II. Syndrome-Based Treatment

II. Syndrome-Based Treatment

(1) Qi Stagnation and Blood Stasis Type

① Symptoms: Fullness and distension in the epigastric region, sometimes sharp like a knife cut, sometimes dull like a needle prick, radiating to the left flank and left shoulder/back, accompanied by nausea, vomiting, belching, irritability, depression, or loss of appetite. The tongue is dark or has ecchymoses, with a white coating, and the pulse is deep and fine or wiry. ② Treatment: Soothe the liver, regulate qi, resolve stasis, and relieve pain. ③ Prescription: Modified Qingyi Decoction. Ingredients: Bupleurum root 15g, Scutellaria root 10g, Aucklandia root 15g, Stir-fried Corydalis tuber 30g, Typha pollen (wrapped) 10g, Five Spirit Resin 10g, Angelica sinensis 10g, Salvia miltiorrhiza 15g, Red Peony Root 10g, Safflower 10g, Peach Kernel 10g. Decoct twice, mix well, divide into three doses, take one dose daily. ④ Note: This syndrome is commonly seen in chronic pancreatitis patients whose main symptom during remission is upper abdominal pain. Soothing the liver, regulating qi, and activating blood circulation to relieve pain are standard analgesic methods. The above formula is essentially Qingyi Decoction without rhubarb, coptis, and mirabilite, with increased Aucklandia and Corydalis, plus the addition of Shixiao Powder, incorporating elements of Siwu Decoction. Removing rhubarb, mirabilite, and coptis effectively leaves only the liver-soothing, qi-regulating formula of Bupleurum root, while Shixiao Powder serves as the primary agent for activating blood circulation and relieving pain. Due to the long duration of the illness, concern exists that the medicinal potency may be insufficient, hence the inclusion of Angelica, Red Peony, Salvia, Peach Kernel, and Safflower. If liver qi stagnation turns into fire, resulting in dry mouth, bitter taste, and slightly yellow, greasy coating on both sides of the tongue, Longdan Grass, stir-fried Gardenia Fruit, and Danpi should be added; for those with accompanying nausea and vomiting, add Ginger Half Summer, stir-fried Evodia Fruit, and Coptis.

(2) Liver Qi Stagnation and Spleen Deficiency Type

① Symptoms: Upper abdominal fullness and discomfort spreading to both flanks, poor appetite, loose stools, foamy, foul-smelling stools, especially after consuming greasy foods, with fat droplets visible in stool analysis. Accompanied by fatigue, pale complexion, shortness of breath, and reluctance to speak, with a pale tongue, plump physique with tooth marks, white and greasy coating, or putrid coating, and a weak, deep pulse. ② Treatment: Soothe the liver, strengthen the spleen, and stop diarrhea. ③ Prescription: Modified Xiaoyao Powder. Ingredients: Bupleurum root 10g, Hangzhou White Peony Root 10g, Angelica sinensis 10g, Salvia miltiorrhiza 10g, Red Peony Root 10g, Poria cocos 20g, Stir-fried White Atractylodes Rhizome 30g, Stir-fried Coix Seed 15g, Atractylodes lancea 10g, Inner Golden Stone 10g, Raw and Cooked Hawthorn Fruit 30g each, Stir-fried Malt 15g, Licorice 5g. Decoct twice, mix well, divide into three doses, take one dose daily. ④ Note: This syndrome corresponds to chronic pancreatitis patients whose main manifestation is steatorrhea. Clinical practice has shown that treating with liver-soothing and spleen-strengthening methods often yields good results; after relief, continued long-term maintenance therapy using modified Shenling Baizhu Powder is recommended to ensure lasting improvement. If liver qi stagnation is mild, Shenling Baizhu Powder combined with Baohe Pill can be used from the outset. For those with obvious qi deficiency, add raw Astragalus and Codonopsis.

