II. Syndrome Differentiation and Treatment

II. Syndrome Differentiation and Treatment

(1) Liver Qi Stagnation Type

① Symptoms: Dull pain in the right hypochondrium, often exacerbated or alleviated by emotional fluctuations; irritability and quick temper; chest tightness with frequent sighing; abdominal distension and poor appetite; pale-red tongue with thin white coating; wiry pulse. ② Treatment Principle: Soothe the liver to resolve qi stagnation, promote bile flow, and harmonize the stomach. ③ Formula: Modified Chaihu Shugan San. Ingredients: Chaihu 10g, Baishao 10g, Zhixiangfu 10g, Zhike 10g, Chuanxiong 10g, Guangmuxiang 10g, Jinqiancao 15g, Chuanlianzǐ 10g, Yujin 10g, Wuyao 10g, Gancao 6g. Decoct twice, mix well, divide into three doses, take one dose daily. ④ Note: This syndrome corresponds to acute simple (non-bacterial) cholecystitis, early stages of certain acute cholecystitis cases, gallstones without obvious obstruction in the common bile duct or gallbladder, or minor exacerbations of chronic cholecystitis. If liver qi invades the stomach, it is termed liver-stomach disharmony, presenting with nausea, vomiting, and acid regurgitation; additional herbs such as Jiangbanxia, Chenpi, fresh ginger, Xuanfuhua, Huanglian, and Wuyu may be added to soothe the liver, harmonize the stomach, and reverse rebellious qi. If qi stagnation transforms into fire, manifesting as restlessness, bitter taste in the mouth, dry mouth, red tongue with yellow coating, and wiry pulse with rapid rhythm, add Danpi, fried Zhizi, Huzhang, and Longdancao to clear liver fire.

(2) Liver-Gallbladder Damp-Heat Type

① Symptoms: Persistent distending pain in the right upper abdomen or epigastrium, sometimes sharp and cramping; hard, full, and tender to palpation; bitter taste in the mouth, dry throat, nausea, vomiting; aversion to food; alternating chills and fever or alternating cold and heat; jaundice of the skin and eyes; dark yellow urine; constipation; red tongue with greasy yellow coating; wiry and slippery or wiry and rapid pulse. ② Treatment Principle: Clear the liver and promote bile flow, unblock the bowels and purge. ③ Formula: Modified Dachaihu Tang combined with Yinchenhao Tang. Ingredients: Chaihu 20g, Huangqin 10g, Banxia 10g, Zhishi 10g, Houpu 10g, Jinqiancao 30g, Yinchen 15g, Zhizi 10g, Huzhang 10g, Gongying 15g, Yujin 10g, Shengdahuang (added later) 10g, Gancao 5g. Decoct twice, mix well, divide into three doses, take one dose daily. ④ Note: This syndrome corresponds to acute suppurative cholecystitis, cholangitis, and cholelithiasis complicated by biliary tract infection. If toxic heat accumulates internally and disturbs the spirit, leading to confusion and delirium, An Gong Niu Huang Wan may be administered. Concurrent Western antibacterial therapy is required, with close monitoring of disease progression; surgical intervention should be promptly considered when indicated.

(3) Blood Stasis Type

① Symptoms: Sharp pain in the right hypochondrium, localized and fixed; pain worsens at night; dull complexion or masses palpable under the ribs; purple-dark tongue. ② Treatment Principle: Activate blood circulation to remove stasis, promote bile flow, and unblock the bowels. ③ Formula: Modified Xuefu Zhuyu Tang. Ingredients: Chaihu 10g, Chishao 10g, Taoren 10g, Danggui 10g, Chuanxiong 10g, Chuan Niuxi 10g, Yujin 10g, Shengdahuang (added later) 10g, Jinqiancao 20g, Huzhang 10g, Honghua 10g, Gancao 5g. Decoct twice, mix well, divide into three doses, take one dose daily. ④ Note: This syndrome is commonly seen in long-standing, refractory cases of chronic cholecystitis and cholelithiasis. Prolonged retention of gallstones leads to tissue hyperplasia within the gallbladder and bile ducts, forming scars or strictures—visible manifestations of blood stasis. This aligns with Ye Tianshi’s concept of “chronic illness entering the collaterals.” In fact, blood stasis obstructing the collaterals is a widespread phenomenon in chronic cholecystitis and cholelithiasis; therefore, for some long-term, refractory cases, regardless of whether blood stasis signs are present, adding two to three herbs that activate blood circulation and remove stasis to the prescription can enhance therapeutic efficacy.

