3.6 Case Dropout Situation

3.6 Case Dropout Situation

One case dropped out from each of the treatment and control groups. The treatment group case was a male who died of massive upper gastrointestinal bleeding three weeks after enrollment; the control group case was a female who voluntarily discontinued treatment two weeks after enrollment.

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4 Case Analysis Report

Patient He Moumou, male, 56 years old, worker, was admitted to the hospital due to "intermittent distension and discomfort in the right upper abdomen for half a year, and bilateral lower limb edema for one month," initially diagnosed as "primary liver cancer" in the outpatient clinic. The patient first experienced upper abdominal distension and discomfort without any obvious cause in March 2012 but did not receive any specific treatment. On July 18, 2012, his symptoms worsened, accompanied by bilateral lower limb edema and cough with sputum. He visited the Second Hospital of Lanzhou University, where a chest X-ray revealed bronchitis in both lungs. After 11 days of symptomatic treatment including anti-inflammatory and diuretic medications (specific drugs unknown), there was no significant improvement. On August 1, 2012, an ultrasound at the Second Hospital of Lanzhou University showed a solid lesion in the right lobe of the liver, with contrast-enhanced ultrasound consistent with massive hepatocellular carcinoma and tumor thrombi in the main portal vein and its left and right branches; B-mode ultrasound also indicated: ① intrahepatic solid lesion, most likely hepatocellular carcinoma; ② solid lesions in the portal vein and its left and right branches, most likely tumor thrombi; ③ secondary changes in the gallbladder; ④ ascites. Prior to admission, the patient’s bilateral lower limb edema, abdominal pain, and abdominal distension gradually worsened. Seeking systematic treatment, he was admitted to the hospital under the diagnosis of "primary liver cancer." Since onset, the patient has been alert, in good spirits, with normal diet and sleep, reduced urine output, normal bowel movements, and no significant change in body weight.

Physical Examination: T: 36.4°C, P: 88 beats/min, R: 22 breaths/min, BP: 106/62 mmHg. Normal development, moderate nutrition, clear consciousness, spontaneous posture, coherent responses, cooperative during examination. Yellowish skin all over the body, no cyanosis or petechiae. Dark red tongue with greasy yellow coating, slippery and rapid pulse. No enlarged superficial lymph nodes in the neck, supraclavicular region, axilla, or inguinal area. No deformities of the head and facial features, scleral icterus, no conjunctival congestion, sensitive pupillary light reflex. Normal auricles, no abnormal discharge from the external auditory canal, no tenderness in the mastoid region. Good nasal ventilation, no abnormal discharge, no tenderness in the paranasal sinuses. No cyanosis of the lips, normal mucous membranes, midline tongue protrusion, no pharyngeal congestion, no enlarged tonsils. Voice is not hoarse. No nuchal rigidity.

Research on Pei Zhengxue's series of prescriptions

No jugular venous distension. Trachea is midline, hepatojugular reflux sign is negative. Thyroid gland is neither enlarged nor tender. Symmetrical thorax, no sternal tenderness, no pleural friction rub heard. No precordial bulge, normal apical impulse, no palpable thrill, no cardiomegaly, heart rate 88 beats/min, regular rhythm, normal heart sounds, no pathological murmurs heard in any valve area. No pericardial friction rub heard. Peripheral vascular signs are negative. Abdomen is distended, with fullness below the right costal margin, varicosity of abdominal wall veins, no intestinal patterns or peristaltic waves seen. Tenderness below the xiphoid process and in the right upper abdomen, no rebound tenderness throughout the abdomen, no abdominal muscle tension, liver palpable 4 cm below the costal margin, medium consistency, mild tenderness, irregular edge, gallbladder not palpable, Murphy's sign negative, spleen not palpable, percussion of abdomen shows tympany, no percussion tenderness in hepatic and renal regions, positive shifting dullness, normal bowel sounds at 4–5 times/min. No deformities of the spine or limbs, bilateral pitting edema of the lower limbs, no bone tenderness, abdominal wall reflex (+), biceps and triceps reflexes (+), patellar and Achilles tendon reflexes (-), Hoffmann sign (-), Babinski sign (-), Chaddock sign (-), Kerning sign (-), Brudzinski sign (-).

