation palpation

Pattern Qi stagnation Dampness Phlegm Deficiency and ST-Heat AETIOLOGY OF DIGESTIVE DISEASES

DIET

Excessive consumption of sugar, sweets, dairy Excessive consumption of sugar, sweets, dairy foods leads to Dampness or Phlegm.

Excessive consumption of cold foods Excessive consumption of cold foods (raw vegetables, fruit, cold drinks, ice-cream) leads to Cold in Stomach or Intestines.

Excessive consumption of hot foods Excessive consumption of spicy foods and alcohol leads to Heat in the Stomach or Intestines. Irregular eating habits These include:

- Eating in a hurry - Eating at one’s work-desk - Eating standing up - Eating while discussing work/business - Eating late at night

These habits lead to Stomach-Yin deficiency

Ren-12 Zhongwan, ST-36 Zusanli, SP-6 Sanyinjiao EMOTIONAL STRESS Anger

Anger affects the Liver and the Heart. It causes rebellious Liver-Qi to invade the Stomach and/or Spleen. This is a frequent cause of epigastric pain (if it affects the Stomach) or abdominal pain (if it affects the Spleen).

Anger that is expressed tends to affect the Stomach more (with Qi rebelling horizontally), while anger that is repressed tends to affect the Spleen more (Qi stagnation). Expressed anger Nausea, belching, acid regurgitation

ST LIV SP Loose stools Repressed anger Worry and pensiveness Worry and pensiveness also affect the Liver causing Liver-Qi stagnation. This may affect the Stomach or Intestines.

Worry and pensiveness also affect the Spleen which will affect the Intestines causing loose stools and/or abdominal pain and distension.

Guilt Guilt may also affect the Liver causing Liver-Qi stagnation leading to epigastric or abdominal pain. ST-40 FENGLONG

1. Subdues rebellious ST-Qi 2. All Full conditions of the Stomach 3. Opens the chest (with LU-7 or P-6) 4. Calms the Mind 5. Regulates the Heart Yao Cheng Wen, A Vernacular Explanation of the Discussion on Stomach and Spleen Pi Wei Lun Bai Hua Jie, Three Qin Publishing House, Xian, 2002, p. 206.

Citing Acupuncture Channels of the Yellow Emperor Huang Di Zhen Jing 黄帝针经.

“The Large Intestine and the Small Intestine pertain to the Stomach Yang Ming. The point of the Small Intestine is ST-39 Xiajuxu and that of the Large Intestine is ST-37 Shangjuxu, both below ST-36 of the Stomach Yang Ming. The Large Intestine controls the Jin fluids and the Small Intestine the Ye fluids. The Small and Large Intestine receive Ying Qi from the Stomach and send the Jin-Ye fluids to the Upper Burner where they irrigate the skin and hair and fill the Cou Li space.” Practically the same quote is in chapter 2 of the Ling Shu.

What this quote is saying is that the Small and Large Intestine, in the field of digestive diseases, come under the sphere of influence of the Stomach. It also confirms the importance of ST-39 and ST-37 for intestinal diseases.

Note the location of ST-37 and ST-39 in relation to ST-40: the former is above it and the latter below. ST-40 is the Luo point and the Great Luo of the Stomach is called Xu Li 虚里. XU LI

. ST-37 Shangjuxu- Upper Great Void . ST-40 .ST -39 Xiajuxu- Lower Great Void

The Small and Large Intestine are different than other organs in so far as their channels have a physiology and pathology that is quite distinct from that of their organs (the Triple Burner is also like this). CHAPTER 2 LING SHU HE-SEA POINTS

After listing all the Shu points of each channel, the Ling Shu has an interesting statement: “These are the Shu points of the 5 Zang and 6 Fu, 25 and 36 respectively. The 6 Fu exit at the three Yang of the leg and connect upward with the arm.”

This statement is saying that all the He-Sea points of the Yang channels are in the leg (because of the Lower He points ST-37, ST-39 and BL-39, Lower He points of Large Intestine, Small Intestine and Triple Burner respectively). These are the “real” He-Sea points, the ones in the arm being “connections”.

The Arm Yang channels probably have Lower He-Sea points in the legs because of the anomaly of their channels being in the arm and their related organs in the lower abdomen (Intestines and Triple Burner). Lower He-Sea points of Large Intestine, Triple Burner and Small Intestine

.. . LI-11, TB-10, SI-8

. BL-39 . ST-37 . ST-39 Ren-12: tonifies ST- Qi, resolve Ren-13: Dampness, subdues tonifies all rebellious Fu . ST-Qi ST-21: . . . Full conditions . Ren-10: of ST stimulates the descending of ST-Qi

Note that “subduing rebellious Qi” (Ren-13) and “stimulating the descending of Qi” (Ren-10) are not the same thing DIAGNOSIS

There are some aspects of diagnosis which particularly apply to abdominal pain. a) nature of pain b) reaction to pressure c) reaction to food d) reaction to bowel movement

a) NATURE OF PAIN A dull pain is due to an Empty condition, whilst a severe pain is due to a Full condition.

A distending pain indicates stagnation of Qi. Patients often describe this as a "bloated" sensation.

A stabbing, fixed and intense pain indicates stasis of Blood, especially if it is associated with a fixed abdominal mass.

A feeling of fullness (which is more intense than "distension"), in Chinese called man, indicates Dampness or retention of food. b) REACTION TO PRESSURE If an abdominal pain is eased by pressing the area of pain this indicates an Empty condition. If it is aggravated by pressure this indicates a Full condition. The “Essential Prescriptions of the Golden Chest” says: “If an abdominal pain improves with pressure it indicates Deficiency, if it is aggravated by pressure it indicates Excess.” c) REACTION TO FOOD Abdominal pain which improves with eating is of an Empty nature; if it is aggravated by eating, it is of a Full nature. d) REACTION TO BOWEL MOVEMENT i) If abdominal pain improves after bowel movements it is said to be substantial in nature and usually due to either Blood stasis, Dampness or retention of food. Both of these are Full types of abdominal pain. ii) Abdominal pain which is not influenced by bowel movements is also of the Full type but is non-substantial in nature and it may be due to stagnation of Qi or Cold. iii) Abdominal pain which gets worse after bowel movements indicates an Empty condition. PULSE DIAGNOSIS The Intestines are reflected in both Rear positions of the pulse. Although the left Rear position corresponds to the Small Intestine and the right one to the Large Intestine (some doctors reverse this), a pathology of the Intestines (whether Small or Large) is often reflected in both Rear positions having the same quality.

If it is of gynaecological origin, one side or the other (more often the left) presents an abnormal quality. This may also be a useful sign to distinguish pain of intestinal origin from that of gynaecological origin in women.

Intestinal Gynaecological Both Rear positions:

Tight and Slow: Cold in the Intestines.

Wiry: stagnation of Qi or stasis of Blood in the Intestines.

Wiry-Rapid-Slippery: Damp Heat in the Intestines and possibly bleeding from the intestinal mucosa. This pulse finding is often seen in Crohn's disease or ulcerative colitis.

Wiry-Hollow: prolonged bleeding from the gut.

Rapid and only slightly Hollow: forthcoming bleeding from the gut.

Slippery-Wiry: Damp Heat and stagnation of Qi or Blood in the Intestines. Kidneys, Chong Mai

Stomach, Spleen, Intestines

Chong Mai, Intestines

Intestines, Kidneys, Bladder, Ren Mai EPIGASTRIC PAIN

The possible patterns are the following:

EXCESS DEFICIENT Cold invading the Stomach Stomach and Spleen Deficient and Cold Retention of food Stomach-Yin Deficiency Liver-Qi invading the Stomach Stomach-Heat Stomach-Fire Stomach Phlegm-Heat Stomach Damp-Heat Stomach and Liver Heat Stasis of Blood in the Stomach Phlegm-Fluids in the Stomach FULL PATTERNS 1) LIVER-QI INVADING THE STOMACH Clinical manifestations Epigastric distension and pain radiating towards the right or left hypochondrium, belching, sighing, irritability, uncomfortable feeling of hunger. The pain comes in bouts clearly related to emotional tension. Tongue: normal body colour or slightly Red sides. Pulse: Wiry. It may be Wiry only on the left side. Treatment principle Soothe the Liver and regulate Qi.

