中医药治疗慢性胃炎的临床体会 谢天佐 陈永祥
Clinical Experiences Using Chinese Medicine to Treat Chronic Gastritis Xie Tian-zuo Chen Yong-xiang
Translated by: J. Heaverlo & Xu Zhijun
Abstract: This thesis studies the disease causes and pathomechanisms of chronic gastritis. It explores the methods of diagnosing and treating chronic gastritis with Chinese medicine, and cites clinical cases for its support. It is intended to prove that beneficial results can be achieved by using a combination of clinical methods such as fortifying the spleen and harmonizing the stomach, and simultaneous supplementing and attacking.
Key words: Gastritis, Chronic: Chinese medicine; Treatment
Chronic gastritis is a common disease of the digestive system. According to Tang Xiao-qun, essentially, repeated lesions of the gastric mucosa will lead to the atrophy of the glands. It can be classified as an inflammatory condition of the gastric mucosa and may be due to various causes. Many patients don’t experience early symptoms, or may present with varying symptoms of indigestion such as: epigastric pain or discomfort, abdominal distention, belching, acid regurgitation, or poor appetite. It is not until the middle stages of the disease will more obvious clinical manifestations appear. This disease has to be diagnosed by gastroscopy; and if necessary, a biopsy will be performed. In Chinese medicine there is not a disease name for “chronic gastritis. According to its clinical manifestations, it is classified within the patterns of: “stomach duct disease”，“glomus and fullness”, “acid swallowing”, and “vomiting”.
1. Understanding the disease causes and pathomechanisms
The clinical manifestations of chronic gastritis may vary and they include: stomachache, distention and fullness, acid swallowing, glomus and fullness, and belching. The causes and pathomechanisms are very complicated. It may arise from: affect-mind inhibition and depressed anger damaging the liver; thereby, the liver-wood cannot freely course spleen-earth; dietary irregularities and excessive drinking of liquor; so that the spleen and stomach are damaged directly; or from constitutional insufficiency and invasion of external evil. Relevant descriptions can be found within the documents of past dynasties. For example, in “Magic Pivot ·Explanation of the Use of Small Needles”, it says, “Excessive cold or warmth, or unclean food may lead to the diseases of the intestines and stomach.” In “Plain Questions ·Great Treatise on the Regular Principles of the Six Origins”, it says, “Depressed wood…will lead to the disease of the stomach duct with heart pains. The throat is blocked and unable to pass food.” In “Jing Yue’s Complete Compendium ·Heart and Abdomen Pain”, it says, “The symptoms of stomach duct pain may be due to diet irregularities, cold, or Qi stagntion.” Li dong-yuan points out in his treatise “On the Spleen and Stomach”, “unclean foods lead to stomach disease, physical taxation leads to spleen disease.” In “Miscellaneous Diseases·Chest Impediment and Heart Pain”, it says, “Excessive food intake, and the inability to digest, will harm the stomach duct. If this condition lasts for a long time, pain will arise even with a slightly irregular diet.”
There are various causes and complicated pathomechanisms with chronic gastritis; however, there are some basic principles of pathogenesis and treatment. For example, in “The Yellow Emperor’s Inner Classic”, it relates, “If the upright Qi is internally maintained, then evil cannot invade.” And, “if evil enters the body, the Qi must be vacuous”. In “ Essential Prescriptions of the Golden Coffer”, it says, “If the true origin of the viscera is unobstructed, the body will be healthy and harmonious”, “evil cannot invade if the spleen is vigorous during the four seasons of the year. Based on these theories and clinical cases, most scholars believe the root cause of chronic gastritis is a vacuity-repletion complex and spleen-stomach vacuity; whereas, the branch is the evil Qi invading the stomach.
