Ulcerative Colitis - A Case Study by Mazin Al-Khafaji (originally published by EJOM) Posted on 3 Jun 12:50
Introduction
Ulcerative colitis is a chronic inflammatory disease of the large bowel with the primary symptoms of frequent diarrhoea mixed with mucus, pus and blood along with abdominal discomfort and tenesmus. Although its aetiology is unknown, many consider it to be an autoimmune disease, a condition whereby the body’s own immune system targets healthy tissue, in this case the mucosal lining of the bowel, triggering a chronic inflammation response that leads to ulceration. The primary location of the disease is the rectum and descending colon, although any part of the large intestine may be involved. In the majority of cases it runs a chronic course characterized by exacerbations and remissions. The challenge for us is not only to treat the active phase of this debilitating disease, but to stabilise the system so that exacerbations are reduced and eliminated, and equilibrium is restored.
Although in traditional Chinese medicine there is no one condition that corresponds exactly with ulcerative colitis, it is best classified under one of the following headings:
- dysenteric disorder, lì jí 痢疾;
- blood dysenteric disorder, xùe lì 血;
- chronic dysenteric disorder jiŭlì 久痢;
- intestinal wind (blood in the stools), cháng fēng 腸風;
- intermittent (resting) dysenteric disorder, xiū xī lì 休息痢;
- intestinal afflux, cháng pì 腸澼.
I would like to present a typical case of ulcerative colitis from my practice to outline some of the fundamental principles required for treatment of both the acute and chronic phases of the disease.
Female Age 56
History
Twelve years prior to her visit, gradually and insidiously, and for no apparent reason she understood, she developed increasing episodes of diarrhoea often mixed with blood and jelly-like mucus along with abdominal pain and discomfort. After visiting her GP, a diagnosis of ulcerative colitis was made and after an initial course of Asacol (Mesalazine, 5-aminosalicylic acid) proved ineffective in controlling her symptoms, she was put on a course of prednisolone. This eventually settled the acute attack after which a colonoscopy was performed that confirmed the initial clinical diagnosis of ulcerative colitis. Over the next few years she relied on regular use of steroid foam enemas, initially Colifoam enemas (low volume enemas that only reach the rectum, therefore only suitable for localised colitis of the rectum, known as proctitis), and more recently Predfoam enemas (higher volume foam enema that reach higher into the colon, usually reserved for ulcerative colitis of the descending colon). Despite the steroid enemas, over the years she has suffered ever increasing episodes of acute diarrhoea mixed with blood and mucus, and on each occasion she received varying length courses of prednisolone ranging from 6 to 8 weeks.
Two years ago she was hospitalised following a particularly severe episode, and after she was again stabilised, this time with intravenous steroids, she was put on a maintenance dose of 10mg of prednisolone for six months. She was eventually weaned off this, and started on the immunosuppressive drug Azathioprine. Although this controlled the condition, within 6 months she developed leukopenia, a drop in the white blood cell count, so the drug was discontinued.
Next she was prescribed Remicade (Ibfliximab) as an infusion once every two months, which again eventually resulted in normalization of the bowels, however 12 months after starting this regime she developed significant fatigue, and elevated temperature. The infusions were then discontinued, and she was prescribed yet another course of prednisolone, before being weaned off to a maintenance dose of 10mg per day along with daily use of Predfoam enemas. Several months ago she discontinued the prednisolone after weaning off in stages.
Initial presentation
The only treatment she was using at the time was regular use of Predfoam enemas, and experimenting with dietary changes to try and control her increasingly overactive bowels. She was opening her bowels 4-6 times a day, as well as 1-3 times at night. Her stools varied from totally liquid diarrhoea to loose and unformed stools with undigested food. Each bowel motion was heralded by urgent tenesmus, and by mucus and occasionally pus. She frequently suffered from a burning sensation around the anus. Over the 6 weeks before treatment started, blood accompanied every bowel motion. She said that the morning motions were often foul smelling and more likely to contain pus and larger quantities of fresh blood and be accompanied by strong rectal pain.
In addition she felt exhausted, breathless on exertion with very little stamina. Her appetite was poor, and she had lost approximately 5 kg over the past year or so. She was extremely cautious with the foods she consumed, eating a well-balanced diet and avoiding anything that in her experience aggravated her bowels such as raw foods, dairy products and sugars.