Acupuncture LIV-14 Qimen, P-6 Neiguan, ST-21 Liangmen, Ren-12 Zhongwan, ST-36 Zusanli, G.B.-34 Yanglingquan. Reducing or even method.

Prescription CHAI HU SHU GAN TANG Bupleurum Soothing the Liver Decoction

Three Treasures: BREAK INTO A SMILE

2) STOMACH PHLEGM-HEAT

Clinical manifestations A feeling of oppression of the epigastrium, dry mouth but no desire to drink, nausea, vomiting, insomnia, mental restlessness, in severe cases manic behaviour or manic-depression and insomnia. Tongue: Red with a very sticky or slippery yellow coating. The tongue may have a wide Stomach-type crack in the centre with a rough, brush-like, dry yellow coating inside it. Pulse: Slippery, Rapid, Overflowing.

Treatment principle Harmonize the Stomach, clear Heat, resolve Phlegm, calm the Mind. Acupuncture ST-21 Liangmen, Ren-12 Zhongwan, Ren-13 Shangwan, P-5 Jianshi, ST-40 Fenglong, P-7 Daling, Du-24 Shenting, G.B.-13 Benshen, ST- 44 Neiting. All with reducing method, except for Ren-12 which should be reinforced.

Herbal treatment Prescription WEN DAN TANG Warming the Gall Bladder Decoction

Three Treasures: CLEAR THE SOUL 3) DAMP-HEAT IN THE STOMACH Clinical manifestations Feeling of fullness epigastrium, dull epigastric pain, dry mouth, no desire to drink, a bitter taste, a sticky taste, nausea, vomiting. There may also be a frontal headache. Tongue: Red with a sticky-yellow coating. Pulse: Slippery, Rapid, slightly Weak-Floating in the right Middle position. Treatment principle Clear Heat, resolve Dampness, harmonize the Stomach.

Acupuncture Ren-10 Xiawan, Ren-9 Shuifen, ST-21 Liangmen, SP-9 Yinlingquan, SP-6 Sanyinjiao, BL-20 Pishu, BL-21 Weishu, Ren-12 Zhongwan, ST-8 Touwei, L.I.-4 Hegu. All with reducing or even method except Ren-12 and BL-20 which should be reinforced.

Herbal treatment Prescription XIANG SHA PING WEI SAN Saussurea-Amomum Regulating the Stomach Powder

Three Treasures: EASE THE MUSCLES

DEFICIENCY

1) STOMACH AND SPLEEN DEFICIENT AND COLD Clinical manifestations Dull epigastric pain which improves with pressure, after eating, and with the application of heat, vomiting of thin fluids, tiredness, poor appetite, chilliness, loose stools, pale complexion. Tongue: Pale, white coating. Pulse: Deep, Weak. Treatment principle Warm the Middle, strengthen the Spleen and Stomach.

Acupuncture Ren-12 Zhongwan, P-6 Neiguan, ST-36 Zusanli, Ren-6 Qihai, BL-20 Pishu, BL-21 Weishu. All with reinforcing method, moxa is applicable.

Prescription HUANG QI JIAN ZHONG TANG Astragalus Strengthening the Centre Decoction

Three Treasures PROSPEROUS EARTH

2) STOMACH-YIN DEFICIENCY

Clinical manifestations Dull epigastric pain, dry mouth, desire to sip liquids, dry throat, dry stools, slight nausea. Tongue: normal colour, dry, no coating, scattered cracks or a central wide Stomach crack. Pulse: Floating-Empty in the right Middle position.

Treatment principle Nourish Yin, benefit the Stomach, stop pain.

Acupuncture Ren-12 Zhongwan, ST-36 Zusanli, SP-6 Sanyinjiao. Reinforcing method. Herbal treatment a) Prescription SHEN LING BAI ZHU SAN Ginseng-Poria-Atractylodes Powder b) Prescription SHAN SHEN MAI DONG TANG Glehnia-Ophiopogon Decoction c) Prescription YI GUAN JIAN and BAI SHAO GAN CAO TANG One Linking Decoction and Paeonia-Glycyrrhiza Decoction d) Prescription YI WEI TANG Benefiting the Stomach Decoction e) Prescription YANG WEI TANG Nourishing the Stomach Decoction

Three Treasures: CENTRAL MANSION or JADE SPRING

ABDOMINAL PAIN

1) STAGNATION OF QI Clinical manifestations Abdominal pain and distension which are clearly related to the emotional state, feeling bloated, constipation, irritability, moodiness, belching, borborygmi. Tongue: there may be no change in the body colour, but in more severe cases it may be Red on the sides. i. Acupuncture Ren-6 Qihai, P-6 Neiguan, P-7 Daling, T.B.-6 Zhigou, G.B.-34 Yanglingquan, LIV-3 Taichong, ST-25 Tianshu, BL-18 Ganshu, SP-6 Sanyinjiao, ST-39 Xiajuxu. Reducing or even method. ii. Herbal therapy Prescription CHAI HU SHU GAN TANG Bupleurum Soothing the Liver Decoction

Three Treasures remedy: BREAK INTO A SMILE 2) STAGNATION OF QI WITH DAMPNESS Clinical manifestations Abdominal pain and distension which are clearly related to the emotional state, feeling bloated, irritability, moodiness, belching, borborygmi, a feeling of fullness and heaviness of the abdomen. Tongue: there may be no change in the body colour, but in more severe cases it may be Red on the sides; sticky coating. Pulse: Slippery and Wiry. i. Acupuncture Points Ren-6 Qihai, P-6 Neiguan, P-7 Daling, T.B.-6 Zhigou, G.B.-34 Yanglingquan, LIV-3 Taichong, BL-18 Ganshu, SP-6 Sanyinjiao, Ren-9 Shuifen, SP-9 Yinlingquan, ST-28 Shuidao, BL-22 Sanjiaoshu, ST-39 Xiajuxu. Reducing or even method. ii. Herbal therapy Prescription SI MO TANG Variation Four Milled-Herb Decoction Variation

Three Treasures: SMOOTH PASSAGE 3) QI STAGNATION, DAMPNESS, QI DEFICIENCY Clinical manifestations Abdominal pain and distension that come and go, worse when tired or when under emotional stress, feeling bloated, constipation or loose stools, irritability, moodiness, belching, borborygmi, a feeling of fullness and heaviness of the abdomen, tiredness, poor appetite. Tongue: there may be no change in the body colour, but in more severe cases it may be Red on the sides; sticky coating. Pulse: Soggy and slightly Wiry. i. Acupuncture - Qi stagnation: Ren-6 Qihai, P-6 Neiguan, T.B.-6 Zhigou, G.B.-34 Yanglingquan, LIV-3 Taichong, BL-18 Ganshu - Dampness: SP-6 Sanyinjiao, Ren-9 Shuifen, SP-9 Yinlingquan, ST- 28 Shuidao, BL-22 Sanjiaoshu, ST-39 Xiajuxu, Ren-5 Shimen. - Qi deficiency: Ren-12 Zhongwan, ST-36 Zusanli, BL-20 Pishu. ii. Herbal therapy SI MO TANG Four Milled-Herb Decoction

Three Treasures remedy: SMOOTH PASSAGE 4) STASIS OF BLOOD Clinical manifestations Severe abdominal pain, masses in the abdomen, dark complexion. Tongue: Purple. Pulse: Deep and Choppy or Deep and Firm. i. Acupuncture Ren-6 Qihai, P-6 Neiguan, P-7 Daling, T.B.-6 Zhigou, G.B.-34 Yanglingquan, LIV-3 Taichong, BL-18 Ganshu, SP-6 Sanyinjiao, SP- 10 Xuehai, BL-17 Geshu, KI-6 Zhaohai and LU-7 Lieque (Yin Qiao Mai), SP-4 Gongsun and P-6 Neiguan (Chong Mai), ST-39 Xiajuxu. Reducing or even method. ii. Herbal therapy Prescription SHAO FU ZHU YU TANG or GE XIA ZHU YU TANG Lower Abdomen Eliminating Stasis Decoction or Eliminating Stasis below the Diaphragm Decoction

Three Treasures remedy: STIR FIELD OF ELIXIR

5) DAMP HEAT IN THE INTESTINES Clinical manifestations Abdominal pain that is worse with pressure and hot food, loose stools with foul smell, mucus and/or blood in the stools, a burning sensation of the anus, thirst, slight sweating, dark urine, a feeling of fullness and heaviness of the abdomen. Tongue: Red body, thick-sticky-yellow coating. Pulse: Slippery and Rapid.

