Chinese Medicine Paper I
Non-operative treatment of senile cholelithiasis with integrated traditional chinese medicine
Cholelithiasis is a common disease in digestive system of the elderly. In recent years, we have adopted non-operative therapy of integrating Chinese traditional medicine and Western medicine to treat 26 cases of cholelithiasis in the elderly and have obtained some experience. The report is as follows.
1 Clinical data
1.1 General information
There were 7 males and 19 females in this group, including 17 cases aged 60–70 years old, 6 cases aged 70–80 years old, and 3 cases over 80 years old. All cases were confirmed as cholelithiasis by B-scan ultrasound. There were 8 cases of gallbladder stones, 9 cases of common bile duct stones, 5 cases of gallbladder bile duct stones, and 4 cases of intrahepatic bile duct stones. There were 5 cases with the diameter of stone <5mm, 6 cases with the diameter of 6–10mm, 11 cases with the diameter of 11–15mm, 2 cases with the diameter of 16–20mm and 2 cases with the diameter of 21–30mm. There were 17 cases of multiple calculi and 9 cases of single calculi in this group.
1.2 Dialectical classification
Dialectical classification mainly involves liver-qi stagnation type, liver and gallbladder damp-heat type, and liver stagnation and spleen deficiency type.
Their common symptoms include distending pain in the right hypochondrium to varying degrees, even reaching to the shoulders and back, nausea, vomiting, aversion to oil, and less belching and anorexia嗳气纳少.
For the liver-qi stagnation type, the symptoms also include shifting pain points, distension and pain in the right hypochondrium, which vary in severity following the emotional changes, bitter mouth and dry throat, pale tongue with white coating and tight pulse. They are mostly seen in the early stage of the disease and sometimes accompanied by biliary colic.
For the damp-heat type of liver and gallbladder, the interaction between cold and heat is noticed, together with paroxysmal biliary colic, and mild and moderate yellow staining of sclera or skin. Urine looks like cypress juice, having red tongue with yellow and greasy coating, and wiry or slippery pulse 脉弦或滑数 is more common in patients with concomitant biliary tract infection.
For liver stagnation and spleen deficiency syndrome, the symptoms include dull pain in the right hypochondrium, anorexia, white tongue coating, and wiry and thin pulse, which are more common in patients with chronic cholecystitis.
2 Treatment methods
2.1 Indications for non-operative therapy of integrating traditional Chinese medicine with modern western medicine
All cases in this group were treated with non-operative therapy of integrated Chinese and Western medicine. The subjects of this therapy were those who met the following conditions: (i) those with gallstones < 5mm and good gallbladder function; (ii) Gallstones > 5mm with cardiopulmonary dysfunction; (iii) choledocholithiasis < 20mm in diameter or mild cholangitis; (iv) those with intrahepatic bile duct stones but cannot be operated on.
2.2 Treatment methods
2.2.1 TCM treatment: the basic prescription of TCM is for oral intake, including 20g of Herba Lysimachiae, 10g of Radix Bupleuri, 12g of Radix Scutellariae, 12g of Radix Curcumae, 12g of Radix Aucklandiae, 12g of Fructus Aurantii Immaturus, 12g of Semen Arecae, and 10g of Radix Glycyrrhizae. The prescription should be decocted with water for oral administration. The drug is taken one dose per day, and the treatment is conducted continuously for 1 to 2 months. Configurations depending on types: for patients with exuberant stagnation of liver-qi, flavoring paste and dried tangerine peel can be added; for patients with exuberant damp-heat, add Jun Chen and Shan Zhi. For patients with exuberant spleen deficiency, Rhizoma Atractylodis Macrocephalae, Poria, and Radix Codonopsis are added. For patients with exuberant Yin deficiency, remove Radix Bupleuri plus Radix Glehniae, and add Radix Paeoniae Alba and Radix Rehmanniae. For patients with extravasated blood, 淤血者加赤芍、丹参 add Radix Paeoniae Rubra and Radix Salviae Miltiorrhizae. For patients with difficult stool and dry constitution, 加大黄、元明粉Dahuang and anhydrous sodium sulfate are added. For severe abdominal pain, add Rhizoma Corydalis 15 and Fructus Citri Sarcodactylis. Patients accompanied with coronary heart disease, hypertension, chronic bronchitis, diabetes, etc., had better follow the therapy principle of integrated traditional Chinese medicine with conventional western medicine for treatment.
