1 Module 13 - Liver and Gallbladder Disorders - Guohui Liu --- Peter Borten, Notes from OCOM DAOM Program, Class of 2008 UC with infective agent: Rather than using only antimicrobial herbs, should use a small amount of da huang. in just hot (boiled) water - just infused. Same preparation can be used for Zhi zi for upper jiao problems. Short cook keeps it from going to the liver & below. Dark red tongue is clear indication of bacterial infection about 70-80% of time. Zhe bei mu: one of best herbs for heartburn bai lian, bai ji can coat and protect an ulcer REFLUX AND STOMACH ULCERS Liver invading Stomach Wiry pulse is enough to dx. Chai hu shu gan san (Si ni san + xiang fu + chuan xiong) + yang hu suo Chong mai connects with Liver and Stomach (via St-30) and includes CV-12, St mu. Therefore, using Sp-4 + PC-6 can help Liver Qi properly ascend, Stomach Qi properly descend. Pressing PC-6 for motion sickness is often not enough need to press Sp-4 too. And when you press PC-6, you should go for sensation to PC-9. Spleen Qi xu + Liver Qi Stagnation Stomach Qi xu vs Spleen Qi xu if patient burps frequently, even with only a small amount of food, as long as they haven t just had a carbonated beverage, and the food tastes bland, this is indicative of Stomach Qi xu. Chai shao liu jun zi tang mod: chai hu, bai shao, dang shen, bai zhu, fu ling, zhi gan cao, xiang fu, chen pi, wu zhu yu, wu ze gu, zhe bei mu. Needle GV-20 pointing posteriorly to subdue Yang. Yang Deficiency and Cold of Spleen and Stomach Huang Qi Jian Zhong Tang mod.: huang qi, dang shen, gui zhi, bai shao, fu ling, bai zhu, gan jiang, wu zhu yu, zhi gan cao Li Zhong Wan is ok, but has no movers - ok if no pain. Stomach Yin Deficiency Involves blood stasis often, tongue purple, fixed pain Yi Wei Tang mod: sha shen, mai dong, shi hu, dang gui, bai bian dou, bai shao, chuan lian zi, zhi
2 gan cao. Don t exceed 12g with chuan lian zi. If patient s stomach is irritated by it, replace with Yan hu suo + Yu jin. Obstruction of Collaterals of Stomach by Blood Stasis Collaterals are hard to treat with plant herbs. Need insects. Shi xiao san + dan shen yin: dan shen, tan xiang, sha ren, pu huang, wu ling zhi, wu ze gu, di yu, san qi, bai shao. Dan shen helps tissue regeneration - use 20-30g. Also can break down Peyronie s disease fibrous tissue. Tu bie chong helps normal tissue regeneration - Dr Liu likes to add for severe cases, or even for not so severe cases. Aspirin is warm in nature, acrid, dispersing. Eventually can create internal heat damage. Modified formulas according to endoscope findings: - superficial ulcers or superficial congestion, rotted lining of stomach: lian qiao, ban zhi lian, jin yin hua - thick and sticky fluid: yi yi ren 30g, dong gua ren 20g - regurgitating substance from duodenum: sheng da huang 2-6g or prepared da huang 15g, huang qin, ban xia, sheng jiang 3 pc - regurgitation of bile: jin qian cao, hu zhang DIET: - cut food into small pieces or eat soft or even fluid foods - no smoking, alcohol, coffee, salad - for epigastric distention after eating, take daikon, onion, avoid cabbage and beans - Not painful, usually just discomfort, distention CHRONIC SUPERFICIAL GASTRITIS Stomach Cold and/or Damp - Liang Fu Wan mod: gao ling jiang, xiang fu, dang shen, chai hu, chuan lian zi, yu jin, fo shou, gui zhi, wu zhu yu, ban xia, fu ling, huo xiang,... - No ice water, no raw produce, course of herbs is one month minimum Stomach Heat da huang huang lian xie xin tang mod: sheng da huang (15g short cook), huang lian, huang qin, chai hu, yu jin, chuan lian zi, fo shou, tai zi shen, pu gong ying, zhu ru, sheng gan cao. Cold herbs can easily stagnate Qi. If pt has more distention with herbs, they are aggravating. Yu jin is useful in this regard. Mixed Heat and Cold in Spleen and Stomach