Treatment principle Clear Heat, resolve Dampness. i. Acupuncture Points ST-25 Tianshu, BL-25 Dachangshu, L.I.-11 Quchi, Ren-10 Xiawan, SP-9 Yinlingquan, SP-6 Sanyinjiao, T.B.-6 Zhigou, ST-37 Shangjuxu, ST-39 Xiajuxu. Reducing or even method; no moxa. ii. Herbal therapy Prescription DA CHENG QI TANG Variation Great Conducting Qi Decoction

Prescription SHAO YAO TANG Paeonia Decoction

Prescription HUANG QIN TANG Scutellaria Decoction

Prescription BAI TOU WENG TANG Pulsatilla Decoction

Three Treasures remedy: EASE THE MUSCLES

6) SPLEEN-QI DEFICIENT AND SINKING Clinical manifestations Dull, central abdominal pain that comes and goes, worse when tired, better with pressure, bearing-down feeling, tiredness, loose stools, poor appetite, weak muscles, depression. Tongue: Pale. Pulse: Weak. i. Acupuncture Points Du-20 Baihui, Ren-12 Zhongwan, Ren-6 Qihai, ST-36 Zusanli, SP-3 Taibai, BL-20 Pishu, ST-39 Xiajuxu. All with reinforcing method. ii. Herbal therapy Prescription BU ZHONG YI QI TANG Tonifying the Centre and Benefiting Qi Decoction

Three Treasures remedies: TONIFY QI AND EASE THE MUSCLES BREAKING CLOUDS (depression)

7) SPLEEN-QI DEFICIENCY WITH DAMPNESS Clinical manifestations Dull, central abdominal pain that comes and goes, worse when tired, better with pressure, tiredness, loose stools, poor appetite, a slight feeling of fullness and heaviness of the abdomen. Tongue: Pale, sticky coating. Pulse: Soggy. i. Acupuncture Points Ren-12 Zhongwan, ST-36 Zusanli, SP-3 Taibai, BL-20 Pishu, Ren-6 Qihai, SP-9 Yinlingquan, ST-28 Shuidao, Ren-9 Shuifen, BL-22 Sanjiaoshu, ST-39 Xiajuxu. Reinforcing method on the first five points; even method on the others. ii. Herbal therapy Prescription XIANG SHA LIU JUN ZI TANG Aucklandia-Amomum Six Gentlemen Decoction

Three Treasures remedies: SOOTHE THE CENTRE CENTRAL MANSION

8) SPLEEN- AND KIDNEY-YANG DEFICIENCY Clinical manifestations Dull abdominal pain that comes and goes, worse when tired, better with pressure and with the application of warmth, better with warm drinks, feeling cold, tiredness, loose stools, desire to lie down, cold limbs, lower backache, dizziness, tinnitus, frequent-pale urination. Tongue: Pale and wet. Pulse: Deep and Weak. Treatment principle: tonify Spleen- and Kidney-Yang, warm Yang, expel Empty Cold. i. Acupuncture Points Ren-12 Zhongwan, ST-36 Zusanli, ST-25 Tianshu, BL-20 Pishu, Ren-6 Qihai, KI-3 Taixi, BL-23 Shenshu, Ren-4 Guanyuan, ST-39 Xiajuxu, ST-37 Shangjuxu. All with reinforcing method; moxa is applicable, especially the moxa box on the lower abdomen. ii. Herbal therapy Prescription LI ZHONG WAN Regulating the Centre Pill

Three Treasures: STRENGTHEN THE ROOT IRRITABLE BOWEL SYNDROME

Irritable bowel syndrome is a functional gastrointestinal (GI) disorder. People with a functional GI disorder have frequent symptoms; however, the GI tract does not become damaged. IBS is a group of symptoms that occur together, not a disease.

In the past, IBS was called colitis, mucous colitis, spastic colon, nervous colon, and spastic bowel.

IBS is diagnosed when a person has had abdominal pain or discomfort at least three times a month for at least 3 months without other disease or injury that could explain the pain. The pain or discomfort of IBS may occur with a change in stool frequency or consistency or be relieved by a bowel movement.

IBS is often classified into four subtypes based on a person’s usual stool consistency. These subtypes are important because they affect the types of treatment that are most likely to improve the person’s symptoms. The four subtypes of IBS are:

IBS with constipation (IBS-C) hard or lumpy stools at least 25 percent of the time loose or watery stools less than 25 percent of the time

IBS with diarrhea (IBS-D) loose or watery stools at least 25 percent of the time hard or lumpy stools less than 25 percent of the time

Mixed IBS (IBS-M) hard or lumpy stools at least 25 percent of the time loose or watery stools at least 25 percent of the time

Unsubtyped IBS (IBS-U) hard or lumpy stools less than 25 percent of the time loose or watery stools less than 25 percent of the time The most common symptoms of IBS are abdominal pain or discomfort, often reported as cramping, along with changes in bowel habits.

To meet the definition of IBS, the pain or discomfort will be associated with at least two of the following three symptoms:

1) bowel movements that occur more or less often than usual 2) stool that appears less solid and more watery, or harder and more lumpy, than usual 3) bowel movements that improve the discomfort (not in Chinese medicine)

Other symptoms of IBS may include

- diarrhea - constipation - stools that are hard, dry, and small, making them difficult to pass - mucus in the stools In Chinese medicine, irritable bowel syndrome would fall under three Chinese diseases:

Abdominal Pain Diarrhoea Constipation

However, in the case of irritable bowel, it would involve all three of these diseases. The main patterns involved in this condition (in varying proportions) are three:

Liver-Qi stagnation (affecting the Intestines) Spleen-Qi deficiency Dampness

Liver-Qi stagnation: distension and pain (not relieved by bowel movement), constipation, bitty stools

Spleen-Qi deficiency: loose stools, worse after bowel movement

Dampness: mucus in stools, fullness (better after bowel movement) Distension Pain Bitty stools Constipation QI Wiry pulse STAGNATION

Mucus in stools Mild DAMPNESS Heaviness distension, QI Fullness Mild pain or DEFICIENCY Slippery pulse no pain Loose stools Better with rest and pressure Essential points ST-25 Tianshu, SP-15 Daheng, BL-25 Dachangshu, ST-37 Shangjuxu, ST-39 Xiajuxu.

Qi stagnation Ren-6 Qihai, T.B.-6 Zhigou, G.B.-34 Yanglingquan, LIV-3 Taichong, BL-18 Ganshu

Dampness SP-6 Sanyinjiao, Ren-9 Shuifen, SP-9 Yinlingquan, ST-28 Shuidao, BL-22 Sanjiaoshu, Ren-5 Shimen.

Qi deficiency Ren-12 Zhongwan, ST-36 Zusanli, BL-20 Pishu, Ren-6 Qihai.

