A Brief Discussion on Liver Cirrhosis

A Brief Discussion on Liver Cirrhosis Pei Zhengxue All types of liver damage can ultimately lead to the development of liver cirrhosis. Among them, hepatitis caused by viruses such as A, B, C, D, E, and G, if left untreated or improperly treated, all have the potential to progress to cirrhosis. Hepatitis B, C, and D are more likely to cause cirrhosis than other types of hepatitis. In addition to cirrhosis caused by hepatitis, malnutrition-related liver changes, chronic alcohol and drug poisoning, and parasitic infections can also lead to cirrhosis. Furthermore, certain diseases such as Wilson's disease, systemic lupus erythematosus, and long-term heart failure can also result in cirrhosis. However, this type of cirrhosis is symptomatic cirrhosis, also known as secondary cirrhosis. The pathological basis of cirrhosis is fibrotic degeneration of liver tissue, which compresses the portal vein system and bile duct system within the liver. Increased portal pressure leads to varices in the esophageal and gastric veins, splenomegaly, ascites, and lower limb edema; increased pressure in the bile duct system causes hepatomegaly and jaundice. When the former is predominant, it is called portal hypertension cirrhosis; when the latter is predominant, it is called cholestatic cirrhosis. There are various theories regarding the causes of cholestatic cirrhosis. Some argue that cholestasis precedes hepatic fibrosis, while others believe the reverse is true. A deficiency in the immune system is characteristic of this type of cirrhosis. Many questions remain to be explored. Clinically, cirrhosis is diagnosed primarily based on splenomegaly, elevated serum globulin levels, and a relative decrease in albumin levels. Ultimately, an imbalance or inversion of the albumin-to-globulin ratio, esophageal varices, enlargement of the portal vein diameter, and ascites serve as diagnostic criteria. For cholestatic cirrhosis, jaundice is particularly pronounced in addition to the aforementioned clinical manifestations. Some patients may also exhibit accelerated erythrocyte sedimentation rate and changes in peptide antibodies. Western medicine mainly focuses on liver protection when treating cirrhosis. When complications such as ascites, upper gastrointestinal bleeding, and hepatic encephalopathy occur, symptomatic treatment is diverse and colorful. Short-term efficacy can be considered satisfactory. However, from a long-term perspective, the results are still unsatisfactory, so Western medicine considers cirrhosis with ascites to be incurable. Traditional Chinese Medicine has a long history of treating cirrhosis and boasts a wide variety of prescriptions. As early as the late Eastern Han Dynasty, the “Jin Kui Yao Lue” proposed the principle of “seeing liver disease, knowing it will spread to the spleen,” indicating that patients with cirrhosis first affect the gastrointestinal tract, leading to abdominal distension, loss of appetite, loose stools, and upper gastrointestinal bleeding. Modern research has confirmed that when cirrhosis causes portal hypertension, the entire gastrointestinal mucosa becomes congested with blood vessels, the veins dilate to varying degrees, the mucosa swells and exudes fluid, and in severe cases, reactive gastric acid secretion increases. Some patients may even develop erosion, ulcers, and bleeding of the gastrointestinal mucosa. Thus, it is evident that the understanding of Traditional Chinese Medicine is completely consistent with that of modern medicine; the difference lies in the fact that TCM recognized this point over 1,000 years earlier than Western medicine. Based on this understanding, the main therapeutic approach of TCM for cirrhosis is to soothe the liver and invigorate the stomach. Soothing the liver involves integrating modern medical concepts such as liver protection, bile promotion, and prevention of fibrosis into a single comprehensive treatment plan, with representative formulas including Xiaoyao San, Chaihu Shugan San, Si Ni San, and Si Wu Tang. Invigorating the stomach means regulating gastrointestinal motility, relieving smooth muscle spasms, preventing mucosal erosion and ulcers, suppressing gastric acid, and enhancing appetite—all combined into a single comprehensive treatment plan, with representative formulas such as Si Jun Zi Tang, Xiang Sha Liu Jun Zi Tang, Ban Xia Xie Xin Tang, Gui Pi Tang, and Bu Zhong Yi Qi Tang. In these formulas, additional ingredients such as Sheng Long Mu and Wuzi Gu are added to enhance acid suppression and wound healing; Dan Shen, Huang Qi, Dang Gui, Bai Shao, Shou Wu, and Huang Jing are added to strengthen liver protection; Dan Shen, Mu Xiang, Cao Kou, Yuan Hu, Chuan Lian Zi, and Zhi Ru Mei are added to relieve spasms and alleviate pain; and Zhi Shi, Hou Pu, Da Huang, Gan Jiang, Fu Zi, San Leng, E Zhu, Rou Gui, Qing Pi, and Jiang Huang are added to eliminate bloating and relieve pain. If there is bleeding, add Xuan