II. Differential Diagnosis and Treatment

II. Differential Diagnosis and Treatment

(1) Spleen-Stomach Deficiency Type

① Symptoms: Epigastric fullness and discomfort, worse after eating, reduced appetite, poor digestion, and loose stools—sometimes even diarrhea and limb fatigue. Gastroscopic examination reveals a mix of red and white in the gastric mucosa, with thin and abundant mucus; gastric juice analysis shows low gastric acid levels. Tongue: The tongue body is large and has tooth marks, the tongue substance is pale red, the coating is thin and white, or just white. Pulse is fine and weak. ② Treatment: Strengthen the spleen and stomach, regulate qi, and relieve pain. ③ Prescription: Modified Xiangsha Liujunzi Decoction. Ingredients: 10g of agarwood, 10g of amomum villosum, 10g of tangerine peel, 10g of pinellia ternata, 10g of poria, 15g of stir-fried atractylodes, 15g of codonopsis, 5g of licorice. Decoct twice, mix well, take one dose daily, divided into three doses. ④ Note: This syndrome type is often seen in the early stages of chronic gastritis, and differentiation is not too difficult. Since spleen-stomach deficiency can further develop into spleen-stomach cold deficiency, careful observation for signs of cold is essential during differentiation. If the diagnosis is accurate, using the original Xiangsha Liujunzi Decoction can yield good results. The formula uses codonopsis, atractylodes, poria, licorice, tangerine peel, and pinellia to tonify qi, strengthen the spleen, and dry dampness, while agarwood and amomum villosum regulate qi, harmonize the stomach, and relieve pain. For patients with food stagnation, add Jiaosanxian, or first use a digestive aid (such as Baohe Wan) to address the symptom, then use Xiangsha Liujunzi Decoction to consolidate the root cause. Renowned veteran TCM physician Professor Jiang Chunhua says that regardless of the nature of chronic gastritis, the standard treatment is always Liujunzi Decoction with appropriate modifications based on the specific condition. Renowned integrated TCM-Western medicine internist Professor Pei Zhengxue has achieved remarkable success in treating chronic gastritis with modified Xiangsha Liujunzi Decoction, earning widespread acclaim. Here, the author appends a famous medical case treated by Dr. Pu Fuzhou, a renowned physician, for readers’ appreciation and reflection. Lin ××, male, 57 years old, first visit on February 23, 1963. Due to overeating, he had experienced epigastric distension, acid regurgitation, belching, loss of appetite, and loose stools more than ten times a day for a month, previously diagnosed as acute gastroenteritis. His pulse was deep and fine at the cun position, slippery at the guan position, and slow at the chi position; his tongue had a white, greasy coating with uneven edges. The diagnosis was stomach stagnation caused by dietary indiscretion, requiring treatment to harmonize the stomach and eliminate stagnation. Prescription: 1 qian each of white atractylodes, 2 qian of magnolia bark, 2 qian of tangerine peel, 1 qian of roasted licorice, 2 qian of charred hawthorn, 3 qian of fried malt, 1.5 qian of amomum villosum, 5 fen of agarwood, 3 qian of poria, 1 qian of fried citron, 3 slices of ginger. Two doses, each decocted twice, totaling 200ml, mixed with brown sugar, taken warm in two doses. On February 25, follow-up visit: after taking the medication, his stomach felt comfortable, with little gas and normal bowel movements. His pulse was slow and deep on the right side, fine and deep on the left side; the white, greasy coating on his tongue had disappeared, though the edges were still uneven. The stagnation had been eliminated, and his stomach qi was gradually recovering, so the treatment focused on strengthening the middle qi and reinforcing the spleen and stomach to consolidate the improvement. Prescription: 2 qian of codonopsis, 2 qian of poria, 1.5 qian of white atractylodes, 2 qian of pinellia, 1.5 qian of tangerine peel, 1 qian of amomum villosum, 5 fen of agarwood, 2 qian of yam, 2 qian of fried malt, 1 qian of fried citron, 2 walnuts (shelled but with husks), 2 jujubes, and 3 slices of ginger. Five doses, prepared and taken according to the same method as before.