Other points Chong Mai (SP-4 Gongsun and P-6 Neiguan), ST-27 Daju, ST-29 Guilai. GASTROESOPHAGEAL REFLUX DISEASE The oesophagus is separated from the pharynx by the upper oesophageal sphincter, which is normally closed by the continuous contraction of the cricopharyngeus muscle. The lower oesophageal sphincter (LOS) consists of an area of the distal end of the oesophagus that has a high resting tone and is largely responsible for the prevention of gastric reflux. GASTROESOPHAGEAL REFLUX DISEASE IN WESTERN MEDICINE Gastroesophageal reflux disease is a condition in which food or liquid travels from the stomach back up into the oesophagus. This partially digested material is usually acidic, and can irritate the oesophagus, often causing heartburn and other symptoms.

Gastroesophageal reflux is a common condition that often occurs without symptoms after meals. In some people, the reflux is related to a problem with the lower oesophageal sphincter. If this sphincter does not close properly, food and liquid can move backward into the oesophagus and may cause symptoms.

The main clinical manifestations of gastroesophageal reflux are:

• Heartburn that is often worse at night (increased by bending, stooping, lying down, or eating, and relieved by antacids) • Belching • Acid regurgitation • Difficulty in swallowing Gastroesophageal reflux may be caused by hiatus hernia. This describes the herniation of part of the stomach into the chest. In a sliding hiatus hernia, the gastro-oesophageal junction “slides” through the hiatus so that it lies above the diaphragm. This type of hernia occurs in approximately 30% of people of 50 years of age and by itself is of no diagnostic significance.

Factors associated with gastroesophageal reflux are: • Pregnancy • Obesity • Fats, chocolate, coffee or alcohol consumption • Large meals • Cigarette smoking • Drugs - antimuscarinic, calcium-channel blockers, nitrates • Systemic sclerosis • Hiatus hernia GASTROESOPHAGEAL REFLUX DISEASE IN CHINESE MEDICINE There are several Chinese disease entities that may correspond to gastroesophageal reflux: in other words, gastroesophageal reflux cannot be equated with any single Chinese disease entity but it overlaps several of them. The main Chinese disease entities resembling some of the aspects of gastroesophageal reflux are listed below. a) CAO ZA: GNAWING HUNGER “Gnawing hunger” is a translation of the Chinese term cao za which literally means “noisy” but the symptoms of this condition do not actually involve a gurgling noise. Chinese books usually explain that this condition is characterized by an uncomfortable sensation of the epigastrium that mimics pain but is not actually pain and mimics hunger but is not actually hunger; it also includes a vexed sensation felt in the epigastrium and a feeling of stuffiness of the epigastrium. This condition may also be accompanied by belching and sour regurgitation. b) FAN WEI: REGURGITATION OF FOOD “Regurgitation of food” indicates a condition in which the patient suddenly brings up food, usually several hours after eating, but without the retching and vomiting sound that occurs in vomiting. There is also a general feeling of tiredness and this condition usually occurs against a background of Deficiency. An essential characteristic of Regurgitation of Food compared to vomiting is that food is vomited several hours after eating: ancient Chinese books say “eats in the morning, vomits in the evening; eats in the evening, vomits in the morning.” c) YE GE: DYSPHAGIA AND BLOCKAGE This condition is characterized by an inability to swallow with the food getting stuck between the throat and the diaphragm; or the food may enter the stomach but the patient quickly spits phlegm. It is generally characterized by Qi stagnation and Phlegm and it is a disease that affects mostly old men.

In Regurgitation of Food (Fan Wei), the food enters the stomach and is then regurgitated and vomited. Contrary to Regurgitation of Food, in Dysphagia and Blockage (Ye Ge), the patient does not vomit; the food goes past the throat, it cannot go past the diaphragm but it is not usually vomited. This Chinese disease entity is composed of two distinct conditions. Ye (Dysphagia) indicates difficulty in swallowing and sour regurgitation; Ge (Blockage), a further pathological development from Ye, indicates a blockage of food in the diaphragm and it includes chest pain, constipation and loss of weight.

The “Complete Book of Jing Yue” says of Ye Ge Dysphagia and Blockage: “Dysphagia and Blockage are due to worry, pensiveness, excessive work and excessive alcohol consumption. Worry and pensiveness make Qi stagnate. Alcohol causes dryness and dries up Blood and Essence. As Qi cannot move properly, the disease of Dysphagia and Blockage is located in the upper part of the body; as Blood and Essence are dried up, it is located in the lower part of the body. Food is stuck in the diaphragm, stools become dry and cannot move.”1

Interestingly, the aetiology of Ye Ge is related to worry, pensiveness, overwork and excessive alcohol consumption: this sums up Western patients.

1. Zhang Jing Yue 1986 Complete Book of Jing Yue (Jing Yue Quan Shu). Shanghai Scientific Publishing House, Shanghai, p. 385. The Complete Book of Jing Yue was written by Zhang Jing Yue and first published in 1624. d) E NI: HICCUP “Hiccup” simply denotes the noisy, spontaneous contractions of the diaphragm that lead to hiccup; there is no vomiting or food regurgitation. e) TUN SUAN: SOUR REGURGITATION This condition consists in the regurgitation of acid, sour fluids coming up gradually and welling up in the mouth before being swallowed. “Tun” in the name of this disease means “to swallow”. f) TU SUAN: SOUR VOMITING This condition consists in sudden vomiting of acid, sour fluids. It differs from sour regurgitation in that the fluids are actually vomited while in sour regurgitation, the sour fluids come up slowly and well up in the mouth before being swallowed.

Thus, the clinical manifestations of gastroesophageal reflux contain elements of all the above Chinese disease entities and therefore, in order to treat gastroesophageal reflux, we should refer to the treatment of all the above conditions. IDENTIFICATION OF PATTERNS AND TREATMENT a) QI STAGNATION WITH PHLEGM Clinical manifestations Acid regurgitation, difficulty in swallowing, epigastric distension, a feeling of oppression of the chest, nausea, a feeling of stuffiness in the diaphragm, the problem fluctuates according to the emotional state, dry throat. Tongue: Swollen. Pulse: Wiry or Slippery or both.

Treatment principle Move Qi, soothe the Liver, resolve Phlegm, restore the descending of Stomach-Qi. i. Acupuncture Points P-6 Neiguan, L.I.-4 Hegu, G.B.-34 Yanglingquan, Ren-13 Shangwan, Ren-12 Zhongwan, Ren-9 Shuifen, ST-40 Fenglong. SP-4 Gongsun together with P-6 Neiguan (Chong Mai), BL-17 Geshu. ii. Herbal therapy Prescription QI GE SAN Opening the Diaphragm Powder

Three Treasures remedy: Bright Spirit b) STOMACH- AND LIVER-HEAT Clinical manifestations Acid regurgitation, bitter taste, dry mouth, vomiting of bitter fluids, headache, thirst, irritability, red face, foul breath, burning epigastric pain, a feeling of heat. Tongue: Red with yellow coating. Pulse: Overflowing-Rapid or Wiry-Rapid.

Treatment principle Clear Stomach- and Liver-Heat, restore the descending of Stomach-Qi. i. Acupuncture Points P-6 Neiguan, Ren-13 Shangwan, L.I.-4 Hegu, ST-44 Neiting, LIV-2 Xingjian, BL-17 Geshu. All with reducing or even method. ii. Herbal therapy Prescription ZUO JIN WAN plus YU NU JIAN Left Metal Pill plus Jade Woman Decoction c) BLOOD STASIS Clinical manifestations Acid regurgitation, difficulty in swallowing even liquids, epigastric pain, bitty stools, vomiting of dark fluids like red beans juice, dark complexion, loss of weight, dry skin. Tongue: Purple. Pulse: Wiry, Firm or Choppy.