Up until now Chinese medicine does not have a standardized treatment for chronic gastritis. What Chinese medicine emphasizes is to assess the patterns and seek the cause to determine the treatment. If it is due to exuberant evil Qi, the treatment should focus on dispelling evil Qi; if it is due to upright Qi vacuity, the focus will be on nourishing the stomach; if it is vacuity-repletion complex, both the root and branch should be treated by using supplementing and dispersion methods. The writer believes that in order to achieve good clinical effects, the following combined treatment methods should be utilized: fortify the spleen and harmonize the stomach with simultaneous supplementing and dispersion methods, regulate and open the liver Qi. Treatment should be a combination of acupuncture and herbal medicine.
2.1 Fortify the spleen and harmonize the stomach using both supplementing and dispersion methods
The spleen and stomach are the root of latter heaven. If their function is exuberant, the upright Qi is easy to recover and disease will easily be cured. As Li Dong-yuan says, “good doctors emphasize the regulation of the spleen and stomach”. Professor Li Pei attaches great importance to fortifying the spleen while treating chronic gastritis. According to him, if the spleen is fortified, the stomach will be calm. In “Plain Questions·Great Treatise on the Correspondences and Manifestations of Yin and Yang”, it says, “To treat disease, it is necessary to seek the root”. Chronic gastritis, in most cases, is due to spleen-stomach vacuity, but very few are due to vacuity alone. More often, the symptoms are combined with some form of repletion evil. It may be Qi stagnation, blood stasis, damp-heat, etc. Therefore, in clinical treatment, the focus should be to treat the root by fortifying the spleen and stomach. At the same time, the branches should also be treated in accordance with the presenting disease evil, such as regulating the Qi, quickening the blood, clearing the heat, etc.
案 赵某，女，56岁，退休干部，2007年7月9日初诊。患者胃脘部痞满不适，隐隐作痛3 年余，2006年11月曾作纤维胃镜检查，提示为慢性萎缩性胃炎，间断服枸橼酸铋胶囊、胃必治等药，无明显疗效。1周前因操劳过度，胃脘部痞满不适加重，时有烧灼样痛，以解痉药治疗，疼痛虽明显减轻但胃脘部痞满仍在，其他症状也无明显改善。就诊时患者胃脘部痞满不适，时轻时重，隐隐作痛，不思饮食，倦怠乏力，气短懒言，大便溏泄，舌质淡，苔薄白，脉沉弱，轻度贫血貌，心肺无异常，腹软无抵抗及压痛，肝脾未触及，肾区无叩击痛，心电图，大便常规及B型超声波检查无异常，血常规显示血红蛋白 92 g/L，白细胞 4.8×109/L，中性粒细胞 0.65，淋巴细胞 0.35，纤维胃镜检查提示慢性萎缩性胃炎。西医诊断为慢性萎缩性胃炎，中医诊断为痞证，证属脾胃气虚型。治以健脾益气，和胃消胀。方选香砂六君子汤加减。
Female, 56 years old. Her first visit to the hospital was July 9, 2007. The patient complained of glomus, fullness, discomfort and dull pain in the stomach duct. This symptom had continued for more than 3 years. It was diagnosed as chronic atrophic gastritis after a stomach fiber endoscopy in November, 2006. She had been continuously taking potassium citrate capsules and gentamycin sulfate injections but without clear results. One week before the first visit, her condition worsened due to overwork: she experienced increased sensations of glomus, fullness and discomfort in the stomach duct. At times, she experienced scorching pain. After taking spasmolytics, the pain was greatly alleviated but the glomus remained. Other symptoms showed no improvement. At the time of examination, she continued to experience intermittent feelings of glomus, fullness and discomfort, and dull pain in the stomach duct. She had no desire for food or drink. She felt tired and a lack of strength. She was short of breath and no interest in speaking. She had sloppy diarrhea. The tongue was pale and the tongue coating was thin and white. The pulses were sunken and weak. She had slight anemia. The heart and lungs were normal. The abdomen was soft and did not feel pain under pressure. The liver and spleen were not palpated. The kidney area showed no tenderness with applied tapping. Electrocardiogram, stool, and B-type ultrasonic examinations were all normal. Hemoglobin was 92 g/L, leucocyte count was 4.8×109/L，neutrophil count 0.65, and lymphocytes were 0.35. According to western medicine, following an endoscopy, her symptoms were diagnosed as chronic gastritis. According to Chinese medicine, this was diagnosed as spleen-stomach Qi vacuity. The treatment should be to fortify the spleen, boost the Qi, harmonize the stomach and disperse distension. The formula was Costusroot and Amomum Six Gentlemen Decoction (with additions and subtractions).