Fu Hua, Sheng Zhe Shi, Han San Qi, Da Huang, Huang Lian, and Huang Qin; if black stools persist, add Zao Xin Tu, Li Zhong Tang, and Fu Zi Li Zhong Tang. Among these herbs, Dan Shen, Huang Qi, and Huang Jing should be used in larger quantities, typically between 20–40 grams. Ascites and edema in patients with cirrhosis are inevitable symptoms in the later stages. Once ascites appears, infectious complications tend to follow closely, so formulas should include Da Fu Pi, Hu Lu Pi, Che Qian Zi, Er Hua, Lian Qiao, Gong Ying, Bai Jiang, Bai Hua She She Cao, and Ban Zhi Lian. During cirrhosis, some liver tissue remains in a state of slow active hepatitis, and the effects of hepatitis viruses continue, so formulas should also include Qin Yuan, Ban Lan Gen, and Da Qing Ye. Patients with cirrhosis may develop liver necrosis due to improper treatment, excessive fatigue, recurrent colds, or emotional stress—this is known as subacute or chronic severe hepatitis. Its clinical characteristics include a rapid worsening of jaundice, relatively normal transaminase levels, a phenomenon known as bilirubin-enzyme dissociation, a shrinking liver dullness boundary, and a dramatic increase in ascites. Severe patients often develop hepatic encephalopathy. At this stage, the condition is critical, and hospitalization for Western medical rescue is generally recommended. However, combined TCM treatment is also very important. TCM’s bowel-clearing therapy often produces remarkably significant effects. The author frequently uses modified Da Chai Hu Tang for nasal feeding to accelerate patient recovery and improvement. The formula consists of: Chai Hu 10g, Zhi Shi 10g, Bai Shao 15g, Da Huang 10g, Hou Pu 10g, Huang Qin 10g, Rou Gui 3g, Huang Lian 3g, Gan Cao 6g, and Mang Xiao 10g (dissolved in water). Two decoctions are prepared, totaling 400 ml, which are administered via nasal feeding three times (with 3-hour intervals). While administering this formula, Western medical treatment proceeds concurrently, including sodium arginine, sodium glutamate, acetylglutamine, heparin, glucagon, antibiotics, large-volume intravenous fluids, and electrolyte correction—all used as appropriate. Two points deserve special emphasis: ① Throughout the rescue process, protect the kidneys to prevent renal dysfunction and the occurrence of hepatorenal syndrome; ② Protect the gastrointestinal tract to prevent gastrointestinal bleeding. For the former, avoid using antibiotics such as streptomycin and gentamicin that can impair kidney function, and promptly correct electrolyte imbalances such as hyperkalemia, hypokalemia, hyponatremia, and hypocalcemia. For the latter, avoid medications that can damage the gastrointestinal mucosa, such as intravenous methocarbamol and oral ranitidine. The aforementioned TCM nasal feeding should be adjusted immediately upon the patient regaining consciousness to include modified versions of Xiao Chai Hu Tang, Xiang Sha Liu Jun Zi Tang, and Li Zhong Tang, to better protect the stomach qi. Regarding gastrointestinal bleeding in advanced cirrhosis, it is another challenging problem in treating this disease. Major bleeding often results from ruptured esophageal or gastric varices, while minor bleeding may be caused by seepage or erosion throughout the entire digestive system. The former is characterized by massive hematemesis and melena, while the latter shows positive fecal occult blood. Western medicine has several effective methods for treating major upper gastrointestinal bleeding, such as the use of vasopressin and octreotide, which have obvious effects. Combined with timely blood transfusions, these methods can alleviate some upper gastrointestinal bleeding. The use of triple-lumen double-balloon catheters can also help some patients, but the author’s experience suggests that prolonged indwelling of such catheters often causes suffocation and agitation, exacerbating bleeding, and that removal of the catheter can lead to rebleeding due to adhesion and traction. TCM treats major upper gastrointestinal bleeding mainly with San Huang Xie Xin Tang, Mi Hong Dan, Huang Tu Tang, and Xuan Fu Dai Zhe Tang. Among these, the combination of San Huang Xie Xin Tang, Xuan Fu Dai Zhe Tang, and Mi Hong Dan yields the best results. The author proposes the following formula: Da Huang 10g, Huang Lian 6g, Huang Qin 10g, Xuan Fu Hua 10g, Sheng Zhe Shi 10g, Ban Xia 6g, Gan Cao 6g, Sheng Jiang 6g, Da Zao 4 pieces, Rou Gui 3g, and Zao Xin Tu 60g (first decocted for 10 minutes to obtain the herbal liquid). Decoct 300 ml (total of first and second decoctions), divided into three doses (with 3-hour intervals), one dose per day. Treatment of black stools prioritizes Huang Tu Tang from the “Jin Kui Yao Lue.” The formula consists of: Huang Qi 20g, Huang Lian 6g, Huang Bai 6g, Bai Shu 10g, Fu Pian 6g, A Jiao 10g (melted), Gan Jiang 6g, and Zao Xin Huang Tu 60g (first decocted for 5 minutes to obtain the herbal liquid). Middle Section Special Lecture 73 Discussing