Treatment principle Invigorate Blood, eliminate stasis, restore the descending of Stomach-Qi.

i. Acupuncture Points P-6 Neiguan, L.I.-4 Hegu, Ren-13 Shangwan, SP-4 Gongsun with P- 6 Neiguan (Chong Mai), KI-21 Youmen, BL-17 Geshu, LIV-3 Taichong. All with even method. ii. Herbal therapy Prescription TONG YOU TANG Penetrating the Deep Decoction

Three Treasures remedy: Red Stirring d) STOMACH-YIN DEFICIENCY WITH EMPTY HEAT Clinical manifestations Acid regurgitation, difficulty in swallowing even liquids, thin body, dry mouth and throat, dry stools, feeling of heat in the evening, night-sweating, 5-palm heat. Tongue: Red without coating, Stomach cracks. Pulse: Floating-Empty or Fine-Rapid.

Treatment principle Nourish Stomach-Yin, clear Empty Heat, restore the descending of Stomach-Qi. i. Acupuncture Points P-6 Neiguan, Ren-10 Xiawan, L.I.-4 Hegu, Ren-12 Zhongwan, ST- 36 Zusanli, SP-6 Sanyinjiao, ST-44 Neiting. P-6, Ren-10 and ST-44 with even method; the others with reinforcing method. ii. Herbal therapy Prescription WU ZHI AN ZHONG YIN Five Juices Calming the Centre Decoction

Prescription SHA SHEN MAI DONG TANG Glehnia-Ophiopogon Decoction

Three Treasures remedy: Jade Spring

e) DEFICIENCY OF YANG OF STOMACH AND SPLEEN Clinical manifestations Acid regurgitation, difficulty in swallowing, chronic condition, pale complexion, poor appetite, feeling cold, loose stools, depression, vomiting of clear fluids, slight abdominal distension. Tongue: Pale. Pulse: Weak-Deep.

Treatment principle Tonify and warm Stomach and Spleen, restore the descending of Stomach-Qi.

i. Acupuncture Points P-6 Neiguan, L.I.-4 Zhongwan, Ren-10 Xiawan, Ren-12 Zhongwan, ST-36 Zusanli, SP-6 Sanyinjiao, BL-20 Pishu, BL-21 Weishu. The first three points with even method, the others with reinforcing method. Moxa should be used. ii. Herbal therapy Prescription BU QI YUN PI TANG Tonify Qi and Promote the Spleen’s Transformation Function Decoction

Prescription DING XIANG TOU GE SAN Caryophillum Penetrating the Diaphragm Powder

f) KIDNEY-YANG DEFICIENCY Clinical manifestations Acid reflux, difficulty in swallowing, vomiting of clear fluids, lower backache, dizziness, tinnitus, tiredness, feeling cold, cold limbs, frequent and pale urination. Tongue: Pale. Pulse: Deep-Weak.

Treatment principle Tonify and warm the Kidneys, restore the descending of Stomach- Qi. i. Acupuncture Points P-6 Neiguan, Ren-10 Xiawan, L.I.-4 Hegu, BL-23 Shenshu, KI-3 Taixi, Ren-4 Guanyuan. The first three points with even method, the others with reinforcing method. Moxa should be used. ii. Herbal therapy Prescription YOU GUI WAN Restoring the Right [Kidney] Pill FULL FULL/EMPTY EMPTY

DRAIN FIELDS SOOTHE THE CENTRE PROSPEROUS EARTH Huo Po Xia Ling Tang Xiang Sha Liu Jun Zi Tang Liu Jun Zi Tang Dampness Spleen-Qi Xu, Dampness, Qi Spleen-Qi Xu stagnation Middle Burner EASE THE CENTRAL MANSION MUSCLES HARMONIZE THE CENTRE Shen Ling Bai Zhu Tang Lian Po Yin Stomach- and Spleen-Qi and Yin ST and SP Qi and Yin Xu, M.B. Damp-Heat Xu, Dampness, Phlegm Dampness

JADE SPRING Sha Shen Mai Dong Tang Stomach- and Spleen-Yin Xu (Lu-Yin Xu)

BREAK INTO A SMILE L.B. Chai Hu Shu Gan Tang Liver-Qi stagnation

SMOOTH PASSAGE Liver-Qi stagnation Lower Burner, Spleen-Qi Xu, Dampness LIU JUN ZI TANG (Prosperous Earth)

Patterns: Spleen-and Lung-Qi Deficiency, Dampness.

Digestive symptoms: poor digestion, slight abdominal distension and fullness, poor appetite, craving for sweets, loose stools.

Tongue: Pale

Explanation: This is a very simple formula which primarily tonifies Spleen-Qi and secondarily resolves Dampness. Spleen-Qi deficiency with Dampness is probably one of the most common clinical findings in digestive problems and it will nearly always be accompanied by tiredness. LIU JUN ZI TANG

IN A NUTSHELL: tonify Spleen-Qi, resolve Dampness.

Pale, sticky coating XIANG SHA LIU JUN ZI TANG (Soothe the Centre)

Patterns: Stomach and Spleen Qi Deficiency, some Stomach-Yin Deficiency, Dampness and stagnation of Qi in Middle Burner

Digestive symptoms: Poor appetite, feeling of fullness, distension and pain of the epigastrium, poor digestion, loose stools.

Tongue: Pale, teethmarks, sticky coating in the centre which may be rootless, possibly small transversal cracks on the side.

Explanation: this formula is primarily for Xu conditions, i.e. Spleen- Qi Xu is primary to the Dampness and the main symptoms will be tiredness and digestive problems. It treats problems of the Middle Burner rather than the Intestines and focuses on digestive problems of the Stomach and Spleen with some Dampness and some stagnation of Qi. XIANG SHA LIU JUN ZI TANG

IN A NUTSHELL: move Qi and resolve Dampness in the Middle Burner, tonify Spleen-Qi. Digestive problems from Qi stagnation and Dampness in the Middle Burner with Spleen-Qi deficiency..

Pale, Swollen, Swollen sides (Spleen Pale, Swollen, Swollen sides (Spleen area) area) SHEN LING BAI ZHU SAN (Central Mansion)

Patterns: Stomach- and Spleen-Qi Xu, Stomach- and Spleen-Yin Xu. Digestive symptoms: dull epigastric pain, slight epigastric fullness, dry mouth, dry lips, loose stools, diarrhoea, nausea, weak limbs, tiredness, tongue with rootless coating, partially peeled, normal colour, cracks. Explanation: this formula has a broad range of action in tonifying Qi and Yin of both Stomach and Spleen; it also resolves Dampness and secondarily tonifies Lung-Qi.

NOTE: Central Mansion is in the “middle” of a continuum of a deficiency of Stomach- Qi, then Qi and Yin, then Yin. Therefore Central Mansion is placed between Prosperous Earth (deficiency of Stomach- and Spleen-Qi) and Jade Screen (definite deficiency of Stomach-Yin, tongue not coating at all and possibly red. Prosperous Earth Central Mansion Jade Spring Liu Jun Zi Tang Shen Ling Bai Zhu San Sha Shen Mai Dong Tang

Qi Xu Qi and Yin Xu Yin Xu SHEN LING BAI ZHU SAN

IN A NUTSHELL: Qi and Yin deficiency of Stomach and Spleen. Digestive problems and especially chronic loose stools or diarrhoea.

1. Pale, 2. Pale, partially partially peeled peeled, deep ST crack, dry

3. Partially 4. Pale, peeled, ST Swollen, crack partially peeled STOMACH- AND SPLEEN-YIN XU SHA SHEN MAI DONG TANG (Jade Spring)

Patterns: Stomach, Spleen and Lung Yin Deficiency, Stomach-Empty Heat

Digestive symptoms: excessive hunger, poor digestion, slight burning epigastric pain, dry stools.