3 Ban xia xie xin tang mod: ban xia, gan jiang, dang shen, da zao, gan cao, huang lian, huang qin, wu zhu yu, chuan lian zi, yu jin,... if severe cramping, use tai zi shen instead of dang shen don t want to tonify too much. Atrophy Gastritis Qi Deficiency of Sp & St deficiency (and blood stasis) is primary factor in atrophy xiang sha liu jun zi tang + gu ya + dan shen zhi gan cao can be 6-10g recovery is very slow Empirical formula from master dong jian hua: xiang fu, su geng, xiang yuan, fo shou, chen pi, zhi ke, da fu pi Damp-Heat in Spleen and Stomach san ren tang mod: esp if heavy sensation in body yi yi ren, bai dou kou, xing ren, hou po, ban xia, tong cao, hua shi, dan zhu ye, huo xiang, or huang lian wen dan tang HIATUS HERNIA etiology: 1. Deficiency of diaphragm muscles 2. Heat in stomach causes rebellion and protrusion of stomach - Disharmony of LV/ST: zuo jin wan mod: huang lian 6, wu zhu yu 1, duan mu li 10 assist metal pill not left metal assist metal to control wood to keep it from attacking earth huang lian s bitter strengthens fire ratio is important. If use 3g huang lian, use only 0.5g wu zhu yu. Perfect for heart heat involvement, canker sores, etc. duan mu li calms shen, neutralizes acid. - needle technique used by dr jin for heartburn: ask patient to suck their stomach in use your hand on CV-15 to press down insert needle at CV-15 and stimulate for about seconds (they can be breathing during this time, just keep belly sucked in) Dr Liu s empirical formula #1: huang lian 2-3g, zi su ye 6-9g, chen pi 6, wu ze gu 10g Dr Liu s empirical formula #2: gua lou pi 12, huang lian 6, ban xia 12, zhu ru 12
4 Peter Eschwey - Severe HTN: dan shen 45g, ge gen 20g, chuan xiong 10g, shan zha 25g The Liver Treating the Heart - will generally be more successful if you go through the liver - especially connecting the kidneys and heart If the Liver is diseased, can bring an end to life very quickly separates the Kidneys and Heart / Fire and Water. Spleen plays a vital role in treatment of Liver disorders - helps course Liver Qi. Treatment of depression is often not very successful without treating Earth. E.g., treating four gates + GV20 not as successful as adding St-36 the bridge. Earth is the bridge. In a preponderance of Yin pathological factors damp weather Liver can not go up very well, can t rise, Qi stagnation results. Wood is 8/3 in month 3 (March) wood starts to grow in month 8 (Aug) wood matures - in the Earth season the difference between these numbers is 5, the number of Earth Earth is contained in all the elements, in the four seasons - and is the difference btw the numbers of each of the seasons. Beyond the typical controlling (ke) associations, Earth can be thought of as controlling all the other elements. The central axis. The center point. Liver is the basic of endurance for whole life. When Liver is diseased, cannot lift, cannot perpetuate the elemental cycle, people can invariably feel tired. The blood of the liver is like the sap of a tree. With sap, it is flexible, not easily cut or broken, not brittle. Without enough blood, the Liver can be overly firm - hard, overbearing. HEPATITIS: - doesn t necessarily have yellow eyes - ji huang - like fulminant hepatitis - life threatening - si ni san - important for hep, especially with rib cage pain - shang han lun set basic framework for tx of hep - the toxic aspect of hep is what makes it contagious - three vicious cycles: - qi & blood stag - damp, qi stag, heat, and toxicity - zheng qi xu and D-H-T - treating H-T successfully depends on treating Qi stagnation - qi must move - stagnation is an important component of hep pathology - in tx of hep it is oft nec to tonify and clear pathological factors at the same time (unless there are external path factors on the surface) - 5 path factors: phlegm, water retention, qi stagnation, blood stasis, and zheng qi xu (qi, blood, yin, or yang xu) - the VENTING (tou) action is important in tx of hep - allowing it to move from one layer to another - which is facilitated by moving qi - lurking pathogen theory is important to understand hep, esp hep B, where sx may disappear for