She also described suffering for many years with episodes of acid regurgitation and attributed this to the frequent doses of prednisolone she had been prescribed over the years. She regularly experienced lower left quadrant abdominal discomfort, flatulence and borborygmus. Her sleep was often disrupted because of the frequent need to wake at night and early morning to empty her bowels, which compounded the malaise she experienced.
She had no feverish sensations, on the contrary she described feeling pronounced sensation of cold of the limbs and body especially following a bad bout of diarrhoea, when fatigued or when she hadn't eaten sufficiently.
Examination
She was thin in body, with a pale complexion.
Tongue – pale, teeth-marked, swollen body, with a thick greasy dirty-white coating, more pronounced at the root.
Pulse – soggy and slightly rapid.
In addition to the usual ALT blood test (footnote 1), I also checked her haemoglobin levels. The liver reading was normal, but haemoglobin was reduced at 9.8g/dl (normal range 12.1-15.1 g/dl).
TCM diagnosis
So let us consider this case in detail. The long history of relapsing diarrhoea, poor appetite, fatigue, borborygmus etc. all point unequivocally towards a weakness of the Earth. This primary pattern of Spleen qi xu is accompanied by stagnation in yang ming and the generation of Heat and Dampness, which in turn leads to further obstruction and stagnation setting up a vicious cycle. This is by far the most common root-pattern encountered for ulcerative colitis. The essence of food is not moved and metabolised, so it accumulates not only blocking correct digestion but preventing proper absorption of nutrients. The source of sustenance, the food consumed, instead of supplying nourishment, turns hot and toxic. It is this Toxic Heat that in turn will injure the vessels and agitate the Blood leading to the appearance of blood in the stools, literally the haemorrhaging of life essence from the body.
The accumulation of toxic Damp Heat can easily be discerned from the bouts of foul smelling diarrhoea with pus, acid regurgitation, along with a sensation of heat around the anus (pus is best interrupted as a sign of Toxic Heat, whereas mucus is best seen as accumulation of Dampness or Dampness and Heat).
This pattern of Spleen qi xu with accumulation of Dampness and Toxic Heat in the yang ming is also exemplified by the soggy and rapid pulse quality (rú mài濡脉.
A soggy pulse is one that is small, soft and floating, thin and lacking in strength, being less thin and discernible than a thready pulse. It can be felt on gentle pressure, but quickly becomes indistinct on further pressure). A soggy pulse is a strong indicator of the presence of qi and Blood xu with accumulation of Dampness internally. The rapid nature is a sign of the presence of Heat. This is further confirmed by the pale swollen, teeth-marked tongue body with the thick greasy dirty-white coating.
It is very common in cases of ulcerative colitis not only to be confronted with pattern of xu and shi, but also with co-existence of Heat mixed with Cold. So in addition to the signs of Heat described above, we can assume from the chronic nature of the condition, along with the sensations of cold she experiences, especially when fatigued, along with the poor stamina, that the weakness has extended to affect the yang qi, the very source of Fire needed for correct digestion.
So how should we proceed?
Treatment plan
When dealing with the initial phase of treating an acute manifestation of a chronic disease we should be informed by a simple but crucially important concept. This principle is expressed in many different ways in Chinese medicine including
‘Attack first before settling’; ’First treat the manifestation, before securing the root’; and ‘First drain the evil, only then harmonize and tonify the upright.’
So despite the considerable evidence of weakness of the zheng qi, it is imperative to initially deal with the accumulation of Toxic Heat and Dampness in the intestine. Failure to do so will mean that there is no clear path to regulating the function of the digestive system and restoring equilibrium.
More specifically, as the major pathology of the acute phase in ulcerative colitis is found in the intestine, we can be guided by the adage ‘Diseases of the fu are best treated by moving and draining.’ The other crucially important factor that should always demand our attention is the constant loss of blood. Bleeding represent the loss of vital fluid and thus must always be addressed as a matter of urgency.
Initial treatment
With this in mind the following formula was constructed:
Bai Tou Weng (Pulsatillae Radix) 15
Huang Qin (Scutellariae Radix) 15
Huang Bai (Phellodendri Cortex) 9
Huang Lian (Coptidis Rhizoma) 9
Bai Jiang Cao (Patriniae Herba Cum Radice) 24
Di Yu Tan (Carbonised Sanguisorbae Radix) 24
San Qi (Notoginseng Radix) 4g (dissolved into the decoction)
Chao Zhi Ke (Aurantii Fructus preparata) 12
Mu Xiang (Aucklandiae Radix) 9
Gan Cao (Glycyrrhizae Radix) 6
The formula was decocted into two 150ml sachets of medicine (footnote 2), to be consumed twice a day before morning and evening meals.