处方： 党参15g, 白术15g，茯苓15g，砂仁10g，甘草6g，大枣6枚，神曲10g，麦芽10g， 山药15g，陈皮10g，蒲公英15g，佛手10g，丹参10g。水煎分早晚温服，1剂/d。嘱患者调饮食、畅情志、勿劳累。守方加减4周，患者自觉症状消失，精神饮食均佳。将上方制成胶囊，2粒/d, 3次/d，连服3个月以巩固疗效。停药后随访半年，胃病未复发。
Formula: codonopsis (dang shen) 15g, white atractylodes (bai zhu)15g, poria (fu ling) 15g, amomum (sha ren) 10g, licorice (gan cao) 6g, jujube (da zao) 6 pieces, medicated leaven (shen qu) 10g, barley sprout (mai ya) 10g, dioscorea (shan yao) 15g, tangerine peel (chen pi) 10g, dandelion (pu gong ying) 15g, Buddha’s hand (fo shou) 10g, salvia (dan shen) 10g. To be taken warm in the morning and evening. One formulation a day.
The patient was instructed to regulate food and drink, smooth the affect-mind, and not to overwork. After using a modified version of this formula for 4 weeks, the patient felt the symptoms disappeared and reported improvement in both spirit and diet. The patient was advised to continue taking the prescription in capsule form at a dosage of 2 capsules three times per day. This was repeated for 3 months to secure the effect of the treatment. After 3 months the gastritis had not returned.
按 本方取四君子汤之义加减，注意补益脾胃，并配理气活血之品，诸药合用，共奏健脾益胃， 攻补兼施之效，使补而不滞，正气恢复，邪去而疾病痊愈。较好地体现了健脾和胃攻补兼施在治疗慢性胃炎中的应用。
Note: The formula utilizes a modified Four Gentlemen Decoction. The emphasis is on supplementing and boosting the spleen and stomach. With the additional herbs, it can also regulate the Qi and quicken the blood. This formula can fortify the spleen, boost the stomach, and simultaneously supplement and attack. It supplements without causing stagnation. It recovers the upright Qi while dispelling evil in order to effectively treat the disease.
• Chronic gastritis and its relationship with the liver
Although chronic gastritis is located in the central burner, it’s predominant relationship is with the liver Qi. This combination forms an imbalance of the liver, spleen and stomach. Clinically, the liver Qi should be regulated, even without the symptom of liver depression. In treatment, liver-coursing medicinals can be added to course the liver Qi, and unimpede the central Qi, in order to recover the function of the spleen-stomach . According to Liu Jing-long and Zhao Rui-hua, beneficial effects can be achieved when treating chronic gastritis with the method of coursing the spleen and harmonizing the stomach. The liver belongs to wood, which governs free coursing and orderly reaching. The spleen and stomach belong to earth, which governs movement, transformation and intake. The relationship between the liver and spleen-stomach is that of wood and earth. The normal free coursing and orderly reaching is beneficial to the absorption and digestion of the spleen-stomach. This is what is referred to as “wood courses earth”. This not only can assist the movement and transformation of the spleen, upbear clear Yang, and deliver the essence of grain and water up to the lungs; but, it also may assist the stomach decomposition intake, downbear the turbid Yin, and deliver the chyme down to the intestines.