5 awhile - venting, again, is an important therapeutic action to resolve (vent from blood level to qi level) - patients need time off from work, need to do taijiquan or qigong, calm their mind. The shen and hun are not anchored. - zang fu dx may not tell you clearly where the pathogen is and where it needs to go; 4 level dx may not describe specifically enough the severity, progression Acute Hep: - DH in LV/GB - Yin Chen Hao Tang very well organized yin chen hao - large dose - 100g fresh/60g dry qi level heat vents heat/tox from blood to qi level da huang - move blood, dischg d-h thru BM - use prepared, 6-12g for strong constitution types, can have up to 5 loose stools for weak constitution types, 1-2 loose Bms is enough sx of griping shoud go away within a few days zhi zi - dischg d-h thru urination patient may have very concentrated urination and loose stool while on this formula liu says large dose of zhi zi can easily cause nausea and vomiting. 3-6g. Having patient inhale gua di - produces similar sensation as interferon therapy - flu-like sx. Do 4x maximum. Chronic Hep B - residual DHT with Qi & blood stag, spleen qi xu - Si ni san + xiao chai hu tang + yin chen hao, tao ren, yu jin - if Lv enzymes & bilirubin very high, can add pu gong ying - when patient is undergoing interferon therapy, chai hu can produce adverse effects on liver - use xiang fu instead - herbs that clear heat and toxicity without suppressing the qi of the liver or spleen: yin chen hao, yu jin, pu gong ying - tongue coating comes and goes. If the tongue body is dark red, there is lingering heat in the gb/lv - even if the loose stools, hypochondriac pain improve. When mental fatigue improves, this is a good sign. - when d-h subsides, use chai shao liu jun zi tang (liu jun zi tang + chai hu, bai shao) - when patient has yin xu, use xi yang shen - if severe qi xu or yang xu or cold sensation of extremities when heat sens subsides, use dong chong xia cao. Use the real thing g / day if the patient can afford it.
6 Chronic Active or Aggressive Hepatitis (CAH) - severe blood stasis is common - palmar erythema - vascular spiders in abdomen - bleeding problems - gums, gi tract - must ascertain ratio of D-H-T - hard stool at beginning, then loose = heat predominates - mushy stool = damp predominates - dry hard stool with strong odor = H-T - loose stool with sour smell = D-H + food retn - alt dry and loose stool = liver Qi stag or dampness - yellow sticky tongue coating may not always indicate D-H. Coffee, orange juice, other things may yellowize the coat. Also, can be caused by any spleen disorder, not just heat. Color of spleen is yellow... any severe spleen problem e.g., water retn d/t spleen qi/yang xu. Tongue body is rarely affected by food. If body is red and coat is yellow, this assures you it s heat. If the body is pale and moist, the yellowness of the coat can often be ignored. - If there is any bleeding or vascular spiders or palmar erythema or dark purple tongue, this indicates xue level heat. - yi er bu tou wei zhi qi yu: when qi is suppressed, cannot expand/vent. Depression. Not much yang comes to the surface thru eyes they may avoid making eye contact, more unable to do so, unable to focus, hold a focus. - hun is only active at night. Shen and hun each have predominating times. If hun shows up in daytime (waking) the shen and hun may be reversed. If you wake feeling refreshed, the hun s activities are balanced. If you have disturbed dreams, wake tired, this shows unbalanced activity of the hun. - choppy pulse - blood xu, blood stasis, or worst, jing xu. A dropping out of pulse - stops/delayed for a split second. Pulse may also be felt as touching your fingers for only a very brief moment - like rain drops hitting the ground in the desert - they disappear immediately. Choppy pulse can also exist in yangming disease - may be full and still choppy; choppy does not imply a particular volume. - interpretation of lab findings: - positive HBV - invasion of toxins or flaring of toxins - if titers are high, more severe - (high) serum bilirubin and ALT - D-H -> toxicity - serum bilirubin, ALT vs serum albumin - xie Qi vs zheng Qi - antigen vs antibody - xie Qi vs zheng Qi - humoral immunity vs cell-mediated immunity
