I. Traditional Chinese Medicine’s Understanding of Upper Gastrointestinal Bleeding

I. Traditional Chinese Medicine’s Understanding of Upper Gastrointestinal Bleeding

Upper gastrointestinal bleeding falls under the categories of “hematemesis” and “melena” in TCM blood syndrome, with numerous discussions throughout history regarding its causes, pathogenesis, and treatment methods. The “Plain Questions·Jue Lun” states: “When Yangming qi reverses, there is wheezing, coughing, fever, easy startle response, nosebleeds, and hematemesis.” The “Plain Questions·Ju Tong Lun” further notes: “Anger causes qi reversal; in severe cases, it leads to hematemesis.” These passages point out that the causes of hematemesis are excessive heat in the Yangming (stomach) and emotional stimulation leading to qi reversal and chaotic blood flow. The “Synopsis of Golden Chamber” advocates: “For those with uncontrollable hematemesis, Baiye Decoction is the primary treatment,” and “If heart qi is deficient, leading to hematemesis or nosebleeds, Xie Xin Tang is the main remedy.” The “Thousand Gold Prescriptions·Hematemesis” records 25 prescriptions for treating hematemesis, including the famous Xijiao Dihuang Decoction, Sheng Dihuang Juice, and Dahuang Powder, all of which are commonly used today for treating hematemesis. In particular, the excellent hemostatic effect of Dahuang in treating upper gastrointestinal bleeding has been confirmed by extensive clinical practice and experimental research. During the Jin and Yuan dynasties, Liu Hejian advocated: “When heart fire is extremely intense, there is excess blood; the fiery qi rises, and in severe cases, blood overflows.” Physicians of the Ming and Qing dynasties also offered valuable insights into treating hematemesis, such as Miao Xiyong, who proposed in his “Xianxingzhai Medical Compendium·Hematemesis” three key principles: “Promote blood circulation rather than stop it,” because promoting blood circulation allows blood to flow along the meridians without stagnation; “Nourish the liver rather than weaken it,” since weakening the liver damages its structure, making it even weaker and unable to contain blood; “Lower qi rather than lower fire,” because excess qi means excess fire, so lowering qi is equivalent to lowering fire. Tang Rongchuan, in his “Blood Syndrome Treatise·Hematemesis,” pointed out that hematemesis should be attributed to the stomach, stating: “The ultimate destination of blood is the ‘blood sea’; Chong is the blood sea, and its meridian belongs to Yangming. No matter how much qi flows downward, it will never reverse upward, yet blood does reverse upward.” He added: “Yangming qi normally flows downward, but now it reverses and flows upward, losing its natural downward direction. Therefore, we must urgently regulate the stomach to restore the normal flow of qi, so that blood does not rush out uncontrollably.” Regarding treatment methods, Tang Rongchuan believed: “Only by stopping the bleeding can the blood return to its proper path and avoid rushing out. Thus, stopping the bleeding is the first priority.” After stopping the bleeding, any blood that has not yet been expelled is considered stagnant blood, so eliminating stagnation is the second priority. Once the bleeding has been stopped and the stagnant blood eliminated, there is still concern that the blood may surge again, so medication is needed to stabilize it, making calming the blood the third priority. Since blood loss is often substantial, qi and blood are inevitably depleted, so nourishing the blood is the final step to consolidate the results. “Stopping the bleeding, eliminating stagnation, calming the blood, and nourishing the blood—these four steps constitute the general framework for treating blood syndromes,” which provides crucial guidance for clinical treatment of hematemesis.