Tongue: Dry, either no coating or rootless coating in the centre, Stomach crack in the midline or scattered small cracks, may be slightly red in the centre.

Explanation: this formula nourishes Stomach-, Spleen- and Lung-Yin and clears Empty Heat.

NOTE: this remedy differs from Central Mansion in that it is aimed more at nourishing Yin of Stomach and Spleen whereas Central Mansion tonifies Qi as well and it also resolves Dampness. SHA SHEN MAI DONG TANG

IN A NUTSHELL: deficiency of Yin of Lungs, Stomach and Spleen.

Stomach and Spleen cracks Stomach, Heart and Spleen cracks

Stomach cracks Deep Spleen cracks Smooth Passage

Patterns: Spleen-Qi Xu, Liver-Qi stagnation, Dampness.

Digestive symptoms: alternation of constipation and loose stools, abdominal distension and pain, stools like pellets, mucus in stools, poor appetite.

Tongue: Pale, normal or Red, sticky coating.

Explanation: this formula is for Irritable Bowel Syndrome. It tonifies Spleen-Qi, moves Liver-Qi and resolves Dampness. CHAI HU SHU GAN TANG (Break into a Smile)

Patterns: Liver Qi invading Spleen and Stomach

Digestive symptoms: epigastric or abdominal distension and pain which is worse when stressed, flatulence, belching.

Tongue: almost normal or slightly red on the sides

Explanation: this formula moves Qi and eliminates stagnation. Abdominal distension is an important indication for the use of the formula. Distension is often described as “bloating” by Western patients. CHAI HU SHU GAN TANG

IN A NUTSHELL: Liver-Qi stagnation in the Middle and/or Lower Burner causing distension and pain. Digestive problems from Liver- Qi stagnation.

Red sides Red sides, yellow coating HUO PO XIA LING TANG (Drain Fields)

Patterns: Dampness, Spleen-Qi Deficiency.

Digestive symptoms: Feeling of fullness and heaviness in the epigastrium, nausea, poor appetite, loose stools.

Tongue: Sticky-white coating

Explanation: this formula is used primarily to drain Dampness and therefore should be chosen if the Excess aspect predominates over the Deficiency. It is appropriate for Dampness without Heat.

Note: Although Liu Jun Zi Tang also treats Spleen-Qi deficiency and Dampness, Huo Po Xia Ling Tang should be used when the Dampness is primary to the Spleen deficiency. If the Spleen deficiency is primary to the Dampness, then Liu Jun Zi Tang is appropriate. HUO PO XIA LING TANG

IN A NUTSHELL: resolve Dampness.

Swollen, thick-sticky- Swollen, thick-sticky-white white coating coating LIAN PO YIN (Ease the Muscles)

Patterns: Damp-Heat in the Middle Burner

Digestive symptoms: a feeling of fullness of the epigastrium, a sticky or bitter taste, poor appetite, loose stools

Tongue: Red or slightly red with a sticky-yellow coating. Even if the tongue is not red, the presence of a sticky-yellow coating is an essential sign for the prescription of this formula.

Explanation: this formula can be used in all cases when the condition is characterised predominantly by retention of Damp-Heat. It is appropriate only when the Excess aspect predominates over the deficiency.

Note: Ease the Muscles differs from Drain Fields in that it resolves the condition of Damp-Heat, as opposed to just Dampness. LIAN PO YIN

IN A NUTSHELL: resolve Damp-Heat from the Middle Burner and from the space between the skin and muscles.

Red, sticky-yellow-dry Red sides, sticky-yellow coating coating MIDDLE BURNER DIGESTIVE REMEDIES

Prosperous Earth Central Mansion Central Mansion Liu Jun Zi Tang Shen Ling Bai Zhu San Shen Ling Bai Zhu San

Central Mansion Soothe the Centre Jade Spring Shen Ling Bai Zhu San Xiang Sha Liu Jun Zi Tang Sha Shen Mai Dong Tang MIDDLE BURNER DIGESTIVE REMEDIES - DAMPNESS

Drain Fields Ease the Muscles Ease the Muscles Huo Po Xia Ling Tang Lian Po Yin Lian Po Yin PROGRESSION FROM STOMACH-QI XU TO STOMACH-YIN XU

Pale=Spleen-Qi Xu Pale, rootless coating, Normal colour, no partially peeled=Stomach- coating=Stomach-Yin Qi and Yin Xu Xu

Normal colour, no Red, no Red, no coating=Stomach- coating=Stomach-Yin Xu coating=Stomach-Yin Yin Xu with Empty Heat Xu, Empty Heat Qi deficiency Qi and Yin deficiency Yin deficiency

PROSPEROUS EARTH CENTRAL MANSION JADE SPRING Liu Jun Zi Tang Shen Ling Bai Zhu San Sha Shen Mai Dong Tang PATTERN Spleen-Qi Xu Spleen-Qi and Yin Xu, Stomach-Yin Xu, Stomach-Qi and Yin Xu, some Empty Heat Dampness SYMPTOMS Tiredness, poor Tiredness, poor appetite, Tiredness, poor appetite, loose stools loose stools, slight appetite, dry stools, epigastric pain, dry dry mouth, slight mouth, dry stools epigastric pain, feeling of heat PULSE Empty of Weak Weak or Floating-Empty Floating-Empty

TONGUE Pale Pale or normal, dry, Normal or slightly rootless coating red, no coating, St cracks PATIENTS’ STATISTICS

I have compiled a statistics of 110 patients suffering from abdominal pain in my practice. There were 94 women (85%) and 16 men (15%): this shows that women are far more prone to stagnation in the Lower Burner than men.

The age distribution was as follows:

Age No % 0 to 10 1 1% 11 to 20 9 8% 21 to 30 17 15% 31 to 40 30 27% 41 to 50 26 24% 51 to 60 16 15% 61 to 70 9 8% 71 to 80 0 0% 81 to 90 2 2% The highest incidence of abdominal pain is therefore in the 31-50 bracket. This is probably a reflection of the main aetiological factors of abdominal pain, i.e. emotional stress and irregular diet.

- Empty: 9 patients (8%). - Full: 26 patients (24%). - Mixed Full and Empty: 75 patients (68%).

An interesting observation emerges from the above breakdown and that is the very small number of patients (8%) in whom abdominal pain was due to a purely Empty condition. By contrast, in 24% of patients, abdominal pain was due to a purely Full condition.

In terms of patterns, the breakdown was as follows:

- Dampness: 38 patients (35%). (Of these, 22 patients had Damp- Heat). - Liver-Qi stagnation: 42 patients (38%). - Kidney deficiency: 40 patients (36%). - Spleen-Qi deficiency: 41 patients (37%). The above statistics confirm my clinical impression about the main patterns seen in abdominal pain: these are in my opinion Liver-Qi stagnation, Dampness and Spleen deficiency. Perhaps the surprising factor in the above breakdown is the high percentage of patients suffering from a Kidney deficiency (36%).

With regard to tongue diagnosis, the breakdown of patients according to tongue-body colour was as follows:

- Red: 47 patients (43%). - Pale: 37 patients (34%). - Purple (Pale-Purple): 9 patients (8%).

The high incidence of Red tongue is due to the prevalence of Heat in general and Damp Heat in particular. Also, in severe Liver-Qi stagnation, the tongue may become Red.

The incidence of Pale tongue ties in almost exactly with the incidence of Spleen deficiency.

Please note that the total number of patients does not add to 110 nor do the percentages add to 100 because each patient may suffer from more than one pattern, e.g. Liver-Qi stagnation and Spleen deficiency. Therefore each patient may appear more than once in the above breakdown. CONSTIPATION

No sail: No wind: No water: Qi or Yang Xu Qi stagnation Blood or Yin deficiency

Kidney-Yang Xu Liver-Qi stagnation Blood Xu (women) Yin Xu (elderly) Stomach In two ways: Stomach-Qi descends and helps movement of stools. Stomach is origin of fluids and deficiency may cause constipation.