In addition to the above formula, she was prescribed an enema, which was composed of the following ingredients-
Qing Dai (Indigo naturalis) 18
Huang Bai (Cortex Phellodendri) 30
Huang Lian (Coptidis Rhizoma) 15
Bai Tou Weng (Pulsatillae Radix) 15
Di Yu Tan (Carbonised Sanguisorbae Radix) 30
San Qi (Notoginseng Radix) 3g (dissolved into the decoction)
Qing Pi (Citri reticulatae viride Pericarpium) 18
Chen Pi (Citri reticulatae Pericarpium) 18
This was decocted into two 120 ml sachets to be used as an enema twice a day in the following way: the liquid is warmed to body temperature, and injected into the rectum. The liquid should be held for as long as is possible. Initially most patients can’t hold it for longer then a few minutes, but fairly quickly retention is possible until the next bowel movement.
She was also advised to start iron supplements.
Explanation of treatment
Bai Tou Weng (Pulsatillae Radix) is bitter, cold and enters yang ming and is chosen to act as the principle ingredient in this formula. It is eminently suitable to treat Damp Heat and Fire Toxin in this region of the body. It also has the ability to cool the Blood, making it useful as an adjunctive herb when the Heat has injured the blood vessels leading to bleeding, as is the case here.
‘The three yellows’ Huang Qin (Scutellariae Radix), Huang Lian (Coptidis Rhizoma) and Huang Bai (Cortex Phellodendri) have similar action in draining Damp Heat from the intestines and lower jiao, and together work as deputies to act synergistically with the principle ingredient, enhancing its efficacy many fold. When used together they have a powerful effect at resolving Toxic Heat from anywhere in the body. In addition Huang Lian (Coptidis Rhizoma) is particularly suited for when heat in the Stomach leads to acid regurgitation, whilst Huang Bai (Cortex Phellodendri) is specifically able to resolve the symptom of burning sensation of the anus.
These herbs are extremely bitter and cold, and have an uncompromising action of clearing Heat and directing qi downwards. It may seem perverse to choose such a descending combination given the disease’s downward flow. In this case the principle of paradoxical treatment “Treat by movement that which is moving” can act as our guide. When coupled with the adage “When the old is expelled, yang ming is revived” it should become clear why this is a good strategy to adopt.
When Dampness or Damp Heat accumulates in the intestine, mucus mixed with the stools is a common finding. Pus on the other hand is more likely to be seen when Blood stasis congeals Toxic Heat in the bowel. Amongst the most effective medicinals to clear this type of toxicity and expel the pus is Bai Jiang Cao (Patriniae Herba Cum Radice), as it clears and resolves Toxic Heat as well as dispelling stasis of Blood. Here I have chosen to use a large dose due to the acute nature of the condition. This action is strengthened further by the ‘three yellows’ and San Qi (Notoginseng Radix).
Qi is the fundamental principle of activity in the body. The strong and persistent presence of Dampness, Heat and Toxin in the intestine further aggravates the flow of qi leading to abdominal discomfort, tenesmus and flatulence. In all stages of the treatment of inflammatory bowel disease, acute and chronic, it is necessary to regulate its flow alongside any other protocols that are adopted. For this reason Chao Zhi Ke (Aurantii Fructus preparata), and Mu Xiang (Aucklandiae Radix) are added. They are both acrid and warm in nature, and will have the effect of regulating and re-harmonising the flow of qi, soothing tenesmus, reducing pain and flatulence. Being warm they will also soften to some degree the bitter cold nature of the principle ingredients, thus making them less injurious to the zheng qi (it should be noted that the dry-fried form of Zhi Ke is chosen in preference to the unprepared form as it is less harsh and more moderate in its action).
