2 Traditional Chinese Medicine’s Understanding of the Pathogenesis of Viral Hepatitis

(2) Traditional Chinese Medicine’s Understanding of the Pathogenesis of Viral Hepatitis Traditional Chinese Medicine views this disease as arising from exposure to damp-heat or epidemic pathogens, where righteous qi and pathogenic qi clash, either latent or manifesting as jaundice. When damp-heat and epidemic toxins remain unresolved and deeply reside in the blood, prolonged exposure leads to imbalances in the internal organs, yin-yang, and qi-blood, resulting in deficiency and dysfunction. This pathological process aligns closely with the concept of acute hepatitis progressing to chronic hepatitis or even liver cirrhosis. Whether the infection is viral carriage, acute, chronic, mild, or severe, the key lies in the virulence of the virus and the varying degrees of the body’s defensive capabilities. Damp-heat and epidemic toxins affect the spleen and stomach, disrupting the functions of the middle burner—transporting, generating, and regulating qi—and causing toxic qi to overflow and invade the liver. This leads to stagnation of liver qi, which then reverses and disrupts the function of the spleen and stomach, resulting in symptoms such as fatigue, reduced appetite, abdominal distension, flank and rib pain, mild hepatosplenomegaly, elevated ALT levels, and positive hepatitis virus markers. If liver qi remains stagnant, qi circulation becomes blocked, meridians become obstructed, and qi stagnates while blood becomes congested, leading to fixed, hardened masses in the flanks, which over time become solid and painful, accompanied by dark complexion, bruised moles, purple tongue, and a wiry, fine pulse. At this stage, chronic hepatitis may progress to liver cirrhosis, with progressive enlargement of the liver and spleen, recurrent or persistent liver dysfunction, and microcirculatory disorders throughout the body. If the spleen fails to rise and the stomach fails to descend, and liver qi cannot be released, bile does not flow along its normal pathway into the bloodstream but instead spills onto the skin, causing jaundice. In cases of severe damp-heat, the jaundice may be bright yellow like orange, accompanied by fatigue, reduced appetite, nausea, flank pain, a yellowish, greasy tongue coating, and a wiry, slippery pulse—this is known as Yangjaundice. A small number of patients exhibit intense heat toxicity, with toxins entering the blood and invading the pericardium, leading to delirium, bleeding, and overall yellowing of the body; these cases are termed Rapid Jaundice or Plague Jaundice. Some patients with Yangjaundice fail to receive proper treatment, leading to prolonged illness, while others develop cold-dampness as a secondary factor, resulting in dull, dark yellow jaundice, accompanied by fatigue, fear of cold, abdominal distension, loose stools, a pale tongue coated with greasy residue, and a deep, fine pulse—these cases are classified as Yinjaundice. The severity of jaundice generally correlates with the degree of hepatocellular necrosis and intrahepatic bile stasis; in cases of severe necrosis, jaundice tends to be more pronounced, with poorer prognoses. However, when inflammation of the capillary ducts predominates and intrahepatic bile stasis develops, the disease course may be relatively prolonged, sometimes lingering for years, and in some cases even progressing to cholestatic liver cirrhosis. Therefore, traditional Chinese medicine considers Rapid Jaundice to be dangerous, while Yinjaundice—or those with phlegm and dampness adhering to the blood—often prove difficult to treat. As such, this disease is often caused by external exposure to damp-heat and epidemic toxins, with the liver being the primary site of onset. However, the liver stores blood, possesses a nature akin to wind and wood, governs the tendons, and shares a common origin with the kidneys. It relies on kidney yin to nourish the liver, and the liver and gallbladder are closely connected; when liver qi becomes stagnant over time, it naturally leads to deficiencies in other