(2) Spleen-Stomach Cold Deficiency Type

① Symptoms: Dull, lingering pain in the epigastric region that persists for a long time, with a preference for warmth and pressure; pain lessens with warmth and worsens with cold. Reduced appetite and poor digestion, with postprandial bloating or even vomiting clear saliva, pale complexion, and even pallor, fatigue, limb weakness, and aversion to cold. Tongue: The tongue body is large with tooth marks on the edges, the coating is white, and the pulse is deep, fine, and weak or slow. Microscopic indicators such as gastroscopy and gastric juice analysis are the same as for the spleen-stomach deficiency type. ② Treatment: Warm the center and harmonize the stomach, tonify qi and strengthen the spleen. ③ Prescription: Modified Huangqi Jianzhong Decoction. Ingredients: 15g of raw astragalus, 15g of codonopsis, 6g of cinnamon, 10g of white peony, 5g of amomum villosum, 15g of atractylodes, 10g of tangerine peel, 10g of agarwood, 5g of processed ginger, and 5g of licorice. Decoct twice, mix well, take one dose daily, divided into three doses. ④ Note: This type represents a further development of spleen-stomach deficiency, characterized by the emergence of cold symptoms on top of the existing deficiency, such as aversion to cold and limb chill, or preference for warmth and pressure in the stomach, with pain lessening upon warming and worsening upon cold exposure. This syndrome is also quite common in clinical practice, and differentiation is not difficult. Huangqi Jianzhong Decoction is a classic prescription for treating spleen-stomach cold deficiency, and the modified version mentioned above is the result of long-term clinical experience by renowned integrated TCM-Western medicine expert Professor Liu Baohou. As long as the diagnosis is accurate, the formula will always be effective. The formula uses astragalus, codonopsis, and atractylodes to tonify qi and strengthen the spleen, cinnamon and processed ginger to warm the center and dispel cold, amomum villosum, tangerine peel, and agarwood to regulate qi and harmonize the stomach, and white peony and licorice to relieve urgency and pain. For patients with obvious acid reflux or clear saliva vomiting, add wu yu, pinellia, and poria to warm the stomach and transform the fluid; for those with severe cold, combine with Liangfu Wan.

(3) Liver-Stomach Disharmony Type

① Symptoms: Epigastric pain and distension radiating to the flanks, recurrent episodes, frequent belching, rumbling acidity, nausea and vomiting, irritability and anger; or dry mouth and bitter taste. Gastroscopic examination may reveal acute inflammatory activity in the gastric mucosa and bile reflux. Tongue: The tongue substance is pale red or red, with thick white or slightly yellow coating. Pulse is string-like. ② Treatment: Soothe the liver and harmonize the stomach, regulate qi and relieve pain. ③ Prescription: Modified Chaihu Shugan San. Ingredients: 10g of bupleurum, 10g of white peony, 10g of cyperus rotundus, 10g of fried citron, 10g of chuanxiong, 10g of tangerine peel, 6g of licorice, 10g of curcuma, 10g of yuanhu, 10g of pinellia, and 10g of ginger. Decoct twice, mix well, take one dose daily, divided into three doses. ④ Note: Liver-stomach disharmony is also a common clinical syndrome. Clinical differentiation should focus on two key aspects: emotional factors and the stomach’s impaired descending function, which lead to symptoms such as nausea, vomiting, and belching. Chaihu Shugan San only serves to soothe liver qi; it must be combined with stomach-harmonizing herbs to completely resolve the problem. In the modified formula mentioned above, bupleurum, fried citron, white peony, curcuma, and chuanxiong soothe the liver and regulate qi, while tangerine peel, pinellia, and yuanhu harmonize the stomach and relieve pain. For those with prominent belching, add sandalwood, spiraea, and ochre; for those with nausea and vomiting, add fried wu yu, ginger, and coptis; for those with severe stomach pain, add frankincense and myrrh.