Female, 57 years old. Her first visit to the hospital was on July 23, 2007. The patient had suffered from gastric distention and fullness repeatedly for two years. It was worsened with anger and especially after dinner. This symptom was also accompanied with belching, acid swallowing, bitter taste, and poor appetite. After multiple treatments there was no improvement in the symptoms. The patient had a withered-yellow facial complexion; her tongue was pale red; the tongue fur was thin and white; and the pulse was stringlike. Gastroscopy indicates that her condition is chronic superficial gastritis. Helicobacter pylori was positive. According to Chinese medicine, this was diagnosed as stomach duct pain due to liver and stomach Qi stagnation. The treatment should focus on coursing the liver, harmonizing the stomach, regulating the Qi and relieving the pain. Chai Hu Liver-Soothing Powder was adopted with abductions and subtractions.
处方: 柴胡10g，川芎10g，香附10g，白芍15g，赤芍10g，陈皮10g，枳壳6g，旋覆花10g，神曲15g，麦芽10g，半夏10g，甘草9g。水煎分服，1剂/d。嘱患者调饮食，畅情志，勿劳累。治疗3个疗程后，诸症消失，胃镜提示：未见异常， HP(-)。随访半年未见复发。
Formula: bupleurum (chai hu) 10g, chuan xiong rhizome (chuang xiong) 10g, cyperus (xiang fu) 10g, white peony (bai shao) 15g, red peony (chi shao) 10g, tangerine peel (chen pi) 10g, bitter orange (zhi ke) 6 g, inula flower (xuan fu hua) 10g, medicated leaven (shen qu) 15g, barley sprout (mai ya) 10g, pinellia (ban xia) 10g, licorice (gan cao) 9g. Take one formula twice a day. The patient was instructed to regulate food and drink, smooth the affect-mind, and not to overwork. After three courses of treatment all of the symptoms disappeared. Gastroscopy indicated no abnormalities. HP was negative.
Note: Chai Hu Liver-Soothing Powder can soothe the liver, resolve depression, disperse food, harmonize the center, regulate the Qi and relieve pain. This case study illustrates that by regulating the liver, the dynamic of the whole body becomes unblocked and the function of the spleen-stomach return to normal.
• 针药结合 内外同治
• Combination of Acupuncture and herbal medicine and the simultaneous treatment of internal and external
Acupuncture is an external method of treatment which works on stomach disease through acupoints and network vessels. Chinese herbal medicine is an internal method of treatment which regulates the stomach directly. Increased results can be achieved by combing these two methods. However, according to Rao Yan, beneficial results may also be achieved by utilizing acupuncture as a single treatment method. Immune functions may be improved by regulating the nervous system. According to Tong Chun-quan, in treating peptic ulcer, it is safer to utilize “threaded acupuncture” which is capable of achieving longer lasting effects. Clinically, it is important to make the correct diagnosis and implement the appropriate method of treatment.
Female, 42 years old. The patient’s initial visit was on September 11, 2007. She had suffered from stomach problems for three years. Three years prior, due to dietary irregularities and camping in the rain, she began to feel distention and oppression in the stomach duct and abdomen. She experienced frequent attacks of dull pain. She had thin stools and fatigued limbs. The previous year, her condition was diagnosed as chronic superficial gastritis with a gastroscopy exam. She took ranitidine, domperidone, potassium citrate capsules, gentamycin sulfate injections without obvious effects. The following symptoms were present at the time of examination: dull pain in the stomach duct which is improved with pressure, distention and oppression in the stomach duct, belching, sloppy stool, frequent sensations of nausea and vomiting, lusterless facial complexion, and cold limbs. The tongue was pale and the tongue coating was white. The pulse was fine and sunken. The Chinese medicine diagnois was stomach duct pain due to spleen-stomach vacuity cold. The treatment focus is to warm the Yang, dispel cold, dry dampness and fortify the spleen. Aconite Center-Rectifying Pill was prescribed, combined with acupuncture. The patient was advised to take 6g of Aconite Center-Rectifying Pill twice a day, mornings and evenings. She was further directed to regulate food and drink, smooth the affect-mind, and not to overwork. The acupoints used were: Leg Three Miles (ST-36, Zu San Li), Central Stomach Duct (CV-12, Zhong wan), Camphorwood Gate (LV-13, Zhang men), and Pass Head (CV-4, Guan yuan). The primary method of acupuncture was supplementation, and was performed once per day. One course of treatment consisted of seven treatments. After three courses of treatment , the stomach duct pain disappeared, the stool was normal, the oppression in the spleen was alleviated, the facial complexion turned moist, and the patient was full of vigor. Three more courses of treatment were added to secure the treatment. On January 6, 2008, a follow up gastroscopy exam showed no abnormalities were found in the upper gastrointestinal tract.