As mentioned above, bleeding represents the leaking away of vital essence of the body, and as a matter of priority needs to be contained as quickly as possible. Di Yu (Sanguisorbae Radix), which has a cold nature, is combined with San Qi (Notoginseng Radix), which is warm in nature, to act synergistically to arrest bleeding and regulate the flow of blood. Di Yu (Sanguisorbae Radix) is used in the charred or carbonized form (tan), as this considerably increases its efficacy in arresting bleeding. It is able to cool the Blood when bleeding in the large intestines is due accumulation of Damp Heat. It is also able to soothe sores and generate flesh, making it ideal for treating ulceration of the bowel.
San Qi (Notoginseng Radix) on the other hand is able to arrest bleeding as well as the very common consequence of bleeding, namely stasis of Blood. When Blood leaves the vessels and is no longer under the motive force of qi, it quickly forms stasis, which not only prolongs bleeding, but also inhibits healing of the tissue and generation of new Blood. In fact stasis of Blood can be assumed in most cases of ulcerative colitis, not only for this reason, but because in practice the presence of ulceration and pus strongly indicates this pathology so is best managed by including ingredients to invigorate Blood - so in this respect San Qi (Notoginseng Radix) is working in unison with Bai Jiang Cao (Patriniae Herba Cum Radice).
Finally Gan Cao (Glycyrrhizae Radix) is used to harmonize the various ingredients allowing them to work as an integrated whole, ameliorate the bitter cold nature of the formula, and protect the stomach.
The ingredients used for the enema also have the four major elements discussed above for the internal medicine, namely drain and resolve Damp Heat and Toxin, move qi, invigorate Blood and arrest bleeding. To achieve this I use the combination of Qing Dai (Indigo naturalis) and Huang Bai (Cortex Phellodendri). They work synergistically to strongly dry Dampness and resolve Toxin. Bai Tou Weng (Pulsatillae Radix) will strengthen this function further. Qing Pi (Citri reticulatae viride Pericarpium) and Chen Pi (Citri reticulatae Pericarpium) are acrid, bitter and warm. They will regulate the flow of qi and temper the cold nature of the primary ingredients.
Di Yu Tan (Sanguisorbae Radix) combined with San Qi (Notoginseng Radix) are very effective to stem bleeding when in contact directly with injured tissue. San Qi (Notoginseng Radix) also reduces swelling, activates blood flow, and transforms stasis, whilst Di Yu Tan (carbonised Sanguisorbae Radix) clears Heat locally and generates flesh, both important features when resolving ulceration of the bowel wall.
Treatment progress
She was seen again two weeks later. She reported that within 3 days of starting the treatment, the urgency and frequency of bowel motions reduced to twice a day (which coincided with the use of the enema), with no urge to open her bowels at night. Although she continued to experience spasmodic pains and tenesmus, they were less pronounced. After 5 days there was very significant reduction in bleeding, no pus had been discernible, with only occasional presence of mucus. The stools were better formed, but still tended to loose and occasionally watery. The burning sensation of the anus had significantly reduced, though not totally resolved.
She continued to feel tired and breathless however, and her appetite remained subdued with episodes of epigastric discomfort and acid regurgitation. The following was then prescribed-
Bai Tou Weng (Pulsatillae Radix) 15
Huang Bai (Cortex Phellodendri) 9
Huang Lian (Coptidis Rhizoma) 9
Wu Zhu Yu (Evodiae Fructus) 3
Yi Yi Ren (Coicis Semen) 30
Di Yu Tan (carbonised Sanguisorbae Radix) 24
San Qi (Notoginseng Radix) 4g (dissolved into the decoction)
Chao Zhi Ke (Aurantii Fructus preparata) 12
Mu Xiang (Aucklandiae Radix) 9
Gan Cao (Glycyrrhizae Radix) 6
In this formula I removed Huang Qin (Scutellariae Radix) and Bai Jiang Cao (Patriniae Herba cum Radice) as there had been a clear reduction in the presence of Damp Heat and Toxic Heat. I chose to use Wu Zhu Yu (Evodiae Fructus) to act together with Huang Lian (Coptidis Rhizoma) to deal with heat in the stomach and the persistent acid regurgitation, but also for its excellent ability to relive spasmodic pains of both the stomach and intestine. Yi Yi Ren (Coicis Semen) is utilized in its capacity to resolve Dampness and start the process of strengthening the Spleen. So although it is an ingredient that treats both the root and the manifestation, it is mild in nature and therefore most suited to this phase of treatment when stronger qi tonics if used would be liable to aggravate Dampness and stagnation. Although the overt bleeding has ceased, it seemed prudent to carry on with the ingredients that deal with this to ensure no recurrence.