Bile reflux is one of the important causes of chronic gastritis, especially in cases of antral gastritis, where it is closely linked with bile reflux, and it is more common in atrophic gastritis than in superficial gastritis. Integrated TCM-Western medicine clinical observations show that patients whose macroscopic diagnosis falls under the category of liver-stomach disharmony often exhibit bile reflux on gastroscopy. Both the gallbladder and the liver belong to the wood element and are responsible for dispersing and draining; moreover, the gallbladder is one of the six fu organs, with a functional tendency toward descending and unblocking. Therefore, bile should naturally descend along the intestines; if the drainage is abnormal, bile excretion is obstructed, causing it to rise instead of fall, resulting in bile reflux into the stomach. Clinically, bile reflux can be classified as cold or heat. Liver qi stagnation belongs to the heat category; if it persists and transforms into fire, it can lead to excessive liver-gallbladder fire, affecting the spleen and stomach and resulting in spleen-stomach damp-heat, manifested as burning and distension in the epigastric region, dry mouth, bitter taste, bad breath, abdominal distension and fullness, thirst without desire to drink, and gastroscopic findings showing acute inflammatory activity in the gastric mucosa, with obvious congestion and erosion, red tongue, yellow and greasy coating, and a slippery, string-like pulse. Treatment involves modifying Hua Gan Jian: 10g of green peel, 10g of tangerine peel, 10g of white peony, 10g of danpi, 10g of fried gardenia, 10g of zexie, 10g of fritillaria, 10g of dandelion, 10g of scutellaria, 10g of pinellia, and 10g of cyperus rotundus. Decoct twice, mix well, take one dose daily, divided into three doses. For cold-type cases, the main pattern is liver-stomach deficiency, manifested as epigastric discomfort, chest and flank distension, gloominess, frequent sighing, loss of appetite, reduced food intake, loose stools, and general fatigue. The representative formula is modified Xiaoyao San: 10g of bupleurum, 10g of white peony, 20g of astragalus, 15g of stir-fried atractylodes, 10g of poria, 10g of yam, 10g of broad bean, 10g of fried citron, 10g of tangerine peel, 10g of fangfeng, and 6g of licorice. Decoct twice, mix well, take one dose daily, divided into three doses.

(4) Stomach Yin Deficiency Type

① Symptoms: Burning pain in the epigastric region, dry mouth and throat, ulceration of the oral and pharyngeal mucosa, reduced appetite and poor digestion, postprandial fullness, dry stools, dry heaving and belching, and a preference for cold drinks. Gastroscopic examination reveals patchy red-and-white mixing in the gastric mucosa, with thinning, drying, and reduced mucus, as well as low gastric acid levels. Tongue: The tongue is red with little moisture, cracked, or with a strip-like peeling in the central part, with no coating; in severe cases, the tongue substance appears red and shiny like a mirror, indicating severe atrophy of the filiform papillae. Pulse is fine or string-like. ② Treatment: Nourish stomach yin. ③ Prescription: Modified Ye’s Stomach-Nourishing Decoction. Ingredients: 10g of northern ginseng, 10g of ophiopogon, 10g of dendrobium, 10g of white peony, 10g of black plum, 10g of dandelion, 10g of fried broad bean, 10g of fragrant wood, and 6g of raw licorice. Decoct twice, mix well, take one dose daily, divided into three doses. ④ Note: This syndrome is a common presentation in atrophic gastritis. The root cause of stomach yin deficiency is atrophy of the gastric mucosa and a decline in its ability to secrete gastric juice. Clinical practice has proven that nourishing stomach yin can reverse gastric mucosal atrophy. Since Qing dynasty physician Ye Tianshi first proposed the method of nourishing stomach yin and invented the stomach-nourishing decoction, subsequent generations have followed this approach and used this formula to treat countless patients. In fact, in Ye Tianshi’s “Clinical Case Records,” the stomach-nourishing decoction was not originally intended for treating stomach pain, but rather for addressing stomach deficiency and reduced appetite, lack of hunger, and disharmony among the nine orifices; Ye used this formula to replenish stomach yin. Modern physicians, building on this foundation and referring to gastroscopic findings, have summarized many practical experiences in drug use. For example, some suggest that whenever gastric juice analysis and fiberoptic gastroscopy confirm chronic atrophic gastritis, regardless of whether the tongue shows signs of stomach yin deficiency, a stomach-nourishing agent should be added during treatment; of course, for those with greasy tongues, complementary diuretic herbs should be used. They have also found that white peony, black plum, schisandra, and hawthorn are top choices for nourishing stomach yin. Professor Hu Jianhua in Shanghai often uses hawthorn, black plum, and papaya as key ingredients for generating body fluids. In fact, papaya was also a favorite ingredient of Ye Tianshi for stimulating appetite and generating body fluids.