(3) Yin Deficiency and Heat Stasis Type

① Symptoms: Dull pain in the upper abdomen, dry mouth and thirst, fatigue, weight loss, five-center heat, soreness in the lower back and knees, tinnitus, and night sweats. Sometimes hunger and frequent urination are also observed. Fasting and/or postprandial blood glucose levels are elevated, with positive urinary glucose. The tongue is red with little coating, and the pulse is wiry and thin with a rapid rhythm. ② Treatment: Nourish yin and resolve stasis. ③ Prescription: Modified Yuye Decoction. Ingredients: Kudzu root 10g, Rehmannia root 15g, Schisandra berry 10g, Chinese Yam 15g, Pollen 10g, Anemarrhena asphodeloides 10g, Chicken Gizzard Stone 10g, Salvia miltiorrhiza 10g, Angelica sinensis 15g, Red Peony Root 10g, Atractylodes lancea 10g, Astragalus 20g, Polygonatum 10g, Polygonatum 10g, and Huangjing 10g. Decoct twice, mix well, divide into three doses, take one dose daily. ④ Note: This syndrome corresponds to chronic pancreatitis patients whose main manifestation is diabetes. Because the onset is slow, patients may not necessarily exhibit the classic "three excesses and one deficiency" symptoms of excessive drinking, eating, urinating, and weight loss. Many patients present with marked weight loss and fatigue, while some experience numbness, pain, proteinuria, and other neurological and microvascular complications. Therefore, pancreatic patients should regularly monitor their blood glucose levels to enable early detection and treatment. The Astragalus, Chinese Yam, Atractylodes, and Polygonatum in the above formula are two well-known herbal pairs frequently used by Mr. Shi Jinmo, a renowned Beijing physician, to treat diabetes. It is said that Astragalus and Chinese Yam work together to lower blood glucose, while Atractylodes and Polygonatum help eliminate urinary glucose. Today, these two herbal pairs have become standard treatments for diabetes in traditional Chinese medicine. Moreover, it must be emphasized that TCM treatment for diabetes focuses on overall regulation and also has therapeutic effects on neurological and microvascular complications; however, for patients with very high blood glucose levels, Western antidiabetic medications (such as insulin) should still be used in conjunction, which readers should be aware of.

(4) Subphrenic Mass Accumulation Type

① Symptoms: Upper abdominal fullness and pain, with a palpable mass in the abdomen, accompanied by loss of appetite, nausea, vomiting, belching, a dark purple tongue, white coating, and a deep, wiry pulse. ② Treatment: Activate blood circulation, resolve stasis, and eliminate masses. ③ Prescription: Modified Subphrenic Stasis-Resolving Decoction. Ingredients: Angelica sinensis 10g, Chuanxiong 10g, Safflower 10g, Citrus Aurantium 10g, Red Peony Root 15g, Salvia miltiorrhiza 15g, Sanleng 10g, Ezhushi 10g, Plantago seeds (wrapped) 10g, Raw Coix Seed 15g, Raw Licorice 6g. Decoct twice, mix well, divide into three doses, take one dose daily. ④ Note: This prescription is recommended for chronic pancreatitis patients when pseudocysts have formed.

Subphrenic Stasis-Resolving Decoction is one of the "Stasis-Resolving Decoctions" created by Wang Qingren, a late-Qing dynasty physician. It is primarily used to treat accumulations, pediatric lumps, pain that does not move, abdominal heaviness when lying down, renal diarrhea, and chronic diarrhea. Its efficacy in treating pseudocysts is well-established. Adding Sanleng and Ezhushi further enhances its ability to eliminate masses; Plantago seeds and Raw Coix Seed promote diuresis and pus drainage, facilitating the elimination of cysts. This formulation embodies early ideas of integrating traditional Chinese and Western medicine.

III. Western Medical Treatment

(1) Treatment for acute attacks is the same as for "acute pancreatitis."

(2) For patients with persistent, unrelenting abdominal pain, consider whether there are pancreatic pseudocysts, chronic peripancreatic infection or fibrosis, pancreatic duct stones or stenosis causing duct obstruction, and take appropriate measures accordingly.

(3) Pancreatic diarrhea:
① Follow a low-fat, high-protein, and high-carbohydrate diet.
② Take pancreatic enzyme tablets at 3–5g after each meal and 1–2g between meals, orally. Alternatively, use strong pancreatic enzyme preparations at 3–6g daily, 1–2g after meals and 0.6g between meals, orally. This can moderately correct exocrine insufficiency.
③ For patients with long-lasting diarrhea, appropriately supplement fat-soluble vitamins (such as K, A, and D), folic acid, and vitamin B₁₂.

(4) Patients with diabetes generally require insulin injections, with dosage determined by blood glucose levels. Currently, insulin injection therapy has become so convenient that it can be administered at home. A device called "NovoPen," an automatic injector with a single-use needle, is easy to operate, safe, and highly suitable for home insulin therapy for diabetic patients.

