V. Bile Reflux Gastritis Esophagitis

V. Bile Reflux Gastritis (Esophagitis) Normally, bile flows from the common bile duct into the duodenum and then mixes with gastric contents before moving into the jejunum; however, when gastrointestinal function is disrupted or there is endocrine dysfunction of the gastrointestinal and pancreatic systems, bile can reflux into the stomach and lower esophagus, stimulating increased gastric acid secretion and causing congestion, edema, and ulcers in the gastric and esophageal mucosa. Clinically, there are three main characteristics: ① burning pain in the epigastric region or lower chest; ② nausea and vomiting, with bile present in the vomitus; ③ acid regurgitation. Pain from esophageal reflux often radiates downward from the xiphoid process to the lower chest. What causes bile reflux? There are three main scenarios: post-gastric surgery (gastric resection or reconstruction); chronic gastritis or ulcers; and autonomic nervous system dysfunction of the gastrointestinal tract. Western medicine typically treats this condition with H2 receptor antagonists to reduce gastric acid production—such as cimetidine, ranitidine, lansoprazole, and omeprazole—and sometimes with prokinetic agents like metoclopramide and domperidone, but overall these are merely symptomatic treatments. In traditional Chinese medicine, the basic pattern recognition for this condition is liver wood overcoming earth, leading to upward rebellion of stomach qi and intense stomach fire; treatment should focus on soothing the liver and harmonizing the stomach, reversing rebellious qi and stopping vomiting, clearing heat and drying dampness. Commonly used formulas include Sini San, Xiaoyao San, Xuanfu Daizhe, Banxia Xiexin, and Xiaoxianxiong, with modifications. The author frequently uses a specific formula that has shown good clinical results. Wei’an San Ni Tang: Chaihu 10 g, Zhi Shi 10 g, Baishao 15 g, Gancao 6 g, Danshen 10 g, Muxiang 3 g, Caokou 3 g, Huanglian 10 g, Wuyu 3 g, Gualou 10 g, Banxia 6 g, Shengzhe 15 g, Chuanxiong 6 g, Xiangfu 6 g, Shan Zhi 10 g, Cangshu 6 g, Shenqu 6 g. The herbs are decocted in water and taken once daily. For chest tightness, add Houpu 6 g and Zhi Shi 10 g; for severe stomach pain, add Huangqin 10 g, Ganjiang 6 g, Yuanhu 10 g, Duanwalei 15 g, and Mingfan 3 g; for severe constipation, increase the dose of Dahuang to 6 g; for difficulty swallowing, add Zhebei Mu 10 g, Sanleng 10 g, and Ezhushi 10 g; for patients with a red tongue and bruising, add Taoren 10 g. VI. Gastric Mucosal Prolapse This condition is not uncommon, yet it is often misdiagnosed clinically. It occurs when the mucosa of the pyloric region separates from the muscular layer and protrudes into the duodenum. Barium contrast radiography reveals a central filling defect in the duodenum as the primary diagnostic indicator. The pyloric muscular layer is abnormally thickened, forming a rigid pyloric sphincter that controls the passage of gastric contents into the duodenum; however, due to frequent fluctuations in its tension, the adhering mucosa tends to detach, resulting in protruding mucosal folds that enter the duodenal lumen with gastric peristalsis, sometimes even reaching the bulb. These changes lead to three major clinical manifestations: ① obstruction; ② bleeding; ③ mucosal congestion, edema, erosion, and ulceration. The main symptom is epigastric pain, usually beginning about 30 minutes after a meal, which is more severe than that of chronic gastritis or ulcers. Pain is often accompanied by nausea and vomiting, and some patients experience significant abdominal distension due to pyloric obstruction, even making it difficult to consume food. Bleeding is usually minor, with positive occult blood in stool and frequent black stools; massive hematemesis is rare. Western medicine once advocated surgical treatment for this condition, but recent scholars have raised objections. Currently, it is believed that except for severe cases where pyloric obstruction is clearly caused by extensive prolapse, routine treatment should be conservative internal medicine. Based on personal experience, the author recommends the following modified formula: Wu Yao 10 g, Chenxiang 3 g, Binglang 10 g, Gancao 6 g, Xiangfu 6 g, Chuanxiong 6 g, Shan Zhi 10 g, Cangshu 6 g, Shenqu 10 g, Mahuang 10 g, Chenpi 6 g, Jiangchong 6 g, Ganjiang 6 g, Baizhi 6 g, Xixin 3 g, Jiegeng 20 g, Danshen 10 g, Muxiang 6 g, Caokou 6 g, Dahuang 6 g, Zhi Shi 10 g, Houpu 6 g. The herbs are decocted in water and taken once daily. Due to pyloric obstruction, medication should be administered in small doses multiple times, mixing the first and second decoctions and dividing the total dose into five portions to be taken throughout the day, about 100 ml each time. VII. Gastric