4. TCM Syndrome Differentiation and Formulas

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It is characterized by a fierce onset and strong infectivity. Damp-heat epidemic toxin invades the human body, leading to impaired liver function in dispersing and draining, spleen qi failing to ascend, and stomach qi failing to descend. As a result, the damp-heat pathogen has no way to retreat, stagnating in the bile ducts and causing jaundice; the damp-heat burns intensely, resulting in yellowing of the skin and eyes, fatigue, decreased appetite, nausea, vomiting, and flank pain. The tongue coating is yellow and greasy, and the pulse is taut and slippery. At this point, jaundice occurs, the condition progresses rapidly, with the interplay between righteous qi and pathogenic factors: when pathogenic factors prevail, righteous qi declines; when righteous qi prevails, pathogenic factors recede. If treatment is inappropriate or delayed, the heat-toxin becomes rampant, invading the nutritive blood and penetrating the pericardium, leading to confusion, delirium, and deep coldness, ultimately resulting in hepatic coma. This can further develop into hepatorenal syndrome, hepatic encephalopathy, and disseminated intravascular coagulation, worsening the condition significantly and making it extremely difficult to treat. Therefore, the pathogenesis of this disease lies in the invasion of external damp-heat epidemic toxin into the liver and gallbladder, causing the liver to lose its ability to disperse and drain, the wood energy of the liver overpowers the earth energy, encroaching upon the stomach, leading to weakness of the spleen and stomach, accumulation of damp-heat, deficiency of the liver and kidneys, yin deficiency with hyperactive fire, and toxicity that damages the nutritive blood. The primary site of the disease is the liver, closely related to the liver, gallbladder, spleen, and kidneys.

In terms of treatment, we follow Professor Pei Zhengxue's "16-character guideline" for integrated Chinese and Western medicine: "Western diagnosis, TCM differentiation, primarily using Chinese medicine, supplemented by Western medicine." Based on Western classifications such as acute jaundice hepatitis, chronic progressive hepatitis, and chronic active hepatitis, we formulate prescriptions that address the root cause of liver disease, focusing on soothing the liver and relieving depression, and maintaining this approach throughout the entire course of chronic hepatitis treatment. Specifically, the medication regimen involves soothing the liver and strengthening the spleen to treat the root cause, clearing heat and detoxifying to lower enzyme levels, and consistently reducing surface antigens. Sometimes, multiple methods are used in combination—for example, a single prescription may include clearing heat and detoxifying, activating blood circulation and removing stasis, tonifying the spleen and kidneys, and soothing the liver and strengthening the spleen. From the perspective of modern Western medicine, these principles encompass key aspects such as inhibiting viral replication, regulating immunity, improving liver function, and combating liver fibrosis. For instance, clearing heat and detoxifying can inhibit viral replication, reduce inflammation, and improve liver function; drugs that activate blood circulation and remove stasis can combat liver fibrosis, improve hepatic blood supply, reduce turbidity, and alleviate jaundice; tonifying the spleen and kidneys can regulate immune system function and correct immune deficiencies; and soothing the liver and strengthening the spleen can restore balance to the body's immune system. Commonly used formulas include Yinchenhao Decoction, Xiaochaihu Decoction, and Qianggan Decoction. Meanwhile, given the high prevalence and strong infectivity of chronic hepatitis B, along with the difficulty of treatment, Professor Pei Zhengxue emphasizes the integration of Chinese and Western medicine, leveraging the strengths of each. On the basis of Chinese herbal treatment, he combines it with antiviral Western medicines, because Western treatment can maximize the suppression or elimination of HBV, reduce hepatocellular inflammation and necrosis, and mitigate liver fibrosis, thereby slowing down and preventing disease progression, reducing and preventing decompensation of the liver, cirrhosis, HCC, and their complications, ultimately improving quality of life and prolonging survival.

Furthermore, Professor Pei Zhengxue believes that Chinese herbal treatment for hepatitis must be tailored to individual syndromes, treating symptoms based on underlying patterns, and combining macroscopic and microscopic perspectives. He considers reduced total protein and albumin levels as signs of deficiency of vital essence, indicating a deficiency syndrome; elevated transaminase levels indicate excess, representing a fullness syndrome. Treatment for the former should focus on replenishing what is lacking, while the latter should aim to reduce what is excessive. Surface antigen positivity is often accompanied by immune responses such as core antibody and e antibody, which Professor Pei Zhengxue views as a mixed deficiency-excess pattern, advocating a harmonizing approach with both tonification and reduction. Typically, this involves modifying Xiaochaihu Decoction combined with Qianggan Decoction, achieving stable results through moderate adjustments.