(5) Surgical treatment may be considered in the following situations:
① Patients with severe, intractable pain that does not respond to medical treatment;
② Patients with pancreatic pseudocysts or pancreatic stones;
③ Patients with biliary tract diseases that can be treated surgically, such as stones or bile duct stenosis;
④ Patients with chronic pancreatitis causing jaundice that is difficult to resolve;
⑤ Patients in whom pancreatic cancer cannot be ruled out.

IV. Prognosis and Outcome

Recurrent chronic pancreatitis, when treated aggressively with integrated TCM and Western medicine, can alleviate symptoms, reduce recurrence, and even achieve clinical recovery in many patients. However, in advanced stages, prognosis is poor due to systemic failure, diabetic complications, and suppurative biliary infections. A small number of patients may develop pancreatic cancer. A minority of patients with recurrent chronic pancreatitis may progress to hemorrhagic necrotizing pancreatitis and ultimately die.

Chapter 12 Upper Gastrointestinal Bleeding

Section 1 Overview

Upper gastrointestinal bleeding refers to bleeding originating from the digestive tract above the Treitz ligament (the boundary between the duodenum and jejunum), including the esophagus, stomach, duodenum, biliary tract, pancreas, and gastrojejunostomy site. If the total blood loss exceeds 1,000 ml (20% of total circulating blood volume), resulting in hematemesis, melena, and acute peripheral circulatory failure (shock), it is classified as acute massive upper gastrointestinal bleeding. This is a common clinical emergency with a mortality rate of 10%, yet the misdiagnosis rate for the underlying cause can reach as high as 20%, making it a serious concern for both patients and healthcare professionals. There are many causes of upper gastrointestinal bleeding, with the most common being peptic ulcers, acute gastric mucosal damage, esophageal and gastric fundal varices, and gastric cancer.

1. Inflammatory Factors
   Gastric ulcers, acute erosions, and hemorrhagic gastritis are common causes of upper gastrointestinal bleeding. Acute hemorrhagic gastritis is often a stress response triggered by severe illnesses such as sepsis, extensive burns, major surgery, shock, cerebrovascular accidents, pulmonary heart disease, severe heart failure, trauma, and malignant tumors. Domestic and international scholars believe that duodenal bulb ulcers are also a common cause of upper gastrointestinal bleeding. In addition, chronic inflammation in various parts of the upper gastrointestinal tract, such as esophagitis, esophageal ulcers, gastric mucosal prolapse, polyps, and tuberculosis, can all lead to bleeding. Inflammation and stones in the biliary tract and pancreatic duct can also cause bleeding.

2. Structural Factors
   Diverticula of the upper gastrointestinal tract, whether accompanied by inflammation or not, can lead to bleeding. Esophageal hiatal hernias manifest as intermittent hematemesis or melena, caused by ischemia, ulceration, and necrosis of the hernia sac lining embedded in the esophageal hiatus.

3. Vascular Factors
   Rupture and bleeding of esophageal and gastric fundal varices are the most common symptoms of portal hypertension complicating cirrhosis. Other conditions, such as congestive heart failure and chronic constrictive pericarditis, can also cause bleeding.

4. Tumor Factors
   Tumors arising in various parts of the upper gastrointestinal tract, such as esophageal cancer, gastric cancer, bile duct cancer, and pancreatic head cancer, commonly present with bleeding as a complication.

5. Systemic Diseases
   In addition to the aforementioned stress responses, systemic diseases such as acute infectious diseases (with disseminated intravascular coagulation), epidemic hemorrhagic fever, and severe hepatitis, as well as hematological disorders like hemophilia, aplastic anemia, leukemia, and thrombocytopenic purpura, and connective tissue diseases such as systemic lupus erythematosus, nodular polyarteritis, and Behçet's disease, can all contribute to upper gastrointestinal bleeding.