As for “melena,” it is similar to what ancient physicians referred to as “remote blood” or “internal toxin.” The “Synopsis of Golden Chamber” first introduced the concept of “remote blood”: “When blood comes out after defecation, this is remote blood, and Huangtu Decoction is the primary treatment.” Ming dynasty physician Zhang Jingyue clarified the specific location of remote blood: “Blood that comes out after defecation originates from a distant place—either the small intestine or the stomach.” In fact, distinguishing between remote and proximate melena based on whether the blood appears before or after defecation is unreliable, and in many cases, blood and stool mix together when they come out. Instead, observing the color of melena can serve as a reference for determining the source of bleeding. Generally speaking, bright red melena indicates a proximate source, while dark purple melena indicates a more remote source. According to the principle in “Compendium of Diagnostic and Therapeutic Principles” that pure, clear blood coming out first is hot, reddish blood is cold, and black blood is stagnant, most melena seen in upper gastrointestinal bleeding is a sign of deficiency-cold syndrome.

Based on the discussions of past physicians on “hematemesis” and “melena” as well as modern medical understanding, the main causes of upper gastrointestinal bleeding are external pathogenic factors and internal injuries caused by diet, emotions, and overwork.

① External Pathogenic Factors Upper gastrointestinal bleeding caused by external pathogenic factors mainly refers to patients with pre-existing ulcers or gastritis who, during late autumn-winter or winter-spring transitions, inadvertently contract the six pathogenic factors, causing their old illnesses to relapse, especially ulcers, which become more pronounced.

② Dietary Irregularities Are the most common triggering factor for upper gastrointestinal bleeding, including overeating, consuming overly spicy or scorching-hot foods, drinking excessive alcohol, and taking certain medications that damage the gastric mucosa. The “Clinical Guide to Medical Cases” states: “Alcohol and heat can weaken the stomach and stimulate blood flow.” Alcohol is a damp-heat product that easily enters the stomach and generates heat, and the fiery pathogenic factors burn the gastric network, leading to bleeding. As stated in the “Classified Treatments and Regulations”: “Melena arises from fire damaging the yin network in the intestines and stomach, with blood and stool coming out together.”

③ Emotional Internal Injuries, where depression turns into fire and wood-fire attacks the stomach, are also common causes of upper gastrointestinal bleeding. Especially for patients with liver cirrhosis who develop esophageal and gastric fundal varices and experience ruptured bleeding, emotional fluctuations often trigger massive hemorrhage, sometimes even more significantly than dietary factors. The author once saw a patient hospitalized for liver cirrhosis who, aware of the severity of his condition, carried an excessive mental burden and frequently lost his temper over trivial matters, resulting in repeated bleeding episodes and ultimately death despite treatment. Depression or emotional suppression can lead to liver qi stagnation turning into fire, which then attacks the stomach, damaging the gastric network and forcing blood upward; or if the stomach already has heat, liver fire disturbs it, causing qi reversal and blood rushing upward, leading to hematemesis. Hence, the “Plain Questions·Ju Tong Lun” says: “Anger causes qi reversal; in severe cases, it leads to hematemesis.” The “Blood Syndrome Treatise” mentions that when liver fire rises, it causes nosebleeds if the path is clear, but hematemesis if the path is blocked; when liver blood seeps downward, it causes hematuria if the path is clear, but melena if the path is blocked—this precisely describes the situation mentioned above.

④ Excessive Fatigue and Overwork, which damages the spleen and stomach, or prolonged illness leading to spleen deficiency and weak spleen qi unable to control blood, causing blood to overflow; or if the spleen and stomach are inherently weak and coupled with cold drinks, leading to cold stagnation in the middle jiao, spleen and stomach qi becoming cold and unable to control blood, resulting in blood spilling out beyond the vessels. Therefore, the “Medical Compendium·Blood Syndrome Treatise” states: “The stomach is responsible for guarding the blood, keeping it contained and stored within itself. When stomach qi is weak, it cannot hold the blood, causing people to vomit blood, which then flows out through the throat and mouth.”

These four causes sometimes act individually, sometimes in combination, with several factors coexisting simultaneously. Most scholars believe that the common patterns of upper gastrointestinal bleeding are damp-heat injuring the stomach, liver fire attacking the stomach, and spleen-stomach deficiency-cold.