4. TCM Syndrome Differentiation and Formulas

5. Qi-Yin Deficiency Syndrome
   Symptoms: Initial infection with hepatitis virus, normal liver function, no significant clinical symptoms; some patients only experience mild fatigue and dry mouth, with a slightly red tongue. This usually corresponds to what modern medicine calls "healthy carriers," with a favorable prognosis, though some may progress to other types. TCM differentiation: Invasion by epidemic toxin and accumulation of damp-heat.
   Treatment principle: Clear heat and detoxify, transform dampness and dispel evil.
   Formula: Shengshan Decoction with modifications: Shengma 3g, Shan Yao 10g, Honghua 6g, Baishao 10g, Huzhang 10g, Wumei 6 pieces, Baizhu 10g, Chantui 6g, Juhua 10g, Gouqi Zi 10g, Nüzhen Zi 10g, Tusi Zi 10g, Gancao 6g, Gua Wei 10g, Ge Gen 20g.

6. Shaoyang Pathogenic Factor Invading Syndrome
   Symptoms: Patients experience bitter taste and dry mouth, pain in the liver region or both flanks, abdominal distension, loss of appetite, fatigue, and weakness; the tongue is red, with a thin yellow or white coating, and the pulse is fine and rapid.
   TCM differentiation: Shaoyang pathogenic factor invades, damp-heat stagnates in the spleen.
   Treatment principle: Harmonize Shaoyang and clear damp-heat.
   Formula: Qianggan Decoction with modifications: Chaihu 10g, Huangqin 10g, Banxia 6g, Dangshen 15g, Gancao 6g, Shengjiang 6g, Dazao 4 pieces, Danshen 20g, Muxiang 6g, Caodou 6g, Dahuang 3g, Huanglian 3g, Huangqi 20g, Danggui 10g, Baishao 10g, Qin 10g, Banlangen 10g, Baihuashe She Cao 15g, Ban Zhi Lian 15g.

7. Qi Stagnation and Blood Stasis Syndrome
   Symptoms: Patients experience bitter taste and dry throat, irritability and tendency to fever, alternating chills and heat, pain in the liver region or chest and flanks, red tongue, thin yellow or white greasy coating, and a taut, rapid pulse. This type of patient is relatively severe, corresponding to chronic active hepatitis or early-stage cirrhosis in Western medicine.
   TCM differentiation: Liver depression and spleen deficiency, blood stasis.
   Treatment principle: Soothe the liver and strengthen the spleen, activate blood circulation and remove stasis.
   Formula: Chaihu Shugan San with modifications: Chaihu 10g, Quanshi 10g (crushed), Baishao 10g, Gancao 6g, Chuanxiong 6g, Xiangfu 6g, Danshen 20g, Muxiang 6g, Caodou Kou 6g, Huangqi 20g, Danggui 10g, Qin Rao 10g, Banlangen 10g, Ze Xie 10g, Huangjing 20g, Yujin 10g, Yanhusuo 10g (with vinegar), Chuanlianzǐ 20g, Zhi Ruxiang 6g, Zhi Meiyao 6g.

8. Yang Deficiency and Water Overflow Syndrome
   Symptoms: Patients experience abdominal distension, aversion to cold and preference for warmth, cold extremities, mental fatigue, dull complexion or sallow yellow hue, cold pain in the lower abdomen, waist, and knees, poor appetite, bloating, or morning diarrhea, undigested food remaining in the stomach, even progressing to diarrhea and incontinence, difficulty urinating or residual dribbling, frequent urination with incontinence, swelling in the lower limbs or whole body, sometimes severe edema, scrotal dampness and coldness or impotence, darkened tongue with tooth marks, white, greasy, or slippery coating, and a deep, weak or slow pulse. This type of patient has already entered the late stage of cirrhosis, with severely damaged liver function, portal hypertension, and the body losing compensatory capacity of the liver, resulting in generalized edema and massive ascites.
   TCM differentiation: Disharmony between spleen and stomach, yang deficiency with water overflow.
   Treatment principle: Strengthen the spleen and stomach, warm yang and promote diuresis.
   Formula: Xiangsha Liu Junzi Tang and Banxia Xiexin Tang with modifications: Muxiang 6g, Sharen 3g, Dangshen 15g, Baizhu 10g, Fuling 10g, Gancao 6g, Chenpi 6g, Banxia 6g, Huangqin 10g, Huanglian 6g, Ganjiang 6g, Dazao 4 pieces, Danshen 20g, Caodou Kou 6g, Dafupi 15g, Hulu Pi 15g, Cheqian Zi 10g.