In the formula of Aconite Center-Rectifying Pill, dried ginger (gan jiang) and aconite (fu zi) can warm the center and dispel cold to assist the Yang. White atractylodes (Bai zhu) can fortify the spleen and dry dampness. Ginseng (Ren shen) can greatly supplement the original Qi of the body so as to aid movement and transformation. Licorice (Gan cao) can harmonize the center and boost the Qi. In this formula, the cold in the middle burner is dispelled by warm medicinals, the vacuity pattern is treated with warm and sweet medicinals. When the clear Yang upbears and the turbid Yin downbears, movement and transformation is strengthened, thereby, harmonizing the middle burner. In addition, Pass Head (CV-4, Guan Yuan) is the gathering point of the original Qi, Central Stomach Duct (CV-12, Zhong wan) and Camphorwood Gate (LV-13, zhang men) are the front-mu points of the spleen and stomach, Leg Three Miles (ST-36, Zu san li) is the uniting point of the foot Yang brightness. Needling these points will have a strong effect on the overall health of the body. Acupuncture and herbal medicine are used in combination to warm and supplement without stagnating, and to move the Qi without dispersing; thereby, the Yang Qi of the spleen-stomach can be recovered and cold-damp can be dispelled. By treating both the root and branch, the upright Qi can be recovered and evil eliminated. Furthermore, according to Li Yan, Aconite Center-Rectifying can also treat functional indigestion leading to chronic gastritis.
According to the New Sydney System, chronic gastritis is classified as: superficial gastritis, atrophic gastritis and special type gastritis. Nowadays, it is commonly agreed that the main cause of chronic gastritis is Helicobacter pylori. In treatment, Western medicine generally adopts a triple therapy method to root out helicobacter pylori. Other medicinals are added to improve the digestive system, such as gastrointestinal drugs and antacids. This works to some extent, but it’s hard to achieve ideal effects because the course of treatment is long, and the symptoms may relapse again and again. Chinese medicine has a unique advantage in treating chronic gastritis. Under the guidance of basic Chinese medicine theory and the practice of identifying patterns to determine treatment, satisfactory effects can be achieved. The root treatment is to protect the stomach Qi; and the branch treatment is to eliminate causitive disease factors. In addition, once the condition is under control, it is important to prevent relapse by keeping in mind, the patient is still in a period of recovery and the function of the stomach is still not completely recovered.
According to Jia Feng-yun, the onset of chronic gastritis is closely related with the affect-mind and diet. According to Yin Yan, it is very important to pay close attention to the diet and health care after treatment. The measures to prevent the relapse should be comprehensive: regulating diet, daily life, physical activity and the mental spirit; the patient should also be careful not to take substances that are harmful to the gastric mucosa. Medicinal food may also beneficial to improve the function of the spleen and stomach and help recover the function of the internal organs. Chinese medicine has a significant effect in treating chronic gastritis with fewer side effects, and for some, may be economically more viable. Therefore, it is widely accepted by patients and has a broad perspective in it’s clinical application.