Epigastric Pain Pei Zhengxue The area between the navel and the xiphoid process of the sternum is commonly referred to as epigastric pain, and pain in this region can be called epigastric pain. Pain in the epigastric region is usually caused by a variety of diseases. Based on over 40 years of clinical experience, the most common cause is chronic gastritis, followed by peptic ulcer disease, cholecystitis (cholelithiasis), pancreatitis, reflux esophagitis, gastric mucosal prolapse, and duodenal diverticulitis. Overall, TCM treatment for epigastric pain has certain advantages over Western medicine, mainly due to flexible syndrome differentiation and a wealth of traditional formulas and single prescriptions. The author believes that before conducting specific syndrome differentiation, it is essential to strictly distinguish the aforementioned Western medical conditions—that is, to first make a Western medical diagnosis. Only when the Western medical diagnosis is clear should TCM syndrome differentiation and treatment be carried out, which will make the differentiation more accurate and the therapeutic effect relatively higher. Japanese practitioners advocate the use of abdominal signs to determine the location of pain, which also carries a certain degree of integration between TCM and Western medicine. The author now provides a general overview of the main characteristics of the primary diseases that cause epigastric pain, then proposes effective formulas based on the principle of syndrome differentiation. These are purely personal experiences, and any shortcomings are welcome to be corrected by colleagues.

1. Chronic Gastritis Old classifications included superficial, hypertrophic, and atrophic types. Recently, experts have found that these three pathological changes often coexist within the same stomach. Since atrophic changes are the most common and widespread, they are collectively referred to as atrophic gastritis. Among them, those with predominantly superficial lesions are called superficial gastritis. Atrophic gastritis is further divided into Type A and Type B depending on whether the patient has antibodies against gastric wall cells. Type A has positive antibodies against gastric wall cells, with lesions mainly concentrated in the body of the stomach. Since the body of the stomach is the main functional part of the stomach, digestion is significantly impaired, gastric acid secretion increases markedly, especially affecting the absorption of B vitamins, leading to anemia. The infiltration of gastric wall cells is mainly lymphatic, so local inflammation seems relatively mild. In addition, the stomach cavity is large, and allergenic substances are relatively scarce, so local pain is not very obvious. In summary, this type is characterized by overall deficiency of vital energy and fullness in the epigastric region, along with disturbances in digestion and absorption. The tongue appearance is plump and thick, with a thin white coating, and the pulse is mostly deep and fine. From the perspective of TCM syndrome differentiation, this type is mostly related to spleen-stomach qi deficiency and dampness stagnation in the middle jiao. The treatment should focus on tonifying qi and strengthening the spleen, as well as moving qi and drying dampness. Formulas such as Xiang Sha Liu Jun Zi Tang, Liang Fu Wan, Da Xiao Jian Zhong Tang, and Li Zhong Tang with modifications can be used, along with calcined tiles, Sheng Long Mu, Wuzi Gu, and other ingredients to achieve good results. Type B has negative antibodies against gastric wall cells, with most lesions concentrated in the antrum. Since the body of the stomach is healthy and digestion is mostly normal, the overall condition of patients is often better than Type A. However, in this type, neutrophils are the most common infiltrating cells in the gastric wall, resulting in obvious local inflammation. Moreover, the antrum is the vestibule before the pylorus, where food enters and is often stimulated by gastric peristalsis before entering the pylorus, thus increasing local pain. In summary, this type has a good overall condition, with less obvious deficiency symptoms, and pain in the epigastric region is often more prominent. Red tongue and greasy yellow coating are the most common tongue appearances, and a stringy, rapid pulse is also frequently observed. TCM often diagnoses this type as damp-heat in the middle jiao and qi stagnation with blood stasis; the treatment should clear heat and dry dampness, move qi and harmonize blood. Formulas such as Ban Xia Xie Xin Tang, Huang Lian Tang, San Huang Xie Xin Tang, Huang Lian Detoxification Tang, Qing Wei San, Dan Shen Yin, and 204 stomach medicines (Xiang Fu, Yuan Hu, Ming Fan, calcined tiles) can be used. The pathology of superficial gastritis is the same as that of atrophic gastritis, but since the condition is milder, it can usually be treated with the above-mentioned methods, and clinical results are often seen.
