(2) Ascariasis Heat Type

① Symptoms: Fever, alternating chills and fever, jaundice, dry and uncomfortable stools, yellowish-red urine, tension in the abdominal muscles of the upper abdomen, obvious tenderness, and percussion tenderness in the right flank area. White greasy or yellow greasy coating,弦滑 or弦数 pulse.

② Treatment Principle: Clear heat and detoxify, promote bowel movement and expel parasites.

③ Prescription: Modified Wu Mei Wan combined with Da Chai Hu Tang. Ingredients: 30g of Wu Mei, 10g of Huang Lian, 10g of Huang Qin, 10g of Huang Bai, 10g of Chuan Jiao, 10g of Xi Xin, 30g of Yin Chen, 20g of Chai Hu, 10g of Zhi Shi, 10g of Bin Lang, and 10g of Sheng Da Huang (added later). Decoct twice, mix well, and take in three doses, 1–2 doses daily.

④ Note: This type often develops from untreated ascariasis stagnation type and is similar to what Western medicine calls biliary ascariasis complicated by infection. If it progresses further, it can turn into hepatobiliary sepsis, including acute suppurative cholecystitis, acute severe cholangitis, suppurative capillary cholangitis, and bile duct bleeding. Research has found that when biliary ascariasis is complicated by Yangming organ real-time issues, adding purgative drugs like Da Huang and Mang Xiao can relieve biliary colic more quickly than using Wu Mei Wan alone, shortening treatment time and increasing cure rate. Additionally, Wu Mei Wan itself has anti-infective effects; the Huang Lian and Huang Bai in the formula are powerful antibacterial and anti-inflammatory agents. At the same time, by increasing bile excretion, the synergistic effect of bile further enhances antibacterial potency. Combined with Da Chai Hu Tang, the power to clear heat, dry dampness, and detoxify is even stronger. Regarding the formation of damp-heat, TCM believes that spleen deficiency generates dampness, liver stagnation turns into fire, and fire accumulates into toxicity—this is the most common complication of biliary ascariasis. Therefore, some clinicians advocate using heat-clearing, detoxifying, and damp-drying medicines early in treatment, which is beneficial for quickly relieving pain, vomiting, restlessness, and syncope. In the aforementioned modified formula, if vomiting is severe, add Jiang Ban Xia and Zhu Ru; if pain is intense, add fried Yuan Hu.

III. Single Prescriptions for Treatment

(1) Take 6ml of edible vinegar or aged vinegar plus 0.5–1g of Sichuan pepper powder, swallow once, and repeat every 4 hours if needed.

(2) Mix 10g of betel nut powder, 8g of raw rhubarb powder, and 1g of Sichuan pepper powder, and consume in several doses within 3 hours.

(3) Use 150–200g of fresh ginger, peel and extract the juice, add 60–100g of honey, take once, 2–3 times daily; reduce dosage appropriately for children.

IV. Acupuncture Treatment

Commonly selected acupuncture points include Jiuyu, Dan Yu, Zhong Wan, Yang Ling Quan, and the gallbladder point (3cm below Yang Ling Quan), or Ying Xiang透Si Bai and Zhong Wan透Liang Men. Use draining techniques, retain needles for 30 minutes, or apply electroacupuncture for 30 minutes with continuous wave, adjusting intensity to a tolerable level, 2–3 times daily.

Acupuncture for pain relief plays an important role in treating biliary ascariasis. Some believe that since preparing and absorbing the herbal formula takes time, it cannot immediately alleviate the patient's pain, so acupuncture is needed for pain relief. The essence of acupuncture for pain relief is to relieve spasm in the bile ducts. In my experience, selecting the gallbladder point for drug blockade (commonly using scopolamine-based drugs like 654-2) is the most effective method. Patients with biliary ascariasis often have very obvious tenderness at the gallbladder point; after drug blockade treatment, they feel as if the tightly contracted internal organs in the upper abdomen suddenly loosen, and the pain disappears accordingly. Seeing patients burst into laughter after their pain is relieved, I deeply admire the miraculous efficacy of acupuncture for pain relief and am grateful to our ancestors for creating such brilliant medical skills.

V. Western Medical Treatment

1. Spasmolysis and Pain Relief: Can use 0.5mg of atropine, combined with 25mg of chlorpromazine; if diagnosis is clear, can also combine with 50mg of pethidine via intramuscular injection. Alternatively, can use 8mg of vitamin K₃ via intramuscular injection for pain relief. In fact, using the above medications for drug blockade at the gallbladder point provides better pain relief than acupuncture alone or intramuscular analgesics. Combining the strengths of both Chinese and Western medicine to create treatments that surpass either approach alone is probably one of the directions future integrative medicine practitioners should strive for.