Section 2 Diagnosis

I. Early Identification

Upper gastrointestinal bleeding can rapidly lead to acute peripheral circulatory failure within a short period, but at this stage, hematemesis and melena may not yet be present, making early diagnosis challenging. The severity of acute peripheral circulatory failure varies depending on the amount of bleeding and the speed of blood loss. With large volumes of bleeding and rapid blood loss, circulating blood volume decreases quickly, venous return is insufficient, and cardiac output drops significantly, resulting in a series of clinical symptoms and signs, such as dizziness, palpitations, sweating, nausea, blurred vision, or even fainting. The patient’s pulse becomes thin and rapid, blood pressure drops, with systolic pressure below 11 kPa (85 mmHg), indicating shock. In the early stages of hemorrhagic shock, blood pressure may still be within the normal range or even temporarily elevated. At this point, attention should be paid to fluctuations in blood pressure and a narrow pulse pressure difference; if rescue is not timely, blood pressure will drop rapidly, potentially becoming undetectable. Due to peripheral vasoconstriction and inadequate blood perfusion, the skin becomes cold and clammy, taking on a grayish-white or gray-purple mottled appearance that persists for a long time after pressure is released. Venous filling is poor, and superficial veins collapse. Oliguria or anuria may also occur. The patient feels fatigued, or even more mentally depressed, irritable, and in severe cases, exhibits delayed reactions and confusion. Elderly patients, due to cerebral arteriosclerosis, may display apathy or confusion even with relatively small amounts of bleeding. In addition, cardiac signs beyond tachycardia often include muffled heart sounds or arrhythmias.

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Due to the occurrence of acute peripheral circulatory failure, hematemesis and melena may not be present. Therefore, to achieve early and rapid diagnosis of massive upper gastrointestinal bleeding, it is essential first to rule out shock caused by other etiologies, such as toxic shock, cardiogenic shock, and anaphylactic shock. It is also necessary to differentiate it from internal bleeding caused by acute hemorrhagic necrotizing pancreatitis or ruptured ectopic pregnancy, spontaneous and traumatic splenic rupture, and arterial aneurysm rupture. In such cases, the simplest method is to promptly perform a digital rectal examination (i.e., inserting the index finger deep into the rectum to check for bloodstains), which can detect unpassed blood stools at an early stage and thus aid in early diagnosis.

Hematemesis and melena are characteristic manifestations of upper gastrointestinal bleeding. After bleeding, melena will invariably occur, but hematemesis is not always present. If the bleeding site is below the pylorus, only melena may appear; whereas if the bleeding site is above the pylorus, hematemesis is often accompanied. However, for lesions above the pylorus, such as those in the esophagus or stomach, if the amount of bleeding is small or the bleeding rate is slow, hematemesis may not occur, and only melena will be observed. That said, if the bleeding from a lesion below the pylorus, such as the duodenum, is substantial and rapid, with blood refluxing into the stomach, then in addition to melena, hematemesis may also occur. Hematemesis typically appears brownish-red, resembling coffee grounds, due to the formation of ferric hemoglobin through the action of gastric acid on the blood. If the amount of bleeding is large and the blood is vomited before being fully mixed with gastric acid, it will appear bright red or contain blood clots. Melena, on the other hand, has a tarry appearance, is viscous and shiny, resulting from the reaction of iron in hemoglobin with intestinal sulfides to form ferrous sulfide. When the amount of bleeding is large and the speed is fast, intestinal peristalsis is strong, and the stool stays in the intestine for a short time, fresh red blood may be seen in the stool. For lower gastrointestinal bleeding, such as that from the jejunum or ileum, if the stool remains in the intestine for too long, it will also appear as melena rather than fresh blood. Therefore, hematemesis and melena are characteristics of upper gastrointestinal bleeding, but they are not fixed.

Clinically, when melena occurs, it must first be distinguished from melena caused by swallowing blood during epistaxis, tooth extraction, or tonsillectomy, or from melena induced by ingesting blood-containing foods. Oral administration of bone charcoal, bone, bismuth preparations (such as Dele granules), and Xue Dan can all lead to melena; careful inquiry into the patient's medical history can easily rule these out. Hematemesis should be differentiated from hemoptysis, with key points listed in the following table.

Appendix: Key Points for Differentiating Hematemesis from Hemoptysis

II. Estimation of Bleeding Volume

The estimation of upper gastrointestinal bleeding volume is mainly based on clinical manifestations of peripheral circulatory failure caused by reduced blood volume, particularly dynamic observation of blood pressure and pulse, combined with the restorative and stabilizing effects of fluid resuscitation and blood transfusion on pulse and blood pressure. Generally speaking:

① A positive fecal occult blood test indicates a daily bleeding volume of more than 5 ml. ② When the daily bleeding volume exceeds 50–70 ml, melena may appear. ③ When intragastric bleeding reaches 250–300 ml, hematemesis may occur. ④ If a single bleeding episode does not exceed 1000 ml, shock generally does not occur. However, if more than 1000 ml of blood is lost within a few hours, or if the loss exceeds 20% of the total circulating blood volume, shock may ensue. ⑤ If the patient’s pulse quickens, experiences dizziness, sweating, or even syncope upon changing from a supine to a semi-recumbent position, this suggests substantial bleeding and warrants urgent blood transfusion. ⑥ In recent years, the use of ¹³¹ chromium-labeled red blood cells—administered via a single intravenous injection—allows for separate measurement of plasma, extracellular fluid, and cellular volume, providing a rapid and simple method for accurate estimation of blood loss.