and Duodenal Diverticula This condition involves outward bulging or pocket-like expansion of the walls of the stomach and duodenum. Such diverticula account for 10%–20% of all diverticula in the digestive tract (according to autopsy data). Gastric and duodenal diverticula are prone to inflammation and symptom development, thus attracting attention. Most cases are congenital; gastric diverticula are less common, while duodenal diverticula are more prevalent. Symptoms only appear when diverticula become inflamed, typically including epigastric pain, nausea, vomiting, and weight loss, with occasional diarrhea. Symptoms often disappear at night and worsen during the day, and may be alleviated by changing body position. Chronic diverticulitis can lead to local bleeding, ulcers, adhesions, gangrene, abscesses, and perforation; occasionally, it may be complicated by cancer (diverticulum of the ampulla), pancreatitis, or duodenal obstruction. Consequently, duodenal diverticulitis can sometimes cause severe pain, with an extremely high misdiagnosis rate. Western medicine finds it difficult to make a clear diagnosis, as diverticula are hard to locate during surgery, making operations challenging and discouraging surgeons. Traditional Chinese medicine focuses on activating blood circulation and removing blood stasis, clearing heat and detoxifying, and regulating qi to relieve pain; formulas include Yiren Fuzi Baijiang Tang, Danshen Yin, Chaihu Shugan San, and Wuma Heji, with modifications. The author frequently uses the following effective formula in clinical practice: ① Wuma Jin Gan Wan: 40 dried plums (pitted), 20 processed Semen Strychni, 20 g of Curcuma, 3 g of Dried Lacquer, 20 g of Potassium Nitrate, 20 g of Alum, 100 g of Agrimony, 100 g of Citrus Peel, 30 g of Cardamom, 30 g of Muxiang, 100 g of Danshen, 200 g of Raw Coix Seed, 200 g of Baijiang, and 100 g of Fupian. All ingredients are ground into powder, sifted, and taken at 5 g per dose, twice daily with warm water. ② Modified Chaihu Tang: Chaihu 10 g, Zhi Shi 10 g, Baishao 10 g, Gancao 6 g, Sanleng 10 g, Ezhushi 10 g, Wuyu 10 g, Wu Yao 10 g, Puhuang 10 g, Wulingzhi 10 g, Rougui 3 g, Danshen 10 g, Muxiang 3 g, Caokou 3 g, Zhimuruyu and Zhimu each 6 g. The herbs are decocted in water and taken once daily. All of the above conditions can cause epigastric pain; individual conditions may occur alone or several may coexist simultaneously. Therefore, when a patient presents with epigastric pain, physicians should conduct a comprehensive analysis and weigh the use of medications, determining which should be prioritized and which should be used later, as well as the severity of each condition, all of which affect adjustments to the prescription and ultimately influence the direct therapeutic effect. In addition to the aforementioned seven diseases, other conditions that can cause epigastric pain include gastric perforation, gastric cancer, liver diseases (hepatitis, liver abscess, liver cysts, hydatid disease), and lower gastrointestinal disorders that can also trigger reactive lesions in the stomach. Gastric perforation often occurs as a complication of gastric ulcers and other gastric diseases, with an acute and severe course. Peritoneal irritation symptoms quickly develop, necessitating immediate surgical intervention. Gastric cancer should also be treated surgically at an early stage, followed by chemotherapy, with traditional Chinese medicine used concurrently to mitigate the toxic side effects of chemotherapy to some extent. Treatment for liver diseases should also focus on addressing the root cause—for example, surgery for hydatid disease, hepatoprotective herbal remedies for hepatitis, antibiotic treatment for liver abscesses, and drainage surgery when necessary. 81 A Brief Discussion on Lung Cancer Presented by Pei Zhengxue, recorded by Zhang Guiqiong Lung cancer is one of the greatest killers of humankind. We say coronary heart disease is the number one killer, but cancer is the biggest killer overall. Among all cancers, lung cancer has the highest incidence, so we can also say it is the biggest killer. The incidence of lung cancer is 40–60 per 100,000 people, with some reports indicating 40–80 per 100,000. Lung cancer mainly affects men; recent data shows the incidence among men is about 103 per 100,000, compared to 80 per 100,000 in the past. Overall, the incidence among men ranges from 80 to 100 per 100,000; the incidence among women is slightly lower, around 50 per 100,000, but in recent years, the incidence among women has been increasing year by year. Three years ago, statistics showed the incidence among women was 20–30 per 100,000; this year, the China Medical Forum Daily reported that according to WHO data, the incidence among women has risen