2.2.2 Acupuncture therapy: acupoints of Ganshu (BL 18), Danshu (BL 23), Yanglingquan (GB 34) and Dannang (BL 20) are pinpointed for acupuncture once or twice a day, with the needle retained for 30 minutes. Therapy for 10 days forms a treatment course and leave two days at the interval between the treatment courses. The acupuncture therapy continues to dredge meridians and collaterals, promote gallbladder function and remove stones in coordination with Chinese traditional medicine.
2.2.3 With western medicine drugs and fluid replacement, correct the imbalance of water and electrolyte. For antipyretic and antibiotics, choose ampicillin, 4g a day to add to 250-500 ml of sugar salt water in the static drops 静滴. Prescribe metronidazole 0.4g each time, 3 times a day, 10–20 days as a course of treatment. If clinical symptoms such as fever do not improve, perform blood culture and drug sensitivity teststo help select antibiotics. For patients with emesis, metoclopramide 5mg should be alternately injected at Zusanli (ST 36). 呕吐者用胃复安5mg足三里交替注射
3 Treatment results
3.1 Efficacy criteria: efficacy is assessed based on clinical symptoms, signs and auxiliary examination results.
3.1.1 Cure: the symptoms and signs disappear completely. The body temperature and hemogram are back to normal. B-scan ultrasonography is used to re-examine cases to ensure that there are no stones remaining in the gallbladder or hepatobiliary ducts.
3.1.2 Markedly effective: symptoms have disappeared, with normal body temperature and hemogram, B-scan ultrasound re-examination indicating significant reduction of gallstones or hepatobiliary calculi.
3.1.3 Improved: the symptoms are basically under control, with normal body temperature and hemogram. No significant reduction of the gallstones or hepatobiliary calculi under B-scan ultrasonography.
3.1.4 No effect: symptoms and physical signs stay unchanged after treatment, and the stones have not been discharged upon B-scan ultrasound examination. The patient needs to be treated by other methods.
3.2 Treatment results: out of the 26 cases, 8 cases cured, accounting for 13%; 12 cases (46%) markedly improved, and 4 cases (15%) improved, 2 cases (7%) ineffective. The overall effective rate is 93%.
4 Example Case
Zhang XX, female, 67 years old, retired worker. Her first diagnosis was made on July 10, 1993. The patient had a history of cholelithiasis in the past. The pain in her right upper abdomen occurred three times in the preceding month. As the symptoms became milder, suddenly, after lunch that day, she had right upper abdominal colic radiating to her right shoulder and back, with continuous moaning, aversion to cold, fever, nausea and vomiting of stomach contents, anorexia, asthenia, and loose stool纳呆乏力，溲赤便约. Also observed were red tongue with yellow and greasy coating and wiry and rapid pulse. Physical examination: T 38.7C degrees, blood pressure 18/12Kpa. Acute pain, mild yellow staining of skin and sclera, cardiopulmonary (1) 心肺(一), abdominal muscle tension, liver, spleen and subcostal untouched. Mofei’s sign is positive. 墨非氏征阳性。
B-scan ultrasonography revealed: (i) Multiple gallstones, the largest of which was 20×25 mm. (ii) Left intrahepatic bile duct stone. Blood white matter count, WBC 8.2×10/L N 0.83 L 0.17. Liver function, jaundice index 29mmol/L, GPT74 units, HBSAg negative. 血白分计数，WBC 8.2×10/L N 0.83 L 0.17。肝功能，黄疸指数 29mmol/L，GPT74单位，HBSAg阴性。
Cholesterol 4.5mmol/L, triglycerides 1.18 mmol/L. In traditional Chinese medicine (TCM), acupuncture at Yanglingquan (GB 34), Ganshu (BL 18) and Danshu (BL 23) is the first choice for relieving pains due to the syndrome of damp-heat in liver and heat accumulation due to qi stagnation. Anti-inflammatory fluid replacement with western medicine has the effects of regulating the balance of water and electrolyte and reducing the fever of acute patients caused by frequent nausea, vomiting, anorexia, or diarrhea triggered by diarrhea drugs. Moreover, the body fluid was quickly replenished, thus avoiding bile concentration, beneficial to the dissolution of gallstones.
Most of the 26 patients had gallbladder and biliary tract inflammation in the past, and the total white blood cells and neutrality were often high. Some patients had jaundice and liver damage to different degrees. Acupuncture, anti-inflammation and fluid replacement, as well as the traditional Chinese medicines of soothing liver, cholagogue and clearing heat, and resolving stasis 中药疏肝利胆清热、化淤诸法 were all conducive to improving the symptoms and controlling inflammation. Practice has proved that acupuncture and the combination of Chinese and western medicine complement each other and can bring out the best effects.
By Mingjie Li & Yangzhen Li, 05/11/1991
Proceedings of First International Conference on Naturopathy in China (37)