I. Traditional Chinese Medicine’s Understanding of This Disease

I. Traditional Chinese Medicine’s Understanding of This Disease

Based on the clinical manifestations of chronic gastritis, in Traditional Chinese Medicine it should be categorized under terms such as “epigastric pain,” “acid regurgitation,” and “noisy discomfort.” In addition, ancient medical texts also mention names like “pain in the epigastrium near the heart,” “fullness and pain below the heart,” and “heartburn-like discomfort.” In vast rural areas, even today, “gastric pain,” including chronic gastritis, is still referred to as “pain in the heart region,” because the heart and stomach are separated only by a thin membrane and are relatively close to each other, hence the origin of these terms. On the other hand, cardiac diseases can also present with “gastric pain” symptoms; for example, some patients with atypical myocardial infarction often experience symptoms that closely resemble “gastric pain,” and if not examined carefully, they may be misdiagnosed, leading to serious consequences.

From the “Yellow Emperor’s Classic of Internal Medicine” to the renowned Qing Dynasty physician Ye Tianshi, generations of medical practitioners have provided profound discussions on the etiology, pathogenesis, and clinical differentiation and medication for “gastric pain.” The “Plain Questions—On Bi” first put forward the theory that “when diet is doubled, the intestines and stomach are injured,” clearly pointing out that dietary indiscretion is an indispensable causative factor in this disease. This argument was fully developed by Li Dongyuan, one of the famous Four Great Masters of the Jin-Yuan period. In his work “On the Spleen and Stomach,” Li Dongyuan stated: “If diet is not regulated and temperature is inappropriate, the spleen and stomach will be injured”; “If the fundamental qi of the stomach is weak and diet is doubled, both the qi of the spleen and stomach will be damaged, and the original qi will also fail to be replenished, thus giving rise to all kinds of diseases.” His formula “Bu Zhong Yi Qi Tang” is a famous prescription for treating deficiency of middle qi, and in “Lan Shi Mi Cang” he recorded that to tonify the spleen and stomach, one should use ginseng, astragalus, and fried licorice; to warm the middle, use evodia, white cardamom, and alpinia; to regulate qi, use magnolia bark, green tangerine peel, bupleurum, thick bark, and amomum; to harmonize the stomach, use roasted malt, Shenqu, pinellia, and tangerine peel; and to nourish the blood, use angelica, peach kernel, and safflower. Ming Dynasty physician Li Zhongzi, in his “Essential Readings on Medical Principles,” pointed out that epigastric pain is also accompanied by “either fullness, or distension, or vomiting, or inability to eat, or acid regurgitation, or difficulty in defecation, or diarrhea, or facial swelling and yellowing,” all of which can be seen in chronic gastritis, reflecting Li’s rich clinical experience. Zhang Jingyue, another great physician of the Ming Dynasty, believed that gastric pain “is most often caused by food stagnation, cold stagnation, and qi stagnation; cases caused by parasites, fire, phlegm, or blood can also cause pain. Most acute cases are due to the first three factors, while chronic cases are more often due to the last four.” This indicates that both acute gastritis and acute exacerbations of chronic gastritis are often triggered by food stagnation, cold congealing, and qi stagnation, whereas the formation of chronic gastritis is related to long-term interference from parasites, fire, phlegm, and blood. Qing Dynasty physician Ye Tianshi, throughout his life, not only made epoch-making contributions to the treatment of external wind-heat diseases, but also his numerous discussions and experiences in differential diagnosis and medication for spleen and stomach diseases had a huge impact on later generations. As he said in “Clinical Guidelines for Medical Cases”: “Food intake is governed by the stomach, while transformation and transportation are governed by the spleen. The spleen thrives when it rises, and the stomach thrives when it descends. Taiyin damp earth needs yang to start moving, while Yangming dry earth needs yin to settle down; the spleen prefers dryness and firmness, while the stomach prefers softness and moisture.” Ye creatively summarized the physiological characteristics of the spleen and stomach—rising and descending, taking in and transforming, drying and moistening—and especially emphasized the view that “the stomach prefers moisture and dislikes dryness,” which was later widely praised by scholars, adding the methods of nourishing stomach yin and lowering stomach qi to Li Dongyuan’s approach of tonifying qi and raising yang, resulting in the widespread application of Ye’s “Stomach-Nourishing Soup.” In addition, Ye’s views such as “long-term illness enters the collaterals,” “long-term pain inevitably turns into heat,” and “initial pain is in the qi, but long-term pain inevitably enters the blood” provide valuable guidance for determining medication regimens in the differential diagnosis and treatment of chronic gastritis. When explaining the pathological mechanism of gastric pain, Ye also pointed out: “Pain means blockage; to unblock, one must investigate qi, blood, yin, and yang—this is the essence of diagnosing illness.” In other words, gastric pain is always caused by blockage of qi flow, but the reasons for this blockage can be divided into qi, blood, yin, and yang. Once these principles are understood, one has grasped the essence of diagnosing illness. During the Qing Dynasty, several other physicians also demonstrated great insight and practicality in the differential diagnosis and medication for gastric pain. For example, Gu Jingyuan advocated using “Peony and Licorice Decoction” as the base for treating gastric pain caused by disharmony between the liver and spleen, combining it with “Four Grind Drink” for qi stagnation, adding “Lost Smile Powder” for blood stasis, and using “Preservation Harmony Pill” for food stagnation. Xu Dachun preferred using “Clear Middle Soup” to treat gastric heat pain and rapid pulse: 3 grams of coptis, 4.5 grams of pinellia, 6 grams of gardenia, 3 grams of cardamom, 4.5 grams of poria, 4.5 grams of tangerine peel, 1.5 grams of licorice, and 3 slices of ginger, made into a powder, 9 grams each time.