She was advised to continue the use of the enema, but only once a day in the morning, instead of twice a day.
After two weeks on the above (4 weeks since the start of the treatment), there was further improvement. The stools were much better formed, although she continued to get bouts of watery stools on occasion. The foul smell and mucus cleared, as did the excessive flatulence. She no longer experienced any burning sensation of the anus, nor spasmodic abdominal pains. The acid regurgitation had also improved considerably, with several days between episodes. Her appetite however remained poor, and she complained of regular borborygmus and feelings of fatigue.
Her ALT levels where checked for the second time, and were found to be normal.
Although her pulse was still soggy, it was no longer rapid. Her tongue was less swollen with a significantly thinner and less greasy coating.
Follow-on treatment
At this stage we could be assured that the majority of Dampness, Heat and Toxin had been cleared. With the yang ming more regulated, we turned our attention to the second phase of treatment, namely to harmonize and tonify the Middle, the root of the disharmony. To this end I prescribed the following-
Zhi Huang Qi (Astragali Radix Preparata) 24
Chao Bai Zhu (Atractylodis macrocephalae Rhizoma Preparata) 15
Dang Shen (Codonopsis Radix) 12
Pao Jiang (Zingiberis Rhizoma Preparata) 12
Huang Lian (Coptidis Rhizoma) 5
Wu Zhu Yu (Evodiae Fructus) 3
Jiao Shan Zha (Crataegi Fructus Preparata) 12
Chi Shi Zhi (Halloysitum rubrum) 24
Sheng Ma (Cimicifugae Rhizoma) 6
Chen Pi (Citri reticulatae Pericarpium) 12
Mu Xiang (Aucklandiae Radix) 9
Zhi Gan Cao (Glycyrrhizae Radix Preparata) 6
She was advised to stop using the enemas.
Zhi Huang Qi (Astragali Radix), Dang Shen (Codonopsis Radix) and Chao Bai Zhu (Atractylodis macrocephalae Rhizoma Preparata) now form the principal ingredients, replacing the cold, bitter draining medicinals used thus far for sweet, warm nourishing ones. Together they are able to tonify and strengthen the origin of the dysfunction, bolstering the Earth and solidifying the source of the root of Later Heaven (Hou tian zhi jing). As a result the transformation and transportation function of the Spleen is enhanced, better nourishment is achieved, and qi and Blood are boosted. The honey-fried form of Huang Qi (Astragali Radix) has a better action of tonifying the Interior and raising the clear yang qi, so is used in preference to the unprepared form (which is better for strengthening wei qi).
Likewise the prepared form of Bai Zhu (Atractylodis macrocephalae Rhizoma) is far superior to the unprepared form in drying Dampness, and treating diarrhoea (the dry frying, usually in hot sand, removes much of the oil in the root, which in fact has a pronounced laxative effect, it is for this reason that the unprepared form, Sheng Bai Zhu (Atractylodis macrocephalae Rhizoma) in large doses is frequently used for qi xu constipation, and should be avoided when treating diarrhoea). Dang Shen (Codonopsis Radix) is effective at tonifying the Middle and strengthening qi in a gentle steady way; not drying nor cloying it is easily tolerated by a weakened spleen.
Whenever the Middle qi is enfeebled, particularly if as a result there is diarrhoea and dysenteric disease, it is essential that when tonification is used, concurrently the qi is also raised encouraging the normal upwards flow of the Spleen, otherwise stagnation may ensue. To achieve this I added Sheng Ma (Cimicifugae Rhizoma). This will act to enhance the upward movement of Huang Qi (Astragali Radix), resulting in a re-establishing of the ascent of clear yang and the dissent of the turbid yin, the very core and essence of digestion.
Although much of the Heat has been drained, when treating ulcerative colitis it is very important to bear in mind, despite lack of any overt symptom or signs, that it is extremely common to have lurking Heat. This, coupled with the weakness of the Earth, invariably leads to ‘Heat wrapped in Cold,’ or the co-existence of Heat and Cold. So the intestines will continue to harbour some Heat (which is easily stirred with inappropriate diet, an invasion of an exterior pathogen or emotional upset), whilst the longer term weakness of the digestive system underlying the condition - an insufficiency of qi and yang - rumbles on. To address this contradiction there seemed no better way than combining Huang Lian (Coptidis Rhizoma) with Pao Jiang (Zingiberis Rhizoma Preparata).