organs, yin-yang, and qi-blood. When toxins penetrate the blood, they may cause hepatic encephalopathy and disseminated intravascular coagulation. In cases of chronic illness, or when liver and kidney yin are deficient, or when spleen and kidney yin are deficient, or when qi stagnates and blood becomes congested, repeated episodes of illness may lead to accumulation, distension, and ultimately liver cirrhosis, ascites, or even cancerous transformation. Ultimately, this can result in liver and kidney failure, as well as systemic failure. Of course, these cases are rare; most patients recover fully with appropriate treatment. (3) TCM Syndrome Differentiation and Treatment Methods Chronic hepatitis B is the most prevalent infectious disease among viral hepatitis. Currently, antiviral drugs such as interferon and nucleoside analogs are the first-line treatments for hepatitis B, achieving significant efficacy in suppressing HBV replication—but they cannot eliminate the ccDNA of HBV within hepatocytes. After stopping medication, the virus may recur, and HBV infection cannot be completely eradicated. In 2006, at the Shanghai–Hong Kong International Liver Disease Conference, the application of traditional Chinese medicine in liver disease research and treatment was highlighted as a major topic of discussion. TCM syndrome differentiation and treatment methods played a crucial role in the management of hepatitis B. The “TCM Syndrome Differentiation Standards for Viral Hepatitis” (Pilot Version), revised in 2004, established the “TCM Syndrome Differentiation Standards for Viral Hepatitis” (Revised Draft) as follows:

1. Acute Hepatitis (1) Clinical Manifestations of Acute Jaundice-Type Hepatitis Due to Damp-Heat Accumulation: The entire body and eyes turn yellow, with a vivid yellow color; loss of appetite, nausea, and aversion to oily foods; dry mouth and bitter taste; heavy and sluggish head and body; fullness in the chest and abdomen; fatigue; constipation; yellowish-red urine; yellowish, greasy tongue coating, with a wiry, slippery, and rapid pulse. Main symptoms include: ① Yellowing of the whole body and eyes, with a vivid yellow color and yellowish-red urine; ② Loss of appetite and nausea, aversion to oily foods; ③ A yellowish, greasy tongue coating. Secondary symptoms include: ① Dry mouth and bitter taste; ② Constipation; ③ Heavy and sluggish head and body; ④ Fullness in the chest and abdomen. Diagnosis requirements: First, patients who meet either symptom ① or ②, or ③, are classified as having this syndrome; second, patients who meet either symptom ① and secondary symptoms ① or ② are classified as having a condition where heat outweighs dampness; third, patients who meet either symptom ① and secondary symptoms ③ or ④ are classified as having a condition where dampness outweighs heat; fourth, patients who meet either symptom ① and secondary symptoms ① or ②, as well as one of the items in symptoms ③ or ④, are classified as having a condition where both heat and dampness are present. For conditions where heat outweighs dampness, treatment focuses on clearing heat, promoting diuresis, detoxifying, and resolving accumulation. Prescription: Yin Chen Hao Tang with additions. Use 30–60g of Yin Chen, 10–30g of Da Huang, 15–30g of Hu Jiang, 30g of Che Qian Cao, 20g of Fu Ling, 15g of Zhu Ling, and 10g each of Ze Xie, Zhizi, and Huang Bo. For constipation, use Da Cheng Qi Tang; for severe liver and gallbladder heat, use Long Dan Xie Gan Tang; for vomiting, add Huang Lian and Zhu Ru. For conditions where dampness outweighs heat, treatment focuses on promoting diuresis, eliminating turbidity, clearing heat, and reducing jaundice. Prescription: Yin Chen Si Ling San with additions. Use 30–60g of Yin Chen, 20g each of Feng Ye Ka, Fu Ling, Zhu Ling, Ze Xie, Bai Zhu, and Sha Ren. For vomiting, add Ban Xia and Chen Pi; for severe abdominal distension, add Da Fu Pi and Mu Xiang. For conditions where both dampness and heat are present, treatment focuses on clearing heat, resolving dampness, and releasing exterior qi. Prescription: Ma Huang Lian Qiao Chi Xiao Dou