Taking into account the understanding of the etiology and pathogenesis of gastric pain across generations of medical practitioners, combined with modern medical research on chronic gastritis, it can be seen that the main cause of chronic gastritis is internal injury. Internal injury factors include dietary injury and emotional/mental exhaustion injury. Among them, dietary injury not only includes overeating, consumption of raw and cold foods, overly hot and stimulating foods, strong alcohol, strong tea, coffee, and other substances that damage the spleen and stomach, but also the use of bitter-cold medicines and certain irritating Western medicines that harm stomach qi, which also falls under the broad category of dietary injury. Emotional/mental exhaustion injury, in a broader sense, also includes pathological reactions in the gastric mucosa caused by severe diseases in other organs (i.e., secondary gastritis).

The occurrence and development of chronic gastritis is precisely the result of the interplay of these causative factors, leading to dysfunction in the spleen and stomach’s abilities to take in and transform, rise and descend, dry and moisten. Subsequently, under this pathological state, on the one hand, pathological products such as phlegm-dampness and blood stasis are generated, while on the other hand, the spleen and stomach become more susceptible to invasion by internal injury factors such as diet, emotions, and fatigue, thus forming a vicious cycle. Since food stagnation, cold congealing, liver qi stagnation, and phlegm-blood stasis are all tangible evils, they often give rise to a pathological mechanism characterized by both deficiency and excess, with deficiency predominating and cold outweighing heat during the course of the disease.

<!-- translated-chunk:4/16 -->

Chronic gastritis, especially chronic atrophic gastritis, is characterized in its development and progression primarily by two major pathological features: spleen-stomach qi deficiency and spleen-stomach yin deficiency, which also represent the two fundamental syndrome types of this disease. However, when examined in detail, spleen qi deficiency and stomach qi deficiency, as well as stomach yin deficiency and spleen yin deficiency, each have their own distinct clinical characteristics; let us briefly explore these separately. The primary physiological function of the stomach is to receive and transform food and fluids, then propel them downward into the intestines. To put it metaphorically, the stomach is like a stone mill for making soy milk: stomach qi serves as the driving force that turns the mill, while stomach yin is akin to the liquid itself. If the driving force is insufficient, the mill will stop turning; if there is a lack of liquid, the beans cannot be ground into soy milk. Similarly, when a person’s stomach qi is deficient, the stomach’s ability to digest and move food downward weakens, leading to symptoms such as poor appetite and reduced food intake. If the condition further progresses, the yang qi of the stomach is damaged, internal coldness arises, and qi stagnation occurs due to cold congealing, causing the stomach’s peristaltic function to decline even more. This can easily result in a pattern of stomach cold with qi stagnation, which is quite common in clinical practice. In addition to poor appetite and reduced food intake, patients may experience bloating, fullness, heaviness, and indigestion after eating, with symptoms worsening after consuming cold or raw foods and alleviating when exposed to warmth. Stomach yin deficiency indicates a depletion of gastric fluids, leaving the stomach without adequate nourishment. Patients often present with dry mouth, dry tongue, reduced food intake, burning sensations in the stomach, and constipation, frequently developing oral ulcers.

When spleen qi is weak and the spleen loses its ability to transport and transform, it becomes difficult to ascend clear qi and descend turbid qi, leading to distension and diarrhea. Although the patient’s stomach still retains some capacity for receiving food, they may feel normal appetite but experience discomfort and fullness in the epigastric region after eating, particularly in the afternoon. Their stools are often loose, accompanied by fatigue in the limbs and general weakness. In severe cases, patients feel a sense of blockage or pressure in the epigastric area, as if something is pushing against it, along with frequent belching. As the condition progresses, they may develop aversion to cold and preference for warmth, with symptoms improving upon warming and worsening in cold conditions, indicating that the pathogenesis has evolved from spleen qi deficiency to spleen yang deficiency. Since spleen qi deficiency and spleen yang deficiency often coexist with stomach qi deficiency and stomach yang deficiency, these syndromes are frequently grouped together clinically as spleen-stomach deficiency and spleen-stomach cold deficiency. These two patterns are very common in clinical practice, especially in northern China, accounting for about 60% of all clinical presentations. Pure spleen yin deficiency is relatively rare, with symptoms almost identical to those of stomach yin deficiency—reduced appetite, dry stools, weight loss—and the absence of oral ulcers is a characteristic feature of spleen yin deficiency. It should be clarified here that, due to different etiologies, spleen and stomach deficiencies may occur sequentially or concurrently, with varying degrees of severity; however, ultimately both organs are invariably compromised, resulting in concurrent spleen-stomach pathology.