III. Determination of Whether Bleeding Has Stopped

The number of days that melena persists after a single bleeding episode depends on the patient’s bowel movement frequency. If the patient has one bowel movement per day, the stool color usually returns to normal after about three days. Melena alone cannot be used to determine whether bleeding has stopped; the patient’s condition must be carefully monitored, especially repeated measurements of blood pressure and pulse, until both return to normal and stabilize, at which point bleeding can be considered to have ceased. The following signs indicate the possibility of continued or recurrent bleeding:

① Recurrent hematemesis, or an increase in the frequency of melena, accompanied by thinning consistency. The color of hematemesis turns bright red, melena turns dark red, and there is increased bowel sound. ② Despite adequate fluid (or blood) replacement, signs of peripheral circulatory failure still show no significant improvement, or although there is some improvement, it recurs or worsens. ③ Even after rapid fluid resuscitation and blood transfusion, central venous pressure remains fluctuating, or drops again shortly after stabilizing. ④ Red blood cell count, hemoglobin level, and hematocrit continue to decline, while reticulocyte count keeps rising. ⑤ Despite sufficient fluid intake and urine output, blood urea nitrogen remains unchanged or increases.

IV. Differential Diagnosis of Bleeding Causes

Careful inquiry into the patient’s medical history and understanding of characteristic features are very helpful in clarifying the cause of upper gastrointestinal bleeding.

1. Peptic Ulcer Most patients have a history of chronic, periodic, rhythmic upper abdominal pain before bleeding, especially with worsening pain prior to bleeding and relief after bleeding. Melena is more common than hematemesis. Hematemesis appears as brownish-red liquid (coffee-ground-like), mostly caused by gastric ulcers.

2. Acute Gastric Mucosal Injury There is a history of drug overdose or accidental ingestion of highly toxic substances, use of aspirin, indomethacin, or excessive alcohol consumption, or presence of stress-related reactions, leading to varying degrees of bleeding.

3. Chronic Gastritis (Gastric Antral Inflammation) Previously, patients have experienced postprandial upper abdominal distension and dyspepsia, with bleeding usually less severe than peptic ulcers. Barium meal radiography or gastroscopy can confirm the diagnosis.

4. Bleeding Due to Rupture of Esophageal and Gastric Fundal Varices Most patients have liver cirrhosis as the underlying cause, primarily presenting with hematemesis, which is bright red and copious. Physical examination reveals hepatic facies, spider angiomas, palmar erythema, ascites, or dilated abdominal wall veins. A hard, nodular left lobe of the liver can be palpated below the xiphoid process. Massive bleeding can lead to hepatic encephalopathy. It should be noted that among patients with upper gastrointestinal bleeding, even if diagnosed with liver cirrhosis, not all cases are due to rupture of esophageal or gastric fundal varices; approximately 30–40% of patients actually have bleeding caused by peptic ulcers, acute gastric mucosal injury, or other reasons, requiring further examination to determine the exact cause.

5. Esophageal Cancer Mostly affects elderly males, presenting with progressive dysphagia (increasing difficulty swallowing), substernal pain, regurgitation, hiccups, and weight loss. Most have small amounts of persistent bleeding, with blood sometimes refluxing and being vomited.

6. Gastric Cancer Commonly affects men over 40, with gradual loss of appetite, abdominal distension, upper abdominal pain, anemia, and weight loss. Fecal occult blood tests remain persistently positive. In later stages, a mass can be palpated in the upper abdomen, and supraclavicular lymph nodes on the left side become enlarged. Gastroscopy and barium meal radiography can confirm the diagnosis.

7. Gastric Mucosal Prolapse Due to relaxation of the gastric antral mucosa, which obstructs the pylorus during gastric peristalsis, causing pyloric spasm and increased gastric motility, pain occurs. Often triggered by eating, pain intensifies when lying on the right side, and recurrent vomiting may occur, sometimes accompanied by bleeding. Diagnosis relies mainly on typical X-ray findings.

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Section 3: Integrated Traditional Chinese and Western Medicine Treatment