Large Intestine The Large Intestine receives fluids from the Small Intestine, reabsorbs some fluids and excretes stools.

Spleen Although Spleen-Qi ascends, it also controls yun hua and deficient Spleen-Qi may fail to move the stools.

Liver Liver-Qi affects the Intestines and moves the stools.

Kidneys Affect constipation in two ways. Deficient Kidney-Yang may fail to move the stools. Deficient Kidney-Yin causes dryness in the Intestines.

Lungs Lungs controls Qi and related to the Large Intestine. Deficient Lung- Qi may fail to descend to the Large Intestine and cause constipation (usually in the elderly). General points: ST-25 Tianshu, SP-15 Daheng, BL-25 Dachangshu, ST-37 Shangjuxu, Ren-10 Xiawan, ST-27 Daju, Ren-6 Qihai.

Kidney-Yang Xu: BL-23 Shenshu, Ren-4 Guanyuan, BL-25 Dachangshu.

Liver-Qi stagnation: LIV-3 Taichong, Ren-6 Qihai, SP-15 Daheng, BL-18 Ganshu.

Blood Xu: Ren-4 Guanyuan, ST-36 Zusanli, SP-6 Sanyinjiao, LIV-8 Ququan.

Yin Xu: Ren-4 Guanyuan, KI-3 Taixi, SP-6 Sanyinjiao. ULCERATIVE COLITIS

Ulcerative colitis is an inflammatory bowel disease that affects the lining of the large intestine and rectum. Crohn's disease is a related condition.

The cause of ulcerative colitis is unknown. People with this condition have an autoimmune disease, but it is not clear whether immune problems cause this illness.

Ulcerative colitis may affect any age group, although there are peaks at ages 15 - 30 and then again at ages 50 - 70.

The disease can begin in the rectal area, and may involve the entire large intestine over time. It may also start in the rectum and other parts of the large intestine at the same time.

Risk factors include a family history of ulcerative colitis, or Jewish ancestry. Symptoms The symptoms vary in severity and may start slowly or suddenly. About half the patients only have mild symptoms. Others have more severe attacks that occur more often. Many factors can lead to attacks, including respiratory infections or physical stress.

Symptoms include:

• Abdominal pain and cramping

• Abdominal sounds (gurgling or splashing)

• Blood and mucus in the stools

• Diarrhea, from only a few episodes to very often

• Fever

• Tenesmus (rectal pain)

• Weight loss

• Children's growth may slow.

ULCERATIVE COLITIS IN CHINESE MEDICINE

Obviously, there is no category of “ulcerative colitis” in the original texts. In Chinese medicine, ulcerative colitis might correspond to various categories of disease:

Dysentery 痢疾 Diarrhoea 泄泻 Blood in the stools 便血 Intestinal Wind 肠风 Intestinal Pi masses 肠癖 PATHOLOGY

Deficiency of Stomach and Spleen A deficiency of Stomach and Spleen is practically always a factor in the development of UC. Spleen deficiency itself may be a cause of the diarrhoea. Spleen deficiency may also cause bleeding.

Dampness (Damp-Heat) In my experience, in UC there is always Dampness and especially Damp-Heat. Dampness obstructs the Intestines and may also cause diarrhoea by itself.

Qi stagnation Qi stagnation is also nearly always present in UC. It causes borborygmi and distension.

Blood stasis Blood stasis may develop from Qi stagnation and it causes intense pain.

Toxic Heat Toxic Heat may develop from Damp-Heat and it is present in acute cases or in flare-ups of chronic cases.

Blood Heat Blood Heat may also develop from Damp-Heat and it causes bleeding. SPLEEN-QI XU DAMPNESS DAMP-HEAT

LIVER-HEAT BLOOD- TOXIC- HEAT HEAT LIVER-QI STAGNATION

LIVER- BLOOD STASIS ACUPUNCTURE

Essential points for ulcerative colitis ST-25 Tianshu . . BL-25 Dachangshu ST-37 Shangjuxu ST-39 Xiajuxu . .. . Points for Damp-Heat Upper Burner: LI-6 Pianli Middle Burner: Ren-9 Shuifen, Ren-12 Zhongwan Lower Burner: ST-28 Shuidao, Ren-5 Shimen, BL-22 Sanjiaoshu, SP-9 Yinlingquan, SP-6 Sanyinjiao.

Please note that, to treat Dampness, must use points from all three Burners Points for Blood stasis SP-4 Gongsun and P-6 Neiguan (Chong Mai), KI-14 Siman, ST-29 Guilai, ST-30 Qichong, SP-10 Xuehai, BL-17 Geshu, LIV-3 Taichong.

Points to tonify Stomach and Spleen Ren-12 Zhongwan, BL-20 Pishu, BL-21 Weishu, ST-36 Zusanli.

Points for Toxic Heat (in addition to Damp-Heat points) LI-11 Quchi, P-3 Quze, P-8 Laogong, LIV-2 Xingjian. IDENTIFICATION OF PATTERNS AND TREATMENT

1) DAMP HEAT Chronic condition, abdominal pain, foul-smelling diarrhoea with mucus and blood, pain alleviated by defecation, tenesmus, borborygmi, rectal pain and burning in anus, possibly fever, thirst, irritability, scanty-dark urine. Tongue: red with thick-sticky-yellow coating. Pulse: Rapid-Slippery.

Treatment principle Clear Heat, resolve Dampness, cool Blood, stop diarrhoea.

Prescription Ge Gen Qin Lian Tang Pueraria-Scutellaria-Coptis Decoction

Ge Gen Radix Puerariae Huang Lian Radix Coptis Huang Qin Radix Scutellariae Gan Cao Radix Glycyrrhizae

Note: can use also variations of Bai Tou Wen Tang 2) STOMACH AND SPLEEN DEFICIENCY Chronic condition, chronic diarrhoea with mucus that may be mixed with blood, dull abdominal pain that is aggravated by diarrhoea, tiredness, poor appetite, abdominal distension, desire to lie down. Tongue: Pale. Pulse: Weak.

Treatment principle Tonify Stomach and Spleen, resolve Dampness, stop diarrhoea.

Prescription Xiang Sha Liu Jun Zi Tang Aucklandia-Amomum Six Gentlemen Decoction

Mu Xiang Radix Aucklandiae Sha Ren Fructus Amomi Dang Shen Radix Codonopsis Bai Zhu Radix Atractylodis Fu Ling Poria Chen Pi Pericarpium Citri reticulatae Ban Xia Rhizoma Pinelliae preparatum Zhi Gan Cao Radix Glycyrrhizae preparatum

3) TOXIC HEAT Acute episode or re-activation of chronic disease, severe abdominal pain, diarrhoea with mucus and blood, pain alleviated by defecation, tenesmus, possibly fever, thirst, irritability. Tongue: red with thick-yellow coating, red points. Pulse: Rapid-Wiry-Overflowing.

Treatment principle Clear Heat, resolve Toxin, cool Blood, stop diarrhoea.

Prescription Bai Tou Weng Tang Pulsatilla Decoction

Bai Tou Weng Radix Pulsatillae Huang Lian Radix Coptis Huang Bo Cortex Phellodendri Qin Pi Cortex Fraxini 4) BLOOD STASIS Chronic condition, chronic diarrhoea, small amount of mucus in stools, dark stools, stabbing abdominal pain, dark complexion, dark rings under eyes. Tongue: Purple. Pulse: Wiry both Chi, Firm in general or Choppy in general.

Treatment principle Move Qi, invigorate Blood, resolve Dampness.