9. Analysis of Prescriptions Used by Professor Pei Zhengxue
   Professor Pei Zhengxue believes that hepatitis is caused by heat-toxin invading Shaoyang; prolonged illness leads to liver qi stagnation, followed by horizontal invasion of the stomach, and if left untreated, it evolves into fire generating dampness, eventually resulting in qi stagnation and blood stasis, with dual deficiency of qi and blood, and yang deficiency with water overflow. The fundamental pathogenesis lies in liver depression and spleen deficiency, so treatment emphasizes soothing the liver and strengthening the spleen to address the root cause, clearing heat and detoxifying to lower enzyme levels, and consistently reducing surface antigens. He proposes specific treatment formulas for different syndrome types: for acute jaundice hepatitis, which falls under the category of damp-heat accumulation, he recommends Yinchenhao Decoction with modifications; for chronic progressive hepatitis, the focus is on harmonizing Shaoyang, using Xiaochaihu Decoction with modifications; if liver function damage is the main issue, he suggests Qianggan Decoction (with Danggui, Baishao, Huangqi, Danshen, Qin Rao, Banlangen, Dangshen, Ze Xie, Gancao, Shan Zha, Shenqu, Mai Ya, Yinchen) with modifications; for patients with hypoproteinemia or inverted albumin/globulin ratio, he adds tonifying agents such as Huangqi, Danshen, Danggui, Heshouwu, Gegen, Xianhe Cao, Shengdi, Han Lian Cao, etc. In terms of dosage adjustments, for those with elevated transaminases, he prescribes Pei’s Five-Flavor Disinfecting Drink (Jinyinhua, Lianqiao, Pugongying, Baijiang Cao, Baihuashe She Cao), etc.; for patients with cirrhosis complicated by ascites, he adds Shipi Yin and Wupi Yin, as well as Wuling San; for severe jaundice, he adds Yinchen, Zhizi, and Dahuang; for jaundice accompanied by constipation, he increases Dahuang, Huangqin, and Huanglian; for jaundice with fever, he adds Zhizi and Shengshi Gao; for jaundice with systemic bleeding, he adds Shengdi, Daji, and Danshen; for liver pain, he adds Yanhusuo, Chuanlianzǐ, Zhi Ruxiang, and Zhi Meiyao; for pain radiating to shoulders and back, he adds Siguoluo, Chenxiang, Puhuang, and Wulingzhi; for poor appetite, he adds Ji Neijin; for abdominal distension, he adds Quanshi, Houpu, and Dahuang; for fever, he increases the amount of Chaihu to 20g, and for persistent high fever, he may add Shengshi Gao up to 30–60g, with some patients even receiving more than 100g; for night-time heat and morning coolness, he adds Qinghao, Biejia, Zhimu, Shengdi, and Danpi; for bone-steaming hot flashes, he adds Yin Chaihu 15g, etc. The content of Chinese herbal treatment for hepatitis is rich and diverse, and Professor Pei Zhengxue has also developed proprietary Chinese patent medicines for treating hepatitis B, including Hepatitis B Sweep Agent and Hepatitis B Health Boost Agent, which are convenient to take and have remarkable clinical efficacy.