Tang combined with Gan Lu Xiao Du Dan with additions—use 10g each of Lian Qiao, Hu Xiang, Bai Kou Ren, Bo He, Huang Qin, Hua Shi, and Ju Pu, along with 10g each of Yin Chen, Chi Xiao Dou, and Huang Bo. Use 30g of Yin Chen, 15g of Chi Xiao Dou, 6g each of Ma Huang, Mu Tong, and Gan Cao, 3 slices of Fresh Ginger, and 6 Jujubes. For conditions where cold-dampness affects the spleen, clinical manifestations include: yellowing of the whole body and eyes, with a duller yellow color; loss of appetite and abdominal distension; or fatigue and weakness, feeling cold and preferring warmth; loose stools; a swollen tongue, pale tongue, white, slippery coating, and a deep, slow, weak pulse. Main symptoms include: ① Yellowing of the whole body and eyes, with a duller yellow color; ② Loss of appetite and abdominal distension; ③ A deep, slow, weak pulse. Secondary symptoms include: ① Fatigue and weakness, feeling cold and preferring warmth; ② Loose stools; ③ A swollen tongue, pale tongue. Diagnosis requirements: First, patients who meet all main symptoms are classified as having this syndrome; second, patients who meet any two of the main symptoms ① and ②, or any two of the secondary symptoms ① and ②, are also classified as having this syndrome. Treatment principles: strengthen the spleen and stomach, warm the center and resolve dampness. Prescription: Yin Chen Shu Fu Tang with additions: use 30–60g of Yin Chen, 60g each of Fuzi, Gan Jiang, and Gan Cao, 20g of Fu Ling, and 10g each of Bai Zhu and Ze Xie. For severe abdominal distension and thick tongue coating, add Cang Zhu, Hou Po, and Da Fu Pi. (2) Acute Non-Jaundice-Type Hepatitis: Damp-Clotting Blockage Syndrome: Clinical manifestations include: discomfort in the abdomen, lack of appetite, heavy and sluggish limbs, lethargy and a desire to lie down, sticky oral sensations, loose stools, a greasy tongue coating, and a slow, moist pulse. Main symptoms include: ① Discomfort in the abdomen, lack of appetite; ② A greasy tongue coating. Secondary symptoms include: ① Heavy and sluggish limbs; ② Sticky oral sensations; ③ Loose stools. Diagnosis requirements: First, patients who meet all main symptoms are classified as having this syndrome; second, patients who meet any one of the main symptoms ① and any two of the secondary symptoms ① and ② are also classified as having this syndrome. Treatment principles: promote diuresis and restore the spleen. Prescription: Yin Chen 30g, Qian Cao 15g, Bai Zhu 15g, Hu Xiang 10g, Ban Xia 10g, Chen Pi 10g, Zhi Ke 10g, Ze Xie 10g, Jiao San Xian 10g. Additions: For gastric fullness and a thick, greasy tongue coating, add Bai Dou Kou 10g, Shi Chang Pu 15g, Hua Shi 20g; for obvious fatigue, add Sheng Huang Qi 10g, Taizi Shen 10g. Liver Qi Stagnation Syndrome: Clinical manifestations include: flank pain and abdominal discomfort, chest tightness and discomfort, frequent sighing, depressive mood, loss of appetite, or a bitter taste and a desire to vomit, dizziness and blurred vision, a white tongue coating, and a wiry pulse; women may experience breast swelling and pain, menstrual irregularities, and dysmenorrhea. Main symptoms include: ① Flank pain and abdominal discomfort; ② A wiry pulse. Secondary symptoms include: ① Loss of appetite; ② Dizziness and blurred vision; ③ Depressive mood; ④ Breast swelling and pain, menstrual irregularities, and dysmenorrhea. Diagnosis requirements: First, patients who meet all main symptoms are classified as having this syndrome; second, patients who meet any two of the main symptoms ① and ②, or any two of the secondary symptoms ① and ②, are also classified as having this syndrome; third, patients who meet any two of the main symptoms ② and ①, are also classified as having this syndrome. Treatment principles: soothe the liver and regulate qi. Prescription: Chai Hu 10g, Sheng Zhi Shi 10g, Yu Jin 15g, Quan Gua Ling 30g, Red and White Peony 15g each, Dang Gui 15g, Dan Shen 15g, Chen Pi 10g, Jiao San Xian 10g. Additions: For obvious jaundice, add Yin Chen 20g, Hu Jiang 15g; for persistent flank pain, add Jin Ling Zi 10g, Yan Hu Suo 10g, Hong Hua 10g.