(4) Liver-Kidney Yin Deficiency Type

① Symptoms: Dull pain in the right hypochondrium, aggravated by exertion; dry mouth and throat; afternoon tidal fever or five-heart vexation; dizziness and blurred vision; red tongue with little coating; wiry and fine or fine and rapid pulse. ② Treatment Principle: Nourish yin and soften the liver, clear heat and promote bile flow. ③ Formula: Modified Yiguanshen Tang. Ingredients: Shengdi 10g, Gouqizi 10g, Beishashen 10g, Maidong 10g, Danggui 10g, Wumei 10g, Baishao 10g, Jiaoshanzha 15g, Chuanlianzǐ 10g, Jinqiancao 15g, Yujin 10g, Zhike 10g. Decoct twice, mix well, divide into three doses, take one dose daily. ④ Note: This syndrome is frequently observed in patients with recurrent, long-standing cholecystitis and cholelithiasis. Repeated attacks deplete the yin essence of the liver and kidneys. Additionally, prolonged liver qi stagnation transforming into fire and damaging yin is another significant factor contributing to liver-kidney yin deficiency. The liver is soft in nature but firm in function; once liver yin is depleted, liver yang becomes overly exuberant, leading to recurrence of gallbladder diseases.

(5) Liver Qi Stagnation and Spleen Deficiency Type

① Symptoms: Distension and discomfort in the right hypochondrium; fatigue and shortness of breath; sallow complexion; poor appetite; aversion to fatty foods; loose stools; pale-red tongue with white coating; wiry and fine pulse. ② Treatment Principle: Soothe the liver and strengthen the spleen. ③ Formula: Modified Xiaoyao San. Ingredients: Chaihu 10g, Hangbaishao 10g, Danggui 10g, Fuling 10g, Baizhu 10g, Xiangfu 10g, Fried Zhike 10g, Fried Yiren 10g, Neijin 10g, Gancao 5g. Decoct twice, mix well, divide into three doses, take one dose daily. ④ Note: This syndrome is a common presentation in chronic cholecystitis and cholelithiasis. For those primarily characterized by spleen-stomach weakness, add Xiangsha Liujunzi Tang to the above formula; if accompanied by extreme fatigue, cold limbs, bland taste, dull complexion, and jaundice of the body and eyes, then add Yinchen Shufu Tang (Yinchen, Baizhu, Fuzi, Ganjiang); if there is belching with foul odor and acid regurgitation, along with thick, greasy tongue coating indicating food stagnation, then combine with digestive aids such as Shenqu, ShanZha, Maiya, Laibuzi, Chenpi, and Neijin.

III. Prescribed Single Formulas for Treatment

1. Patent Medicines

   ① Xiaoyao Wan: Has certain efficacy for chronic cholecystitis, 6–8g each time, three times daily.

   ② Xiaoyan Lidan Pian: Functions to reduce inflammation and promote bile flow, 10–15g each time, three times daily.

   ③ DanShiTong: Promotes bile flow and stone expulsion, reduces inflammation and clears heat, 10–15g each time, three times daily.

   ④ Baijin Jiangzhi Wan: Dries dampness, resolves phlegm, lowers blood lipids, and is effective for obese patients with cholelithiasis, 10–15g each time, twice daily, taken with warm water, one course lasting 20–30 days.

   ⑤ DanNing Pian: Protects the liver and promotes bile flow, has antibacterial and anti-inflammatory effects, relieves spasm and pain, 10–15g each time, three times daily; for acute cholecystitis, one week per course; for chronic cholecystitis, one month per course; for cholelithiasis, two months per course.