2. Peptic Ulcer Disease This includes gastric ulcers and duodenal bulb ulcers, with some patients having both. Unlike chronic gastritis, this disease involves ulceration of the mucosa, with a significant increase in gastric acid. Clinically, the main symptoms are epigastric pain and acid regurgitation. The pain point of gastric ulcers is slightly to the left of the line connecting the navel and the xiphoid process; the pain point of duodenal ulcers is slightly to the right of the same line. In terms of the intensity of pain, duodenal ulcers are more severe than gastric ulcers. Both types of pain are closely related to diet, and both subside after meals. After eating, gastric ulcers start hurting after 1 hour and stop on their own after 2 hours; duodenal ulcers start hurting after 2 hours and continue until the next meal—this is a characteristic of duodenal ulcers. Besides pain, acid regurgitation, belching, and abdominal distension are also common features of both. Given that this disease often involves acid regurgitation, belching, and abdominal pain, TCM syndrome differentiation often treats it as spleen-stomach deficiency-cold. Moreover, since both types involve pain, TCM believes that cold attracts pain, and pain prevents flow, and pain arises from lack of flow. Ancient scholars believed that deficiency-cold was the correct treatment; however, in recent years, Western medicine has discovered that Helicobacter pylori is the main cause of this disease. Some people have achieved good results using antibiotics such as metronidazole and tetracycline, and TCM colleagues have subsequently applied formulas such as Xie Xin, San Huang, and Qing Wei in clinical practice with good results. The author’s experience is that the principles, methods, formulas, and medicines for this disease should be the same as those for chronic gastritis, but it is essential to emphasize adding a larger amount of herbs that suppress gastric acid, such as Sheng Long Mu, Wuzi Gu, and calcined tiles. The Zu Jin Wan formula, composed of Huang Lian and Wu Zhu Yu in a 3:1 ratio, is a powerful acid-suppressing agent in TCM. This formula originates from “Dan Xi Xin Fa,” where the original ratio was six parts Huang Lian to one part Wu Zhu Yu. Based on the author’s clinical experience, a 3:1 ratio is the optimal choice. Whether it’s chronic gastritis or peptic ulcer disease, stubborn epigastric pain can occur. When the aforementioned syndrome-differentiated formulas prove ineffective, the patient’s tongue often shows petechiae, and the pulse is mostly slippery and rapid with astringent qualities. In such cases, TCM diagnoses it as “the disease has entered the meridians,” and recommends using blood-activating and stasis-resolving herbs to achieve effectiveness. According to verification by Western fiber gastroscopy, this type of epigastric pain is often associated with duodenal bulb ulcers—deep ulcers that are accompanied by extensive mucosal erosion. If it’s atrophic gastritis, it’s often accompanied by intestinal metaplasia or atypical hyperplasia. The author frequently uses the following formulas to treat this type of epigastric pain with good results. Compound Danshen mixture: Dang Gui 10g, Bai Shao 15g, Chuan Xiong 6g, Huang Qi 20g, Liang Jiang 6g, Zhi Ru Mei 6g each, Dan Shen 10g, Tan Xiang 6g, Sha Ren 6g, Xiang Fu 6g, Yuan Hu 10g, calcined tiles 20g, Ming Fan 3g, all decocted and taken once daily. Another formula that can also be effective is Compound Chi Shi Zhi Powder: Ji Nei Jin 200g, Wuzi Gu 200g, Bai Shao 200g, Sheng Cao 100g, Han San Qi 200g, Chi Shi Zhi 200g, Xiang Yuan 100g, Dan Shen 100g, Mu Xiang 60g, Cao Kou 100g, all ground into powder, sifted through a 76-mesh sieve, 6g per dose, twice daily, taken with warm water.
3. Cholecystitis (Cholelithiasis) Cholecystitis and cholelithiasis often occur together, with each causing the other. About two-fifths of epigastric pain falls into this category. In addition to pain in the upper part of the epigastric region (slightly higher than the pain in the stomach and duodenum, mostly below the xiphoid process), it is often accompanied by pain in the right subcostal area and radiates to the right shoulder and back; some patients may only experience pain in the right back. Pain in the gallbladder is often exacerbated by consuming greasy foods, meat, eggs, and dairy products. Most patients can be diagnosed via ultrasound; however, a small number of patients do not show gallbladder-related features or stone echoes on ultrasound, making this type of cholecystitis the easiest to misdiagnose. The author frequently encounters patients with long-term right-back pain who have tried countless remedies without success.