2. Parasite Expulsion: Patients with biliary ascariasis should undergo early parasite expulsion promptly. Can use 3g of Chu Wei Ling tablets, taking one dose before bed and another the next morning. For children, calculate 0.1–0.15g per kilogram of body weight, with a total dose not exceeding 3g. Alternatively, can use 10ml of 30% magnesium sulfate orally, three times daily.

3. Anti-Inflammatory and Bile-Promoting: For simple biliary ascariasis without obvious infection in the early stages, using both Chinese and Western medicines to promote bile drainage is the most important measure to prevent infection. Commonly used are 0.25g of dehydrocholic acid three times daily, or 0.2g of sodium cholate three times daily. When infection occurs, antibiotics should be administered, especially if there is chronic inflammation or stones in the bile ducts, as roundworms often trigger acute infections. Therefore, preventing bile duct infection should occupy a very important position in the treatment of biliary ascariasis.

4. Nutrition and Balance of Water and Electrolytes: Timely and appropriate supplementation of nutrition, water, and electrolytes to prevent acidosis is essential.

5. Surgical Treatment: Non-surgical treatment for biliary ascariasis is generally effective, with a cure rate of 95%. However, surgical treatment should be considered in any of the following situations: incision of the common bile duct to remove the roundworms.

① Biliary ascariasis complicated by acute suppurative cholangitis, cholecystitis, necrotic acute pancreatitis, etc.

② Severe complications such as hepatic abscess caused by roundworms, perforation of the gallbladder, bile duct bleeding, or toxic shock.

③ Cases where internal medicine treatment is ineffective, or although symptoms disappear, they recur multiple times within a short period.

VI. Prevention

First and foremost, prevent intestinal roundworm infection and treat intestinal roundworm disease early. When treating intestinal roundworm disease, pay attention to using appropriate medications and sufficient dosages to avoid improper medication or insufficient dosage, which could instead stimulate the roundworms to ascend into the bile ducts.

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Chapter 9: Cholecystitis and Cholelithiasis

Section 1: Overview

Cholecystitis refers to inflammation occurring in the gallbladder and can be divided into acute cholecystitis and chronic cholecystitis. Cholecystitis and cholelithiasis are often causally related, like twin sisters; clinically, they often coexist. The reason is that stone formation stimulates the gallbladder wall to become inflamed, and the presence of inflammation, in turn, creates conditions conducive to stone formation. In recent years, with the significant improvement in material living standards among urban and rural residents and the increased cholesterol content in diets, the incidence of gallstones has risen markedly, and the number of patients experiencing acute attacks of cholecystitis has also increased compared with the past. The incidence is approximately 1% of the adult population and accounts for 5%–10% of general surgery inpatient admissions. The incidence of cholecystitis and cholelithiasis is higher in middle age and older, with obese women being about four times more likely to develop these conditions than men.

Although acute cholecystitis can also be triggered by other factors (such as typhoid fever, sepsis, and other systemic infections), obstruction of the gallbladder neck by stones leading to impaired bile excretion is a major cause. Impaired bile excretion leads to bile stasis, which further concentrates the bile, and the high concentration of bile salts irritates the mucosa of the gallbladder wall, causing acute inflammatory changes. On the other hand, once bile stasis occurs, the environment inside the gallbladder becomes favorable for bacterial growth and reproduction, promoting the onset and progression of inflammation. Of course, bacteria can also enter the bile duct from the intestine, probably because, after bile excretion is blocked, bacteria in the duodenum lose the inhibitory effect of bile and rapidly proliferate. Regardless of the cause of cholecystitis, the pathogenic bacteria are mostly the same, mainly Escherichia coli, Bacteroides, and Pseudomonas aeruginosa.

If acute cholecystitis recurs frequently, the constant mechanical stimulation of the gallbladder wall by stones, coupled with the chemical erosion of concentrated bile and the action of bacterial toxins, can lead to ulcers or thickening and hyperplasia of the gallbladder wall, eventually resulting in gallbladder atrophy and adhesions around the gallbladder (perigallbladder inflammation), clinically manifesting as chronic cholecystitis.

Cholelithiasis can be broadly classified according to the location of the stones into gallbladder stones, intrahepatic bile duct stones, and common bile duct stones; according to composition, into cholesterol stones, bilirubin stones, and mixed stones; according to shape, into muddy sand-like stones and hard stones; a single stone is called a solitary stone, while two or more are called multiple stones. The formation of stones is closely related not only to infections in the biliary tract but also to bile stasis and cholesterol metabolism disorders. Interestingly, researchers have found that many stones contain roundworm eggs or even parts of roundworm bodies, indicating that roundworm infection is crucial for stone formation. In addition, overly slow gallbladder motility and prolonged retention of cholesterol crystals in the gallbladder, accumulating (possibly centered around roundworm bodies, like a snowball rolling and gradually growing larger), also contribute significantly to stone formation.

Section 2: Diagnosis