   ⑥ DanLe Capsules: Reduces inflammation and dissolves stones, 10g each time, three times daily.

2. Single Prescriptions

   ① Weilingxian 30g, decocted in water, divided into two doses, one dose daily, treats chronic cholecystitis.

   ② Niudan San: One fresh black cow gall bladder, 100g black beans, 30g each of Yujin, Banxia, Zhike, Muxiang, and Baizhu; place all ingredients inside the cow gall bladder, seal it, let the bile soak the herbs, then bake on a tile until dry, grind finely, and encapsulate for future use; take two capsules each time, three times daily, one course per batch. Avoid oily and fishy foods. Treats chronic cholecystitis.

   ③ Daodao Paishi Tang (Prescription from Tianjin Nankai Hospital): Composed of Jinqiancao, Yinchen, Yujin, Zhike, Muxiang, and Shengdahuang. Primarily used during cholelithiasis attacks. Suitable for common bile duct stones less than 10mm in diameter, as well as residual stones after surgery in the hepatic duct.

   ④ Dan’an Tang: Jinqiancao 30–60g, Baishao 15–20g, Dahuang 6–15g, Chaihu 15g, Yinchen 30g, decocted daily, one dose per day, used for gallstone colic.

IV. Acupuncture Treatment

1. Body Acupuncture

   Generally select acupoints such as Gallbladder Point, Yanglingquan, Qiuxu, Zusanli, Riyue, Taichong, Neiguan, Zhongwan, Danyu, Qimen, etc., applying strong stimulation or electrical stimulation. If used for stone expulsion, combining with herbal medicines for stone removal usually yields better results.

2. Ear Acupuncture (Ear Pressing)

   Typically select acupoints such as Liver, Pancreas, Gallbladder, Stomach, Duodenum, Subcortex, Sympathetic, etc., using ear needles or Wang Buliu Xing medicinal seeds, alternating between both ears, one course lasting one month. Simultaneously combine with herbal treatment.

3. Water Acupuncture

   Use vitamin K₃, atropine, etc., injecting into Yanglingquan or Gallbladder points on both sides, which is very effective in relieving gallstone colic.

4. Moxibustion

   Mostly used for patients with chronic cholecystitis. Choose acupoints the same as "body acupuncture." Also need to combine with herbal treatment.

5. Thread Embedding Therapy

   Select acupoints mainly including Danyu, Ganyu, Riyue, Qimen; routinely disinfect, embed intestinal thread, fix with adhesive tape, embedding 3–4 acupoints each time. For patients with shorter disease courses and milder symptoms, a single session can eliminate symptoms. Suitable for recurrent gallstone colic.

6. Magnetic Therapy

   Various types of magnetic therapy devices can be used, selecting acupoints the same as "body acupuncture." Has certain therapeutic effects in relieving gallstone colic.

V. Qigong Therapy

While undergoing drug treatment for chronic cholecystitis and cholelithiasis, practicing certain qigong exercises can be beneficial without harm.

Qigong Exercise 1: Can be performed in sitting, standing, or lying positions. Place the tongue against the palate, relax the body, clear distracting thoughts, breathe in through the nose and out through the nose, slowly inhale, direct the mind to the dantian (three fingers below the navel), feel the qi, then guide it upward to the Qimen acupoint under the right flank (at the intersection of the fifth to sixth rib on the right side and the midclavicular line), and maintain awareness for 10 minutes. Morning practice is generally recommended.

Qigong Exercise 2: Adopt the supine position. Relax the entire body from head to toe, place both hands flat at the sides, palms up, breathe naturally, clear distracting thoughts, focus on the dantian for 3–5 minutes, gently raise both hands to the ears, press the inner ear acupoints of the liver, gallbladder, etc., 36 times, then gently lower both hands back to their original positions. After relaxing all muscles again, visualize the gallbladder area, repeatedly recite silently: "Gallstones shattered, expelled from the gallbladder, righteous qi arrives, stones leave the body." Repeat this silent recitation 36 times, then pause for a moment, press the Laogong acupoint on the right hand onto the gallbladder area under the right flank, massage clockwise 36 times, then counterclockwise 36 times, while silently reciting the above four phrases. After massaging, you can peacefully fall asleep.