Auxiliary Examinations: Complete blood count shows: WBC: 11.25×10⁹/L, RBC: 5.8×10¹²/L, HGB: 165 g/L, PLT: 345×10⁹/L, N: 78.1%; biochemical tests show: ALT: 232 IU/L, AST: 258 IU/L, γ-GT: 60 U/L, GGT: 563 IU/L, AKP: 501 IU/L, TBIL: 48.4 μmol/L, DBIL: 34.2 μmol/L, IBIL: 14.2 μmol/L, TG: 2.28 mmol/L, BUN: 5.1 mmol/L, Cr: 115 μmol/L, UA: 519 μmol/L; tumor markers: CEA: 3.7 ng/ml, CA19-9: 410.6 U/ml, SF: >653.4 ng/ml, AFP: >1000 ng/ml; electrocardiogram shows: basically normal ECG; on August 1, 2012, an ultrasound at the Second Hospital of Lanzhou University showed a solid lesion in the right lobe of the liver, with contrast-enhanced ultrasound consistent with massive PLC and tumor thrombi in the main portal vein and its left and right branches; B-mode ultrasound indicated: ① intrahepatic solid lesion, most likely hepatocellular carcinoma; ② solid lesions in the portal vein and its left and right branches, most likely tumor thrombi; ③ secondary changes in the gallbladder; ④ ascites.

Traditional Chinese Medicine Diagnosis and Differential Diagnosis: The patient is a 56-year-old male admitted with "intermittent distension and discomfort in the right upper abdomen for half a year, and bilateral lower limb edema for one month." Admission symptoms include bilateral lower limb edema, abdominal pain, abdominal distension, reduced urine output, and normal bowel movements; dark red tongue with greasy yellow coating, slippery and rapid pulse. Based on the four diagnostic methods, this condition falls under the category of "accumulation" in TCM, with syndrome belonging to "liver depression and spleen deficiency." The patient has depressive mood, dietary damage, and exposure to pathogenic factors, which invade the body and linger, leading to disharmony among the internal organs, stagnation of qi and blood, generation of phlegm-turbidity, qi stagnation and blood stasis, and eventually accumulation. Over time, accumulation leads to severe depletion of righteous qi and excessive pathogenic qi, manifesting as large, hard masses that cause pain. This condition can be differentiated from "fullness," where the main symptom is subjective feeling of blockage and fullness in the epigastrium, but physical examination reveals no obvious signs of gas accumulation or distension, and no palpable mass—this is how it differs from accumulation clinically.

TCM Diagnosis: Accumulation—Liver Depression and Spleen Deficiency

Western Medical Diagnosis: Primary Liver Cancer, cT4N0M0, Karnofsky Performance Status: 70 points

Treatment: ① Routine internal medicine nursing care; Level 1 nursing care; Record 24-hour intake and output; ② Light, easily digestible soft diet; ③ Treatment: Administer 250 ml of Ganxingling intravenously once daily; 500 ml of 10% glucose solution plus 100 units of coenzyme A, 40 mg of ATP, 3.0 g of vitamin C, 0.2 g of vitamin B6, and 10 ml of 10% potassium chloride intravenously once daily; 250 ml of 5% glucose solution plus 1.8 g of reduced glutathione intravenously once daily; spironolactone 40 mg orally three times daily; torasemide 20 mg intramuscularly twice daily; Pei's Soft Liver and Anti-bloating Pills, one packet twice daily orally.

After two weeks of combined traditional Chinese and Western medical treatment, the patient's edema subsided, with no abdominal pain or distension, and normal bowel movements. Shifting dullness disappeared. Laboratory tests showed: complete blood count: WBC: 4.5×10⁹/L, RBC: 5.6×10¹²/L, HGB: 146 g/L, PLT: 130×10⁹/L; liver function: ALT: 45 IU/L, AST: 38 IU/L, γ-GT: 20 U/L; kidney function: BUN: 4.1 mmol/L, Cr: 105 μmol/L; AFP: 302 ng/ml. Imaging examinations: abdominal color Doppler ultrasound showed a solid lesion in the right lobe of the liver (11.3×10.8 cm). The patient's condition improved, and he was discharged as instructed, with recommendations to continue taking Soft Liver and Anti-bloating Pills and attend regular outpatient follow-up visits.

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Discussion

PLC has a high degree of malignancy, with subtle early symptoms that make early diagnosis difficult. The disease progresses rapidly, and most patients lose surgical opportunities by the time of diagnosis. At this stage, combination therapy is the primary choice—comprehensive treatment—but currently there is no unified standard for such comprehensive treatment. Traditional Chinese and Western medicine combination demonstrates significant advantages: TCM herbs are used throughout all stages of PLC treatment, playing a prominent role, and when perfectly integrated with Western medicine, they complement each other's strengths, enabling breakthrough progress in PLC treatment.