In practice I always retain a small dose of a cold, bitter Heat-clearing medicinal to the very end of treatment to ensure any lurking Heat is kept in check. Huang Lian (Coptidis Rhizoma) is ideal for this purpose as it drains Fire and resolves toxicity from the yang ming. (An alternative that suits some patients better is small doses of Da Huang (Rhei Radix et Rhizoma.)
Although considered less warming than Gan Jiang (Zingiberis Rhizoma), Pao Jiang (Zingiberis Rhizoma Preparata) has a superior action in treating lower abdominal problems and has the added benefit of arresting any bleeding that may still occur. This is important because once the Heat has been cleared, the strategy for arresting bleeding can shift from one of cooling and clearing to tonifying and warming. Another very important indication for Pao Jiang (Zingiberis Rhizoma Preparata) is its ability to reduce the water contents in the colon, and it is strongly indicated when watery stools persist.
The warming element is embodied by the combination of Wu Zhu Yu (Evodiae Fructus), and Pao Jiang (Zingiberis Rhizoma Preparata). In this way the Spleen’s function of holding Blood in the vessels is enhanced and firmed up.
Another important element to introduce once the acute phase is over, is astringing the intestines. This not only stabilises diarrhoea, but also helps stop bleeding. For this purpose I added Chi Shi Zhi (Halloysitum rubrum), which is sweet, sour, warm and astringent in nature. It is able to successfully bind up the intestines, as well as stop diarrhoea and bleeding.
Jiao Shan Zha (Crataegi Fructus Preparata) is sweet, sour and warm and used not only in its capacity for awaking the Spleen, stimulating the appetite and aiding digestion, but in its considerable ability in harmonizing and invigorating the Blood within the intestine. Any long-term inflammatory changes to tissue are served well and restored to normal more rapidly by activating and harmonizing the Blood in the final stages of treatment. Shan Zha (Crataegi Fructus) has long been extolled for its undoubted benefits in treating dysenteric disorder with or without accompanying pus and blood. It is able to transform stasis without injury to the zheng qi, nor damage to the newly formed Blood.
As already stated, regulating the flow of qi of the digestive system is always an important feature of treating ulcerative colitis at all stages. To this end Chen Pi (Citri reticulatae Pericarpium) and Mu Xiang (Aucklandiae Radix) are used together.
This encourages a restoration of the normal peristaltic action of the bowel as well as combating any tendency to stagnation that may be generated by the use of tonics.
Finally Zhi Gan Cao (Glycyrrhizae Radix Preparata) is substituted for Sheng Gan Cao (Glycyrrhizae Radix) not only to harmonize the formula, but to enhance the tonic properties of the primary ingredients.
Further treatment progress
After three weeks on the above (7 weeks since the start of treatment) her bowels had normalised. She passed well-formed stools once a day with no sign of any diarrhoea, blood or mucus. Her appetite had improved considerably with only one episode in the recent weeks of acid regurgitation, which followed eating inappropriate food. Her vitality had also changed to the better, although she could still suffer with some breathlessness on exertion.
Her tongue and pulse also reflected the improvement. Her tongue coating was white rather than dirty-white, thinner and no longer greasy, but rather slightly slippery. The body of the tongue had changed to a pinker colour. The pulse was more moderate, and less obviously soggy.
A further minor modification was made to the above formula:
Zhi Huang Qi (Astragali Radix Preparata) 30
Chao Bai Zhu (Atractylodis macrocephalae Rhizoma Preparata) 15
Dang Shen (Codonopsis Radix) 12
Tu Si Zi (Cuscutae Semen) 15
Dang Gui (Angelicae sinensis Radix) 9
Pao Jiang (Zingiberis Rhizoma Preparata) 12
Huang Lian (Coptidis Rhizoma) 3
Wu Zhu Yu (Evodiae Fructus) 3
Jiao Shan Zha (Crataegi Fructus Preparata) 12
Chi Shi Zhi (Halloysitum rubrum) 24
Sheng Ma (Cimicifugae Rhizoma) 6
Chen Pi (Citri reticulatae Pericarpium) 12
Sha Ren (Amomi Fructus) 6
Mu Xiang (Aucklandiae Radix) 9
Zhi Gan Cao (Glycyrrhizae Radix Preparata) 6
To enhamce the tonic properties of the formula I increased the dose of Zhi Huang Qi (Astragali Radix Preparata) to 30g and added Tu Si Zi (Cuscutae Semen). Tu Si Zi (Cuscutae Semen) is acrid, sweet and neutral in nature and is able to warm the primal yang, tonify the Spleen and Kidney yang and prevent diarrhoea. It achieves this without the cloying nature of some of the other tonics that could have been considered. I also deemed it appropriate to more directly tonify the Blood by using Dang Gui (Angelicae sinensis Radix). This ingredient, in combination with Zhi Huang Qi (Astragali Radix Preparata), will of course strongly build the Blood (Dang Gui Bu Xue Tang). The need to do this has been evident from the outset, but it is prudent to be wary of using such a rich cloying ingredient too early on when the ability of the Spleen to assimilate it is still compromised.