VI. Dietary Therapy

During acute attacks of cholecystitis and cholelithiasis, dietary therapy is a necessary adjunct; for chronic cholecystitis, dietary therapy can serve as the primary treatment.

(1) During acute attacks, temporary fasting is required, with intravenous fluid replacement. Once symptoms subside, high-sugar, low-fat liquid or semi-liquid diets can be adopted, such as rice soup, thin porridge, lotus root starch, soy milk, almond tea, etc., gradually transitioning to regular meals. Avoid irritating foods and strong seasonings.

(2) For patients in the chronic quiescent phase, the diet should provide sufficient calories, protein, and carbohydrates, along with abundant vitamins. Protein sources should be easily digestible fish, shrimp, lean meat, rabbit, chicken, tofu, and other soy products (the lecithin contained in soybeans has a good stone-dissolving effect). Obese patients should limit calorie and carbohydrate intake to help lose weight and avoid bloating. Choose foods rich in potassium, iron, and vitamins (vitamin K also helps relieve bile duct spasms and pain caused by cholelithiasis).

(3) Dietary Recipes

① Tomato Tofu Vegetarian Soup Noodles: 100g of dried noodles, appropriate amounts of tomatoes and tofu, prepared as usual to make soup noodles, without oil or with just a few drops of sesame oil. Tomatoes are rich in various vitamins, while tofu is quite rich in protein and has anti-inflammatory effects. The whole dish is delicious, easy to digest, and suitable for patients with gallstones to eat regularly.

② Dandelion Porridge: 50g of dried dandelion (70g fresh), 100g of japonica rice; wash and chop the dandelion (with roots), decoct to extract juice, remove residue, add washed japonica rice and appropriate amount of water, cook together to make thin porridge. Take twice daily, consume warm, one course lasts 3–5 days. Suitable for cholecystitis and cholelithiasis during attack phases.

③ Corn Silk Tea Substitute: 30–60g of dried corn silk, steep in boiling water for 10–15 minutes, then drink. One course lasts 10–15 days; corn silk has a bile-promoting effect, can facilitate bile secretion, and can be used as a bile-promoting drug for patients with chronic cholecystitis and bile secretion disorders.

④ Anti-Inflammatory and Bile-Promoting Tea: 30g each of corn silk, dandelion, and yinchen, add 1000ml of water, decoct to extract juice, remove residue, add appropriate amount of sugar, drink warm, 250ml each time, three times daily. The whole formula has obvious effects of clearing heat, detoxifying, promoting urination, and facilitating bile flow, suitable for cholecystitis and gallstones during febrile and painful periods.

⑤ Radish Juice: 1000–1500g of fresh white radish, wash, slice, mash, extract about 100–150ml of juice, drink cold, finish one serving at a time. Take two to three times daily. According to modern pharmacological research, drinking radish juice can prevent gallstone formation, so it can be used for prevention of cholelithiasis.

VII. Western Medical Treatment

(I) Acute Cholecystitis

(1) Diet. See the aforementioned "Dietary Therapy."

(2) Gastrointestinal Decompression. Its purpose is: ① to empty the stomach and duodenum, reducing stimulation of bile secretion and facilitating bile drainage and expulsion; ② to eliminate and reduce gallbladder contractions caused by cholecystokinin, thereby decreasing the occurrence of gallstone colic and alleviating pain.

(3) Selective use of antibiotics. Antibiotics should be chosen prioritizing penicillin, ampicillin, oxacillin, cephalosporins IV and V, tetracycline, erythromycin, etc. The concentrations of these antibiotics in bile are significantly higher than in blood.

(4) Bile-promoting drugs. Commonly used bile-promoting drugs include magnesium sulfate (5–20g each time, oral), dehydrocholic acid tablets (0.25g each time, three times daily), and cholic acid tablets.

(5) Antispasmodic and analgesic drugs. Commonly used drugs include atropine, nitroglycerin, and aminophylline. If necessary, 50mg of pethidine can be administered via subcutaneous injection, or vitamin K₃ 8–16mg can be tried intramuscularly.