(5) Stomach Channel Blood Stasis Type

① Symptoms: Epigastric pain, localized and resistant to pressure; long-standing stomach pain that does not heal, with positive occult blood in the stool or black stools; gastroscopic examination reveals congestion and swelling of the gastric mucosa, accompanied by ecchymoses or bleeding points. Tongue: The tongue substance is dark red or purplish, with ecchymoses, and the pulse is string-like and rough. ② Treatment: Unblock the channels and relieve pain. ③ Prescription: Modified Danshen Drink combined with Shixiao San. Ingredients: 10g of danshen, 10g of sandalwood, 10g of amomum villosum, 10g of raw pu huang (packaged), 10g of wulingzhi, 10g of pinellia, 10g of tangerine peel, 10g of wine rhubarb, and 6g of licorice. Decoct twice, mix well, take one dose daily, divided into three doses. ④ Note: Actually,

34 Integrated TCM-Western Medicine Treatment for Epigastric Pain

Blood stasis is a common accompanying sign throughout the evolution of this disease. Microcirculatory dysfunction exists throughout the entire course of the illness, only varying in degree at different stages. Ancient practitioners believed that prolonged illness eventually invades the channels because, in the late stages, microcirculatory dysfunction becomes apparent on a macroscopic level. Therefore, at different stages of the disease, incorporating blood-circulating and stasis-resolving herbs can significantly improve therapeutic outcomes, especially for long-standing cases. In “Clinical Case Records,” Ye Tianshi documented using Shixiao San combined with Jinlingzi San to treat stomach pain caused by long-term blood stasis blocking the stomach channels: “Mr. Pan had a string-like, rough pulse, missed periods, alternating between cold and heat, and suffered from stomach pain that resisted pressure, with nausea and refusal to eat. This was due to long-term stomach pain and blood stasis accumulating in the stomach channels. It was recommended to use pungent herbs to unblock stagnation, such as chuanlianzi, yanhu, guizhi, wulingzhi, pu huang, and xiangfu.”

Additionally, blood stasis is a pathological product, meaning it arises from deficiency; therefore, blood-circulating and stasis-resolving treatments should be based on reinforcing deficiency. Another point is that, for patients with atrophic gastritis who, upon pathological examination, are found to have intestinal metaplasia, atypical hyperplasia, multiple polyps, or pseudo-polyps, it can be considered channel damage with blood stasis. Based on differential diagnosis, additional herbs such as danshen, danggui, safflower, chuanxiong, sanleng, ezhushi, and jiuxiangchong can be selected to promote blood circulation, dissolve stasis, soften hard masses, and disperse nodules; alternatively, ba yue zha, sheng yi ren, ezhushi, bo mo, etc., can be used for prevention of malignant transformation. Some have observed that adding 30g each of baihua she shi cao and tufuling, and re-examining the gastroscopy three months later, can eliminate intestinal metaplasia in one-third to one-half of the cases. These clinical medication experiences can all be referenced.

III. Single Prescriptions and Medicinal Diet

(1) 15g each of peach kernels and wulingzhi, lightly stir-fried and ground into powder, mixed with rice vinegar to form pills about the size of small beans. Take 15–20 pills each time, washed down with hot water; pregnant women should avoid this. Treats blood-stasis-related stomach pain.

(2) 4.5g each of wulingzhi and dried alum, finely ground together, taken twice daily with hot water. Treats blood-stasis-related stomach pain.