2. Chronic Hepatitis: Damp-Heat Syndrome in the Liver and Gallbladder: Clinical manifestations include flank and rib pain, loss of appetite and nausea, aversion to oily foods, a sticky, bitter taste in the mouth, yellowing of the whole body and eyes, sticky, foul-smelling stools, yellow urine, a yellowish, greasy tongue coating, and a wiry, fast, or slow, wiry, fast pulse. Main symptoms include: ① Flank and rib pain; ② A yellowish, greasy tongue coating. Secondary symptoms include: ① Loss of appetite and nausea, aversion to oily foods; ② Yellowing of the whole body and eyes; ③ Yellow urine. Diagnosis requirements: First, patients who meet all main symptoms are classified as having this syndrome; second, patients who meet any two of the main symptoms ① and ②, or any two of the secondary symptoms ① and ②, are also classified as having this syndrome; third, patients who meet any two of the main symptoms ② and ①, are also classified as having this syndrome. Treatment principles: clear heat, promote diuresis, and detoxify. Prescription: Hu Jiang 15g, Long Kui 15g, Yin Chen 10g, Qian Cao 10g, Pu Gong Ying 15g, Ban Lan Gen 10g, Che Qian 10g, Hua Shi 10g, Tong Cao 6g. Additions: For liver energy that is overly hot and where heat outweighs dampness, add Long Dan Cao 10g, Huang Qin 10g, Zhizi 10g; for dampness that outweighs heat, add Huang Bo 10g, Cang Bai Zhu 10g, Hu Xiang 10g, Pei Lan 10g. When toxic toxins are abundant, add Bai Hua She Tiao Cao 15g, Ku Shen 15g, or苦味叶 Xia Zhu 10g. Liver Qi Stagnation and Spleen Deficiency Syndrome: Clinical manifestations include flank and rib pain, chest tightness and discomfort, depressive mood, reduced appetite, a bland taste, abdominal fullness and discomfort, especially in the afternoon, little energy and talkative, fatigue and weakness, a pale complexion, loose stools or indigestion after eating raw, cold, or fatty foods—each time consuming raw, cold, or fatty foods exacerbates the condition. The tongue is pale with tooth marks, coated with white, and the pulse is deep and wiry. Main symptoms include: ① Flank and rib pain; ② Abdominal distension and loose stools. Secondary symptoms include: ① Chest tightness and depression; ② Fatigue and weakness; ③ A pale tongue with tooth marks. Diagnosis requirements: First, patients who meet all main symptoms are classified as having this syndrome; second, patients who meet any two of the main symptoms ① and ②, or any two of the secondary symptoms ① and ②, are also classified as having this syndrome; third, patients who meet any two of the main symptoms ② and ①, are also classified as having this syndrome. Treatment principles: soothe the liver and strengthen the spleen. Prescription: Chai Hu 10g, Zhi Ke 10g, Qing Pi 6g, Chen Pi 6g, Bai Shao 12g, Chuan Xiong 10g, Huang Qi 10g, Bai Zhu 10g, Fu Ling 10g. Additions: For obvious qi stagnation, add Chuan Lian Zi 15g, Mu Xiang 10g; for patients whose right flank pain is predominant, add Dang Gui 15g, Yu Jin 15g. For patients with spleen deficiency and loose stools, add Cang Zhu 15g, Shan Yao 15g, Mu Xiang 10g, Roasted Broad Bean 10g. If morning nausea or occasional nausea occur, adjust the dosage of Chai Hu to 3–6g.

Liver and Kidney Yin Deficiency Syndrome: Clinical manifestations include hidden pain in the right flank, which worsens with exertion, soreness and weakness in the lower back and knees, stiffness in the limbs, muscle twitching, dizziness and blurred vision, tinnitus like a cicada, dry eyes and throat, insomnia with frequent dreams, hot flashes or restlessness in the five internal organs, nocturnal emission in men, scanty or absent menstruation in women, a thin tongue, a red tongue with little saliva, cracked tongue, a flower-like coating or little coating, or a red, shiny surface without coating, a fine, wiry pulse. Main symptoms include: ① Dizziness and blurred vision; ② Soreness and weakness in the lower back and knees; ③ A red, dry tongue. Secondary symptoms include: ① Restlessness in the five internal organs; ② Insomnia with frequent dreams; ③ Hidden pain in the right flank, which worsens with exertion; ④ A fine, wiry pulse. Diagnosis requirements: First, patients who meet all main symptoms are classified as having this syndrome; second, patients who meet any two of the main symptoms ① and ②, or any two of the secondary symptoms ① and ②, are also classified as having this syndrome; third, patients who meet any one of the main symptoms ① and any two of the secondary symptoms ① and ②, are also classified as having this syndrome; fourth, patients who meet all secondary symptoms are classified as having this syndrome. Treatment principles: nourish the kidneys and nourish the liver, benefiting yin. Prescription: Sheng Di 15g, Shu Di 15g, Sang Ji Sheng 10g, Nu Zhen Zi 20g, Wu Wei Zi 15g, Red Peony 15g, White Peony 15g, Dang Gui 15g, Dan Shen 15g. Additions: For internal heat and night sweats, add Dan Pi 15g, Di Ge Pi 15g; for obvious dry mouth and thirst, add Tian Hua Fen 15g, Lu Gen 10g.