(6) Surgical Treatment. Surgical intervention is indicated in the following cases: ① when medical treatment fails and the condition continues to progress; ② when there are severe complications such as gallbladder necrosis, perforation, or diffuse peritonitis; ③ for patients with recurrent acute attacks. Surgical methods generally include cholecystectomy and cholecystostomy.

(II) Chronic Cholecystitis

In the past, surgical treatment was advocated for chronic cholecystitis, with the belief that cholecystectomy was the definitive cure, as it could completely eliminate the lesion and prevent complications (such as cancer). However, in recent years, due to the widespread occurrence of "post-cholecystectomy syndrome" and advances in traditional Chinese medicine and lithotripsy, the "authority" of surgical treatment has begun to waver. Patients in the following situations should receive medical treatment: ① poor general health, unable to undergo surgery; ② uncertain diagnosis of chronic cholecystitis; ③ mild symptoms, infrequent acute attacks; ④ no gallstones in the gallbladder, or although there are stones, they are small and may be removed or dissolved with medication. The main methods of medical treatment are: ① low-fat diet to reduce bile secretion and lighten the burden on the gallbladder; ② bile-promoting drugs; ③ anthelmintic therapy; ④ for calculous cholecystitis, lithotripsy can be used—for cholesterol stones, ursodeoxycholic acid can be used, or in recent years, Aihuo Dantong, 100mg each time, three times daily.

(III) Cholelithiasis

1. Surgical Treatment

   Surgical treatment is the traditional method for treating cholelithiasis. Generally speaking, for simple gallstones, surgical outcomes are usually satisfactory, with success rates exceeding 95%. Only a small number of elderly or frail patients may experience some complications, leading to adverse consequences. Primary bile duct stones, especially intrahepatic bile duct stones, have relatively poor surgical outcomes.

2. Stone-Dissolving Treatment

   Currently, there are two main approaches to stone dissolution: oral stone dissolution and infusion stone dissolution.

   (1) Oral Stone Dissolution. The indications for oral stone dissolution are limited to cholesterol stones.

   ① General conditions: No severe jaundice, fever, abdominal pain, or other complications; patients with severe liver, kidney, or pancreatic diseases, as well as those with peptic ulcers or enteritis, are not suitable for this method.

   ② Conditions of gallstones, gallbladder, and bile ducts: Among cholesterol stones, layered floating gallstones are most suitable. Stones with a transverse diameter of less than 15mm are preferable; for stones larger than 15mm, if the gallbladder function is good, they can also be tried.

   ③ Dosage and duration: CDCA (ursodeoxycholic acid) and UDCA (chenodeoxycholic acid) are both dosed at around 10–15mg per kilogram of body weight per day; to limit side effects, the daily dosage is preferably kept between 400–600mg, and the treatment generally takes effect after 3–6 months of use.

   (2) Infusion Stone Dissolution. Since oral stone dissolution and surgical treatment are still effective for gallstones and cholesterol stones, infusion stone dissolution has higher therapeutic value for hepatobiliary duct stones and bilirubin-based stones. Commonly used bilirubin-dissolving agents include EDTA-Na complex solution, CDTA complex solution, HMP-Na solution, protease-based solvents, etc.

3. Lithotripsy is an emerging treatment method in recent years. Common lithotripsy techniques include extracorporeal shock wave lithotripsy, ultrasonic lithotripsy, laser lithotripsy, hydraulic lithotripsy, and extracorporeal vibration lithotripsy.

4. Comprehensive Stone Removal Treatment is a method that integrates effective measures from both traditional Chinese medicine and Western medicine, coordinating them within a specified timeframe to achieve the goal of stone removal through steps such as increased bile secretion → contraction of the common bile duct sphincter → increased biliary pressure → relaxation of the sphincter → expulsion of stones. Specific methods are shown in the table below.

VIII. Prevention

Prevention of cholecystitis and cholelithiasis should focus on controlling biliary tract infections, avoiding the formation of bile that leads to stone formation, and preventing bile stasis. Specific preventive measures include the following points.