(3) 30g of lily bulbs and 20g of danshen, decocted on an empty stomach. Treats stomach pain due to虚热.

(4) 30g of lily bulbs, 9g of wu yu, and 9g of yuanhu, decocted and taken. Treats stomach pain due to虚寒.

(5) Xiangsha Yangwei Pills (composed of atractylodes, tangerine peel, magnolia bark, agarwood, amomum villosum, etc.), made into water pills, 6 pills each time, twice daily. Can strengthen the spleen and stomach, regulate qi, and relieve pain. Mainly indicated for stomach pain caused by spleen deficiency and liver qi stagnation.

(6) Warming Umbilicus Paste (composed of agarwood, fennel, frankincense, cinnamon, musk, etc.), applied once per session, gently melted over low heat and applied to the umbilical area. Functions to warm the center and dispel cold, warm the abdomen, and relieve pain. Mainly indicated for stomach pain due to spleen-stomach cold deficiency.

(7) Turtle Paste (composed of turtle, raw sanleng, frankincense, myrrh, etc.), applied once per session, gently melted over low heat and applied to the umbilical area. Functions to dissipate accumulation, resolve stasis, and relieve pain. Mainly indicated for stomach pain caused by qi and blood stagnation.

(8) Fuzi Lizhong Pills (composed of aconite, dried ginger, ginseng, atractylodes, licorice), made into honey pills, 1 pill each time, twice daily. Suitable for stomach pain due to spleen-stomach cold deficiency.

(9) Beneficial Spleen Cake: 120g of atractylodes, 60g of dried ginger, 60g of chicken gizzard, and 250g of cooked jujube flesh. Roast the atractylodes, dried ginger, and chicken gizzard until crispy, grind them into fine powder, mix with steamed jujube flesh (peeled) and pound thoroughly to make jujube paste, then form 6 small cakes and bake them over low heat. Eat as a snack on an empty stomach, chew slowly and deliberately, 1 small cake per day. This recipe originates from “Medical Insights from East and West” written by the renowned physician Zhang Xichun. Functions to tonify qi and strengthen the spleen, aid digestion, stimulate appetite, and is suitable for chronic gastritis with indigestion, reduced appetite, and diarrhea—conditions associated with spleen-stomach cold deficiency.

(10) Buddha’s Hand Porridge: 15g fresh Buddha’s hand, 100g glutinous rice, and appropriate amount of rock sugar. When the glutinous rice porridge is cooked to about 80% doneness, wrap the Buddha’s hand in a cheesecloth bag and add it to the porridge, cook for another 15 minutes, remove the bag, and add rock sugar. Drink warm in moderation, twice daily. Functions to regulate qi, relieve pain, and nourish the stomach, suitable for stomach pain caused by liver-stomach disharmony.

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(11) Black Plum Paste: 2,500 g of black plums and appropriate amount of malt syrup. Boil the black plums until soft, remove the pits, then reduce the juice and pulp over low heat. Add malt syrup and mix well, then cool and store in a porcelain bottle. Take 10 ml before meals, three times daily. Suitable for patients with chronic atrophic gastritis and hypochlorhydria.

(12) Mutton Soup: 500 g of mutton, 100 g of radish, 3 cardamom pods, 3 g of dried tangerine peel, 3 g of ginger, 5 g of galangal, 3 g of amomum villosum, 3 g of pepper, and 3 g of white onion. Bring to a boil over high heat in an earthenware pot, skim off the foam, then simmer over low heat for 2–3 hours until the mutton is tender. Eat the meat and drink the soup while hot. Functions: warm the middle burner and tonify deficiency, dispel cold and relieve pain; suitable for spleen-stomach deficiency-cold syndrome.

IV. Acupuncture Treatment

(1) Acupuncture Treatment: When chronic gastritis causes epigastric pain and vomiting, the acupoints selected and the techniques used are the same as those for "acute gastritis," so further details are omitted.

(2) Moxibustion Treatment: Select the acupoints Zusanli and Shenque, suitable for deficiency-cold type stomach pain.

V. Western Medical Treatment