7 - xiao chai hu tang - tonifies well, but doesn t move blood or address toxicity - yi guan jian - good when there is more yin xu, but doesn t address D, H add yin chen hao - dr. liu believes yin yang huo is hotter than xian mao - Liver should be straight, firm, and resolute and also supple, gentle, and agreeable. Both yin and yang. In liver heat / blood damage, the yang qualities will be emphasized. - the acrid flavor regulates and lifts the Qi of the liver, helps its Yang Qi fcn better. The sour flavor nourishes the blood/yin, strengthens the body of the liver. The liver is vulnerable to agitation - mainly because of damage to its yin (blood) - the sweet flavor can counteract this agitation. - early hepatitis, patient is often depressed. Then later, more angry, agitated as liver yin/blood damaged and yang rises. - treatment duration keep on each formula for a couple months. Treatment course should last a couple years. - three main approaches: - to relieve D-H-T: bai hua she she cao, lian qiao, ban lan gen, hong teng, bai jiang cao, jiao gu lan, tu fu ling, ji cu gao + local herbs tian ji huang, chui peng cao. Liu likes the combination of pu gong ying + ji gu cao - 30g each. - to discharge D-H-T: - via urine: yi yi ren, che qian zi, ban zhi lian che qian zi especially good if spleen is damaged - via stool: da huang, hu zhang - che qian zi tonifies Jing, can help sperm disorders (seed for seed) - ban zhi lian especially helpful for ascites - to vent the pathogen: when the pathogen is attached to a material substrate - blood - becomes difficult to clear, especially without damaging the blood. However, if it is vented to the Qi level, it can then be released with minimal damage. - favorite venters: bai hua she she cao, da qing ye, pu gong ying, yu xing cao, yu jin, jin yin hua, pei lan - pei lan, especially for ulcerative colitis, with D-H, blood - vent via skin: can apply herbs to Lv-14, BL-18 especially pounded fresh dandelion, twice a day, can make big difference. Others: yin chen hao, hong hua, chi shao, san leng, e zhu, wu ling zhi, pu huang, a wei, xue jie, ru xiang, mo yao, mang xiao, chuan shan jia... - Kamto: dandelion also very useful topically for first stage of br ca. - Brain fog due to insufficient lifting of Liver Qi to head. Lift it with mai ya (when food stag), with pu gong ying (when H-T), with yin chen hao (when D-H), with yu jin
8 - Liver also needs to descend its Qi. When blocked, use chuan lian zi (easier on Stomach when taken in capsule) or qing pi - Chai hu helps both lifting and descending and treats both the liver and gallbladder. 6-15g. However, in SHL, 24g in xiaochaihutang. - xiang fu can also help lifting up and down, but does not treat the gallbladder. If gallbladder issues or jaundice, won t work - use chai hu. If chai hu seems too drying, use with bai shao. - when liver attacks transversely, causing bloating, etc., use bai ji li g - yu jin also ideal when jaundice is present with liver qi stagnation g - sweetness - helps counteract liver attacking spleen. Gan cao, da zao. The sweetness of ren shen also, especially when severe fatigue. Less warm than bai zhu. - when herbs fail to tx hypochondriac pain, must subdue the Liver yang. Use xia ku cao, mu li, dai zhe shi. - coursing liver qi without damaging yin - ask patient frequently if any dry mouth, dry eyes, etc. are developing. - moving blood: 6 forms - move and nourish blood: he shou wu, dang gui, ji xue teng. Ji xue teng beneficial for vascular spiders, palmar erythema (can also add di long) - promote blood circulation and stop bleeding: qian cao (tan), pu huang (tan), wu ling zhi, xue yu tan, san