from the original 20–30 per 100,000 to 50 per 100,000, indicating a sharp increase in the incidence among women, which has drawn the attention of the medical community. Previously, it was believed that lung cancer was more common among men and rare among women, and that smoking was the main cause, with men smoking more and women smoking less. However, the incidence among women has now increased significantly, and the rate of increase is not proportional to smoking rates, so the conclusion that smoking causes lung cancer is being reconsidered. Experts now unanimously agree that, like other cancers, lung cancer is also related to heredity, genes, and mutations; heredity, genes, and mutations are the causes of cancer. Smoking can be regarded as a temporary irritant factor. Below is a brief introduction to the clinical diagnosis, classification, staging, surgery, chemotherapy, targeted therapy, and traditional Chinese medicine treatment of lung cancer. 82 I. Pathological Classification of Lung Cancer Pathologically, lung cancer is divided into adenocarcinoma, squamous cell carcinoma, small cell carcinoma, and alveolar carcinoma. Alveolar carcinoma accounts for a very small proportion, only about 1% of all lung cancers. The remaining 99% is evenly distributed among squamous cell carcinoma, adenocarcinoma, and small cell carcinoma, each accounting for one-third. II. Clinical Manifestations of Lung Cancer In summary, the main symptoms are cough, sputum production, hemoptysis, and chest pain. Cough: Because lung cancer originates in the bronchi—strictly speaking, it is bronchial lung cancer—it grows on the inner lining of the bronchi, so cough is the first symptom triggered by the disease. The second symptom is sputum production: since the cancer causes a reactive secretion, even before infection sets in, this secretion appears in the form of sputum, making sputum production the second symptom. Hemoptysis: At the onset of lung cancer, the tumor infiltrates nearby blood vessels and capillaries, leading to hemoptysis. Chest pain: Lung cancer initially invades the pleura, and invasion of the pleura causes pain because the pleura contains sensory nerves. Remember that the clinical manifestations of lung cancer are cough, sputum production, hemoptysis, and chest pain. In addition, lung cancer has another important symptom that distinguishes it from the common cold: “wheezing.” Why does it wheeze? Because when lung cancer develops, the hilar lymph nodes are invaded, and these lymph nodes compress the bronchi, leading to asthma. Therefore, along with cough, sputum production, hemoptysis, and chest pain, there is also wheezing and shortness of breath. Wheezing is essentially shortness of breath, so if we encounter an upper respiratory patient who, in addition to cough, sputum production, hemoptysis, and chest pain, also exhibits wheezing within a short period of time, there is a 70%–80% chance that it is lung cancer—this is based on many years of experience. III. Staging of Lung Cancer When lung cancer has not yet metastasized to the hilar lymph nodes, it is classified as Stage I; once hilar lymph node metastasis occurs, it becomes Stage II; when mediastinal lymph node metastasis occurs, it becomes Stage III; and when distant organ metastasis occurs—such as supraclavicular, brain, or liver metastasis—it becomes Stage IV. Thus, the current TNM clinical staging system defines T as primary tumor, N as regional lymph node metastasis, and M as distant organ metastasis. Primary tumors are classified as T1 or T2; if there is no NOMO, it is Stage I; if hilar lymph node metastasis occurs, it becomes Stage II, and N becomes N1; if mediastinal lymph node metastasis occurs, N becomes N2 or N3, marking Stage III; and if supraclavicular, brain, or bone metastasis occurs, M becomes M1, signifying Stage IV. To reiterate: hilar lymph node metastasis means Stage II, mediastinal lymph node metastasis means Stage III, distant organ metastasis means Stage IV, and no hilar lymph node metastasis means Stage I. Stages I, II, and III are suitable for surgery, while Stage IV is not; distant organ metastasis is also not suitable for surgery. However, for Stage I, surgery, chemotherapy, and radiation therapy can be performed or not, since it is only a primary tumor; but for Stages II and III, radiation therapy and chemotherapy must be combined. The issue of chemotherapy and radiation therapy for Stage I primary tumors is still debated; recently, the National Comprehensive Cancer Network (NCCN) released guidelines stating that Stage I lung cancer still requires preoperative and postoperative chemotherapy, thereby overturning our traditional view. IV. Diagnosis of Lung Cancer Since the development of imaging diagnostic tools, diagnosing lung cancer has