A small number of patients with atrophic gastritis presenting as spleen-stomach cold deficiency may, over time, develop heat due to prolonged cold, with the cold transforming into dryness in the Yangming channel (referring to the stomach), leading to a thin yellow coating on the tongue, dry mouth, bitter taste, and a craving for cold drinks. After drinking, patients still feel discomfort in the stomach, suggesting that the underlying pattern remains spleen cold with mixed heat. The spleen governs the transformation and transportation of dampness, so it dislikes dampness; when spleen qi is weak, it cannot properly transform and transport dampness, resulting in dampness and stomach heat combining to form a warm-heat pattern. However, spleen-stomach damp-heat patterns vary greatly among individuals, with different degrees of dampness and heat, manifesting as either heat predominating over dampness or dampness predominating over heat. Spleen-stomach damp-heat is commonly seen during the active phase of atrophic gastritis, particularly in patients positive for Helicobacter pylori, or those complicated by peptic ulcers, and is more likely to occur in patients with alcohol and tobacco habits. Elderly patients with atrophic gastritis sometimes exhibit both spleen qi deficiency and stomach yin deficiency simultaneously, forming a pattern of spleen-stomach qi-yin deficiency. Of course, when stomach yin deficiency is predominant, signs of yin deficiency with excess fire may also appear, such as one or several superficial ulcers in the oral cavity, a red tongue with little coating, or a central patch of peeled-off coating on the tongue. Some patients are prone to irritability and depression, leading to liver qi stagnation. Prolonged liver qi stagnation can invade the stomach, resulting in liver-stomach disharmony, with symptoms including chest and flank distension and fullness, epigastric pain and pressure, belching, and even nausea and vomiting. If the stagnation persists and transforms into fire, patients may experience bitterness in the mouth and dry stools. When liver qi fails to disperse effectively, it leads to stagnation of the spleen's earth element, known as liver-stomach deficiency, manifested as depression, gloominess, involuntary sighing, epigastric discomfort, abdominal distension and pain, reduced appetite, and loose stools. Modern research shows that liver-stomach disharmony and liver-spleen disharmony are often accompanied by bile reflux.

Blood stasis is both a pathological product of spleen-stomach deficiency and a contributing factor to the further progression of chronic gastritis. Ye Tianshi once said, “In the early stages of illness, it resides in qi; over time, it inevitably enters the blood,” and this is precisely the principle behind it. Chronic gastritis that persists for a long time and recurs frequently most profoundly affects the ascending and descending movement of qi in the middle jiao. Spleen-stomach qi deficiency or spleen-stomach qi stagnation inevitably leads to blood stasis in the stomach, becoming a fundamental pathological change in the later stages of chronic gastritis. In fact, blood stasis exists throughout the entire process of the disease’s onset, development, and transformation, varying in degree. In some cases of atrophic gastritis, blood stasis is significant, with blood obstructing the channels and causing pain when blocked, resulting in stabbing or piercing pain in the epigastric region, localized and resistant to pressure, or even bleeding due to damage to the vessels, with blood spilling out through vomiting or seeping into the stool, giving the feces a tarry appearance, and the tongue appearing dark purple. With the widespread use of fiberoptic gastroscopy, our understanding of blood stasis in chronic gastritis has deepened, and it has become one of the microscopic diagnostic indicators for identifying blood stasis. Generally speaking, the more severe the inflammatory infiltration in the gastric mucosal tissue, the more severe the blood stasis; the milder the infiltration, the milder the blood stasis; the more pronounced the fibrous tissue proliferation, the more severe the blood stasis, and vice versa. Pale or mottled (patchy) mucosal color under gastroscopy, thinned mucosa, blue-tinged blood vessels, and granular or pustule-like elevations are also considered signs of blood stasis. In elderly patients with atrophic gastritis, the gastric mucosal blood vessels are often twisted, the vessel walls are thickened, the lumens are narrowed, blood flow is impaired, and the glands receive insufficient nutrient supply, which may also be one of the reasons why glandular atrophy is more common and severe in older adults. Extensive clinical practice and experimental studies have shown that traditional Chinese medicines with the functions of promoting blood circulation and resolving stasis can inhibit connective tissue hyperplasia, improve microcirculation in the gastric mucosa, and even promote the disappearance of inflammatory cell infiltration. Therefore, in the differential diagnosis and treatment formulas for chronic gastritis, especially atrophic gastritis, appropriately adding some blood-circulating and stasis-resolving herbs can indeed enhance clinical efficacy. Traditional Chinese medicine holds that “qi is the commander of blood, and blood is the mother of qi; when qi flows, blood flows, and when qi stagnates, blood also stagnates.” Thus, stasis-resolving herbal medicines must be combined with qi-tonifying and qi-regulating agents to achieve the desired therapeutic effect.