qi (caution with its warmth) - promote blood circulation and transform blood stasis: transform here may also be interpreted as purify dissolve clean restores the blood back to its normal form. Tao ren, hong hua, dan shen (restores damaged tissue to normal), yi mu cao (good when there is D-H), san qi, chi shao, chuan xiong, da huang. - dissipate blood stasis: e zhu, san leng, ru xiang, mo yao. If patient gets tired, consider damage to blood. - open channels and collaterals: di long, di bie chong, shui zhi, meng chong, ze lan (very mild). Shui zhi best as powder, not cooked. - mobilize the heart to pump the blood: gui zhi, xie bai - avoid damaging blood. This is not a short treatment. Combine movers with blood tonics. - si gua luo - good doctrine of sigs for fibrosis/cirrhosis fibrous network - enlargement of liver and spleen: - dan shen 30g + qian cao 15 - (another combo - see notes) - nourishing yin without impeding spleen function or trapping pathogens: - yin xu + blood stasis: shu di, bai shao, han lian cao, dan shen - qi and yin xu: huang jing, shan yao - add pei lan, zi su geng, huo xiang, mai ya for the spleen - add chen pi, sha ren ke, gu ya for the stomach
9 - tonifying yang without exacerbating heat: dong chong xia cao, tu si zi, xian mao, yin yang huo. Start out with small doses (3-6g), check for symptoms of heat worsening. - san jian san: bie jia, chuan shan jia, di bie chong for both liver and kidney xu + blood stasis another combo: chai hu, jiang can, tao ren - e jiao: important post-chemo support herb. 6-10g. - decreasing ALT: - suppress inflammation: use sour flavor to subdue overactivity of Yang. Bitter cold herbs with a slightly sour flavor xia ku cao, long dan cao, da huang, yu xing cao, wu wei zi. - wu wei zi - shell is sour & sweet; kernel is bitter, purgent; ground and taken whole: also slightly salty. Used for any of 5 organs. - absence of tongue coating: yin damage - use large dose of wu wei zi and wu mei - sticky coating which is hard to eliminate - pu huang, wu ling zhi - combo to decrease aminotransferase: - da huang (3-5g) + wu wei zi (6-9g) - wu wei zi + bai hua she she cao + dan shen - wu wei zi will gradually bring Lv enzymes to normal. After that point, can t stop wu wei zi suddenly. Can decrease the dose by 1.5g every two weeks. Course of tx will take over 3 months. - wu wei zi can irritate the stomach. Can encapsulate if so & take after a meal. - if aminotransferase is steadily high & your methods fail, consider dispersing wind add fang feng 15-20g. - another avenue: apply herbs via CV-8. Use pre-heaven ba gua. - sheng di + shu di - sheng di 50g + shu di 6g for xu heat in menopause Hep B Carrier: Lurking D-H Cirrhosis: - poor blood circulation, yin/blood damage - must nourish blood/yin, support circulation - support source Qi from the spleen - Lv qi stag with deep D-H-T: xiao chai hu tang + si ni san modification - Blood stasis + Heat: xue fu zhu yu t mod - Deficiency of Qi and Yin of Liver + blood stasis: difficult to treat. Yi guan jian modified - nourish the yin without cloying. Bie jia is not cloying, though it is heavy and hard to digest (include mai ya for this) - Liu Wei Di Huang W. - add some warmer herbs too, so as not to impede circulation - You Gui Wan + Dang Gui Bu Xue Tang (small doses of fu zi, rou gui) - management for ascites: - mild approaches: - tonify spleen and discharge water: bai zhu (30g), huang qi, che qian zi, huang qi,
10 lai fu zi (60g), dang shen (30) - one practitioner used huge doses of shu di to tonify the spleen (indirectly, by strengthening the kidneys) like 120g shu di a day. - aggressive draining: use harsh cathartics for 1 day, then tonify for 1-2 days (with ren shen and huge doses of huang qi [60-420g/day]) gallstones: - yu jin, hai jin sha, ji nei jin, chuan lian zi - formula for gallstones. Needs herbs to move qi and relax muscles around bile duct. Add bai shao, zhi gan cao, zhi shi. - blood stasis can lead to water retention.