become much easier. First comes X-ray; chest X-rays are the basic requirement for diagnosing lung cancer. Even today, with the advancement of CT and MRI, chest X-rays cannot be completely replaced. Lung cancer displays the following characteristics on chest X-rays: first, relatively dense shadows; second, these shadows have lobulated edges; third, there are spicules and radiating crowns around the edges. Some spicules and radiating crowns develop into “rat-tail” shapes, while others become “rabbit-ear” shapes. These features are also reflected in CT scans; the advantage of CT over chest X-rays is that CT provides cross-sectional images, allowing us to see three layers. If there are large, uniform, and excessive shadow formations, it indicates a mass effect, meaning there is a lump, a space-occupying lesion. On MRI, since MRI mainly focuses on signals—whether they are high or low—on T1 images, air, blood, water, and bone all appear as low signals, essentially black. To put it simply, air, blood, water, and bone all appear black. However, on T2 images, water turns into a high signal, which helps us differentiate. Generally, cancers are mixed signals; whether on CT or MRI, cancers always present mixed signals—neither high nor low. Therefore, when identifying lung cancer on MRI, we need to look for mixed-signal space-occupying lesions. CT provides clearer images than MRI, but MRI is better than CT at detecting mediastinal lymph node metastasis, while ultrasound cannot visualize the lungs. V. Surgical Treatment of Lung Cancer The first complete pneumonectomy was performed in 1933 at Washington Hospital of Saint Louis University in the United States, and the first lobectomy was performed in 1948 at Massachusetts General Hospital in the United States. In 1993, the same hospital performed the world’s first minimally invasive lobectomy using thoracoscopy. Since then, it has been widely accepted that minimally invasive lobectomy is superior to non-minimally invasive surgery, and that simple lobectomy is superior to complete pneumonectomy. Minimally invasive surgery causes less trauma, and patients recover more easily. What is the situation in our province and country now? Currently, all provinces across the country perform lobectomies for lung cancer, and complete pneumonectomies are only used in special circumstances. However, minimally invasive lobectomies performed under thoracoscopy have not yet been implemented in less developed provinces. Our hospital has already purchased thoracoscopy equipment and is preparing to carry out this procedure. Lobectomies performed under thoracoscopy result in less trauma than non-minimally invasive surgeries, and minimally invasive lobectomies are superior to non-minimally invasive ones. Therefore, lobectomies now require accompanying chemotherapy before and after the operation. VI. Chemotherapy for Lung Cancer In the 20th century, chemotherapy regimens were quite chaotic—Zhang San would choose one, Li Si would choose another. Since evidence-based medicine began to be practiced worldwide, Americans were the first to conduct multi-center, large-sample, randomized double-blind retrospective studies on combination chemotherapy, ultimately screening out these regimens. For lung cancer, the universally accepted regimens are NP, GP, and TP. These three chemotherapy regimens are now considered the preferred options for treating lung cancer worldwide. The NP regimen uses vinorelbine and cisplatin; the GP regimen uses gemcitabine and cisplatin; and the TP regimen uses docetaxel and cisplatin. Cisplatin can be administered in two ways: divided doses or a single dose. With divided doses, it’s 30 mg three times a day; with a single dose, it’s 120 mg once a day. Vinorelbine (NVB) and gemcitabine (GEM) are administered once a week, while docetaxel (TXT) is administered once every three weeks. VII. Targeted Therapy for Lung Cancer The chemotherapy drugs we just discussed are cytotoxic agents that, while killing tumors, also cause significant damage to normal tissues, resulting in severe side effects. Some lung cancer patients, upon seeing chemotherapy drugs, say they’d rather die than undergo chemotherapy. Why? Because the side effects are so severe. The main side effects include nausea, vomiting, hair loss, and decreased blood counts, among others. To address these toxic side effects, targeted therapy has been developed. It began in 1978 when American scholar SUDen inoculated gastric cancer cell lines onto rabbit corneas, discovering that numerous blood vessels grew around the cell lines, even invading them. From this, he concluded that tumor growth requires a blood supply. After seven or eight years of research, he finally found that there is a vascular endothelial growth factor in the serum.