To ensure that the Dang Gui (Angelicae sinensis Radix) is well tolerated, I also included acrid, warm and aromatic Sha Ren (Amomi Fructus), which is wonderfully effective at promoting the movement of qi, strengthening the Spleen and aromatically resolving Dampness.
She was seen again 3 weeks later (10 weeks since start of treatment), when she reported feeling the best she had felt in years. Her appetite had continued to improve, and she had put on 1.5 kg since the start of treatment. She had felt energetic enough to start exercising regularly, with no sign of undue breathlessness on exertion.
A blood test to check her haemoglobin was performed and her levels were within normal range at 12.7.g/dl (normal range 12.1-15.1 g/dl). The above formula was prescribed for a further 3 weeks on a full dose, and for two weeks on half dose, after which she was discharged.
Summary
The above is a typical xu complicated by shi case of ulcerative colitis. Damp Heat with toxic heat & stasis combined with an underlying deficiency of zheng qi & yang. When faced by an acutely ill patient who is weak, with frequent episodes of diarrhoea and serious blood loss, it can be confusing to know how to begin treatment, with many worrying that strong bitter and acrid medicinals will further weaken the patient. The truth is the more acute the condition the more straightforward and unequivocal the initial treatment can be – ‘when faced with acute manifestation, look to the branch; when confronted by a chronic pattern, look to the root’.
As we can see the initial formulae were all directed at the manifestation. Draining damp and heat, resolving toxin, moving blood and arresting bleeding. Only once the acute expression had been subdued, did I gradually introduce medicinals that strengthened the Middle and tonified yang qi.By following these simple guidelines, even complex cases of ulcerative colitis can be managed, acute phases subdued, and equilibrium restored.
Footnote
-
I routinely do an ALT check on all patients before commencement of treatment and after 3-4 weeks of being on the herbs. After that, the blood test is repeated every 10 weeks as long as the treatment continues.
2. At my clinic, Avicenna, all herbs for patients are decocted on site using special decocting and packaging machines in the following way. The herbs are thoroughly mixed, placed in a muslin bag and soaked for an hour in the pressurized chamber of the decocting machine. The lid is secured and heat applied. Since the vessel is totally enclosed, the steam formed will build up the pressure so that the water will boil at around 125-130° centigrade, rather than the normal 100° centigrade at atmospheric pressure. Once the cooking process is complete (usually 20 minutes), the pressurized liquid is sent to a second machine where it is immediately vacuum packed in sachets. Each sachet (ranging is size from 50 ml for babies and children, to 280 ml for external applications, and every volume in-between) is then preserved for up to 2-3 months with no deterioration in its contents and without the need for refrigeration. There is considerable research and clinical data from trials in Chinese hospitals to endorse the benefits and superior results of herbs decocted under high pressure, as opposed to them being cooked on a stove at home. (See for example, a study by Zhe Jiang Chinese Medicine Research Institute reported in Zhe Jiang Zhong Yi Za Zhi, Vol-9. 2005; Weiqing Liang, Junxian Zheng, Jinbao Pu, Kemin Wei. A summary of this can be seen on http://www.avicenna.co.uk/news-lifestyle/article/view/the-avicenna-centre-new-developments-in-the-practice-and-dispensing-of-chinese-medicine-1/268/)
The high-pressure and temperature-controlled decoction method extracts significantly higher proportions (as high as 30-40%) of the active ingredients of the herbs thereby making the formula much more powerful and effective, and enhancing the synergistic effect of the ingredients.