Prescription Shao Fu Zhu Yu Tang Dispelling Stasis in the Lower Abdomen Decoction

Dang Gui Radix Angelicae Pu Huang Pollen Typhae Chi Shao Radix Paeoniae rubra Wu Ling Zhi Excrementuym Trogopterii Mo Yao Resina Commiphorae Myrrhae Rou Gui Cortex Cinnamomi cassiae Chuan Xiong Radix Chuanxiong Yan Hu Suo Rhizoma Corydalis Xiao Hui Xiang Fructus Foeniculi Gan Jiang Rhizoma Zingiberis Prescription Ge Xia Zhu Yu Tang Dispelling Stasis below the Diaphragm Decoction

Dang Gui Radix Angelicae Chi Shao Radix Paeoniae rubra Wu Ling Zhi Excrementuym Trogopterii Chuan Xiong Radix Chuanxiong Yan Hu Suo Rhizoma Corydalis Tao Ren Semen Persicae Hong Hua Flos Carthami Wu Yao Radix Linderae Mu Dan Pi Cortex Moutan Zhi Ke Fructus Aurantii Xiang Fu Rhizoma Cyperi Gan Cao Radix Glycyrrhizae HERBS FOR MODIFICATIONS

Astringent, stop diarrhoea

Qian Shi Semen Euryales ferocis Pao Jiang Rhizoma Zingiberis officinalis preparatum He Zi Fructus Terminaliae chelubae

NOTE: using astringent herbs to stop diarrhoea is not advisable in acute inflammation with diarrhoea, mucus and blood: this is treated by clearing Heat and resolving Dampness. Astringing can be used when we are treating the Root, i.e. tonifying the Spleen.

Treating diarrhoea by purgation

Da Huang Radix et Rhizoma Rhei Ma Chi Xian Herba Portulacae oleraceae Hu Zhang Radix et Rhizoma Polygoni cuspidati

NOTE: this method is used for acute inflammation with mucus and blood and with tenesmus. Stopping bleeding

Xian He Cao Herba Agrimoniae San Qi Radix Notoginseng (also stop bleeding) Qian Cao Gen Radix Rubiae cordifoliae (also stop bleeding) Di Yu Radix Sanguisorbae (also stop bleeding)

NOTE: the method of stopping bleeding is particularly applied when there is more blood than mucus. In order to stop bleeding must always treat the Root, i.e. clearing Heat, cooling Blood, draining Dampness and stopping bleeding or tonifying Qi. Which means that there must be also herbs that clear Heat such Huang Qin or Huang Lian. FORMULAE

Bai Tou Weng Tang Pulsatilla Decoction (Damp-Heat)

Bai Tou Weng Radix Pulsatillae Huang Lian Radix Coptis Huang Bo Cortex Phellodendri Qin Pi Cortex Fraxini

Tong Xie Yao Fang Important Formula for Painful Diarrhoea (Liver-Qi invading the Spleen, Dampness)

Bai Zhu Radix Atractylodis Bai Shao Radix paeoniae alba Chen Pi Pericarpium Citri reticulatae Fang Feng Radix Saposhnikoviae Shen Ling Bai Zhu San Ginseng-Poria-Atractylodes Powder (Qi and Yin Xu of Stomach and Spleen) Ren Shen Radix Ginseng Bai Zhu Radix Atractylodis Fu Ling Poria Shan Yao Rhizoma Dioscoreae Lian Zi Semen Nelumbinis Bai Bian Dou Semen Lablab album Yi Yi Ren Semen Coicis Sha Ren Fructus Amomi Jie Geng Radix Platycodonis Gan Cao Radix Glycyrrhizae

Ge Xia Zhu Yu Tang Dispelling Stasis below the Diaphragm Decoction (Blood stasis) Dang Gui Radix Angelicae Hong Hua Flos Carthami Chi Shao Radix Paeoniae rubra Tao Ren Semen Persicae Wu Ling Zhi Excrementuym Trogopterii Mu Dan Pi Cortex Moutan Chuan Xiong Radix Chuanxiong Zhi Ke Fructus Aurantii Yan Hu Suo Rhizoma Corydalis Xiang Fu Rhizoma Cyperi Gan Cao Radix Glycyrrhizae Wu Yao Radix Linderae Gen Gen Huang Qin Huang Lian Tang Pueraria-Scutellaria- Coptis Decoction (Damp-Heat)

Ge Gen Radix Puerariae Huang Qin Radix Scutellariae Huang Lian Radix Coptis Zhi Gan Cao Radix Glycyrrhizae

Shao Yao Tang Paeonia Decoction (Damp-Heat)

Huang Lian Radix Coptis Huang Qin Radix Scutellariae Da Huang Radix et Rhizoma Rhei Dang Gui Radix Angelicae sinensis Bai Shao Radix Paeoniae alba Gan Cao Radix Glycyrrhizae Mu Xiang Radix Aucklandiae Bing Lang Semen Arecae Rou Gui Cortex Cinnamomi EXAMPLE OF FORMULA FOR UC FROM DAMP-HEAT WITH BLEEDING

Bai Tou Weng Tang Pulsatilla Decoction 1) Treat Root Clear Heat, drain Bai Tou Weng Radix Pulsatillae Dampness. cool Blood Huang Lian Radix Coptis Huang Bo Cortex Phellodendri Qin Pi Cortex Fraxini 2) Harmonize Blood Dang Gui Radix Angelicae sinensis a) Stop bleeding Bai Shao Radix Paeoniae alba b) Nourish Blood Di Yu Radix Sanguisorbae c) Calm Blood Mu Dan Pi Cortex Moutan d) Invigorate Blood Huang Qi Radix Astragali

3) Astringe

4) Treat Qi

EXAMPLE OF FORMULA FOR UC FROM DAMP-HEAT WITH BLEEDING Li Zheng Quan, Practical Study of Stomach and Spleen in Chinese Medicine Shi Yong Zhong Yi Pi Wei Xue, Chongqing Publishing House, Chongqing, 1992, p. 582.

1) Treat Root Huang Bo Cortex Phellodendri Clear Heat, drain Huang Lian Radix Coptis Dampness. cool Blood Di Yu Radix Sanguisorbae Huai Hua Flos Sophorae Bai Tou Weng Radix Pulsatillae 2) Harmonize Blood Bai Shao Radix Paeoniae alba a) Stop bleeding Mu Dan Pi Cortex Moutan b) Nourish Blood Mu Xiang Radix Aucklandiae c) Calm Blood Xian He Cao Herba Agrimoniae d) Invigorate Blood Gan Cao Radix Glyryrrhizae

3) Astringe

4) Treat Qi

ASSOCIATION OF STOMACH AND LARGE INTESTINE IN DIGESTIVE PATHOLOGY

A pathology of the Stomach is very often associated with the same pathology in the Large Intestine. This happens especially with Yin Xu and Dampness. This is because the Stomach and Large Intestine are connected through the Yang Ming

STOMACH

YANG MING

LARGE INTESTINE CLASSICAL ANTECEDENTS CORRESPONDENTS

PROSPEROUS EARTH Liu Jun Zi Tang

CENTRAL MANSION Shen Ling Bai Zhu San

SOOTHE THE CENTRE Xiang Sha Liu Jun Zi Tang

HARMONIZE THE CENTRE Shen Ling Bai Zhu San

JADE SPRING Sha Shen Mai Dong Tang

DRAIN FIELDS Huo Po Xia Ling Tang

EASE THE MUSCLES Lian Po Yin

RED STIRRING Xue Fu Zhu Yu Tang CLASSICAL ANTECEDENTS CORRESPONDENTS

BREAK INTO A SMILE Chai Hu Shu Gan Tang

CLEAR THE SOUL Wen Dan Tang

STIR FIELD OF ELIXIR Ge Xia Zhu Yu Tang

BREAKING CLOUDS Bu Zhong Yi Qi Tang

STRENGTHEN THE ROOT You Gui Wan

Thank you for attending this online course with Giovanni. Giovanni also has several online CEU courses available, make sure you take this opportunity to visit his websites after attending the webinar to see all of the resources he has to offer.

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