10. Clinical Case Examples by Professor Pei Zhengxue
    Case 1: Mr. Liu, male, 38 years old. Chief complaint: Diagnosed with hepatitis B for over one year. Over the past year, the patient has felt fatigued, nauseous and averse to oil, followed by jaundice of the skin and eyes, yellow urine, and abnormal liver function tests at a local hospital. HBSAg was positive, and he was hospitalized for acute hepatitis B. After treatment, his symptoms largely disappeared, and his liver function basically returned to normal before discharge. However, HBSAg remained positive, and in the past two months, he again felt fatigued, nauseous and averse to oil, with hidden pain in the liver area, accompanied by irritability and bitter taste in the mouth. At the time of examination, the patient’s skin and eyes were slightly yellow but not very vivid, urine was yellow, tongue coating was yellow and greasy, and pulse was taut and slippery. Physical examination: The liver could be palpated 1.5 cm below the xiphoid process, soft in texture, tender to pressure, and there was percussion tenderness in the liver area; the spleen could not be palpated below the ribs. Laboratory tests: ALT 330 U/L, AST 101 U/L; HBSAg positive, HBeAg positive, anti-HBc positive, anti-HBe negative, anti-HBs negative.
    [Western Diagnosis] Chronic Active Hepatitis B.
    [TCM Differentiation] Shaoyang pathogenic factor invades, damp-heat stagnates in the spleen.
    [Treatment Principle] Harmonize Shaoyang and clear damp-heat.
    [Prescription] Xiaochaihu Decoction and Qianggan Decoction with modifications: Chaihu 15g, Huangqin 10g, Banxia 10g, Dangshen 15g, Yinchen 15g, Danshen 20g, Qin Rao 10g, Danggui 10g, Baishao 10g, Yujin 10g, Yi Ren 30g, Wu Zhu Yu 4g, Guai 20g, Yanhusuo 10g, Chuanlianzǐ 10g, Gancao 6g, Shengjiang 3g, Dazao 4 pieces. Decocted in water, one dose per day, totaling 30 doses, taken orally.
    After taking 30 doses consecutively, the patient’s mental state and appetite improved, jaundice subsided, pain in the liver area almost disappeared, the liver shrank back, and the tongue coating became thinner and slightly yellow. AST dropped to 88 U/L, the original formula removed Yanhusuo and Guai Wei, added Biejia 20g, and after another 30 doses, the pain in the liver area disappeared, the tongue and pulse returned to normal, ALT dropped to 34 U/L, HBeAg turned negative, anti-HBe turned positive, and the rest remained unchanged.
    In the third consultation, the formula removed Wu Zhu Yu and Chuanlianzǐ, added Huangqi 30g, Xian Mao 10g, fried Baizhu 10g, Huangjing 20g, and continued taking the medicine for three months, during which HBSAg also turned negative, and anti-HBs turned positive.

Case 2: Ms. Xie, female, 25 years old. Chief complaint: Found to have hepatitis B five years ago, with liver pain for two months. The patient was diagnosed with hepatitis B five years ago and improved after treatment, but HBSAg remained positive despite multiple treatments, never turning negative. In the past two months, she has experienced obvious pain in the liver area, reporting pain in both flanks, especially the right flank, accompanied by fatigue, loss of appetite, nausea and aversion to oily foods, afternoon low-grade fever, and heat in the palms and soles. Physical examination: Dull yellow complexion, slight yellowing of the sclera, flat abdomen, liver palpable 3 cm below the xiphoid process, ribs palpable 1.5 cm below, medium consistency, tender to pressure, with percussion tenderness in the liver area, and no palpation of the spleen below the ribs. Tongue slightly purple with ecchymoses, yellow coating, and a taut, fine pulse. Laboratory tests: ALT 860 U/L, HBSAg positive, HBeAg positive, anti-HBc positive, anti-HBs negative, anti-HBe negative.
[Western Diagnosis] Chronic Active Hepatitis B.
[TCM Differentiation] Qi stagnation and blood stasis, fire damaging yin, damp-heat not yet eliminated.
[Treatment Principle] Regulate qi and activate blood circulation, nourish yin and clear heat while promoting diuresis.
[Prescription] Qianggan Decoction with modifications: Chuan Ni Xi 10g, Danpi 10g, Danshen 20g, Mai Dong 10g, Shengdi 10g, Baishao 10g, Banlangen 10g, Danggui 10g, Chuan Xiong 6g, Yuan Hu 10g, Chuanlianzǐ 10g, Yujin 15g, Sheng Yi Ren 30g, Biejia 20g, Banxia 10g, Yinchen 20g, Shengjiang 2g. Decocted in water, one dose per day, totaling 30 doses, taken orally.
After taking 30 doses consecutively, the pain in the liver area greatly decreased, the patient’s mental state and appetite improved, the fever subsided, the heat in the palms and soles lessened, jaundice disappeared, the complexion became more radiant, the liver shrunk back, the xiphoid process reached 1.5 cm, the texture became softer, the tongue became lighter, still with some ecchymoses. The original formula removed Banxia and Shengjiang, added Wu Zhu Yu 5g, and after another 30 doses, the pain in the liver area basically disappeared, the liver shrank back, and the patient’s mental state and appetite improved. ALT dropped to 62 U/L, HBeAg turned negative. In the third consultation, the formula removed Yuan Hu and Chuanlianzǐ, added fried Baizhu 12g, and took the medicine for 25 doses, grinding it into a fine powder, taking 15g twice daily with warm boiled water, adding one jujube per dose. After nearly five months of continuous use, all symptoms disappeared, the complexion became radiant, the tongue returned to normal, ALT dropped to 25 U/L, HBSAg also turned negative, and both anti-HBs and anti-HBe turned negative. Follow-up for one year showed normal results.