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Abstract: Mr. Luo reported that he had recurrent abdominal pain for more than 2 years, and in the past 1 week, he had increased abdominal pain, relieved mucus stools about 3-5 times a day, reduced pain after stooling, accompanied by weakness, reduced appetite, worry and anxiety, and restless sleep at night, so he was admitted to our hospital. After admission, the patient was examined and a colonoscopy was performed. The diagnosis of Western medicine was chronic colitis; the diagnosis of Chinese medicine was abdominal pain – damp-heat in the large intestine. We used Ge Gen Scutellaria Tang with addition and subtraction to clear heat and dampness, permeate dampness and stop diarrhea, the symptoms disappeared and the treatment effect was good.
Basic information】Male, 34 years old
Disease Type】Damp-heat in large intestine
Hospital】The First Affiliated Hospital of Nanchang University
Date of Consultation】October 2021
Treatment Plan】Therapeutic treatment with Chinese herbal medicine (Ge Gen, Scutellaria Baicalensis, Huang Lian Tang plus reduction: Ge Gen, Scutellaria Baicalensis, Huang Lian, Roasted Licorice, Poria, Atractylodes Macrocephalae, Xian Ling Spleen, Xian He Cao, Hooked Vine, Wu Ling Li, Pu Huang, Citrus Aurantium, Atractylodes, Dang Shen, Poria)
[Treatment Period] 1 month of inpatient treatment
Treatment effect】abdominal pain and diarrhea disappeared, good treatment effect
I. Initial consultation
Mr. Luo, 34 years old, presented in October 2021 with complaints of recurrent abdominal pain for 2 years, recurrence with diarrhea and mucus stools for 1 week. Mr. Luo had abdominal pain with no obvious cause 2 years ago, mainly in the middle and lower part of the body, which is intense during attacks and can be relieved on its own after a few minutes. At the time of diagnosis, he saw a sad face, sighing constantly, mental fatigue, red tongue, yellow fur, and slippery pulse. Previous history of chronic colitis, colonoscopy showed colitis, hemorrhoids, admission to the hospital Western diagnosis: chronic colitis; Chinese diagnosis: abdominal pain – large intestine damp-heat evidence.
(Western medical diagnosis)
II. Treatment history
After identification, Mr. Luo was found to have damp-heat evidence in the large intestine, so the treatment was to clear heat and dampness, penetrate dampness and stop diarrhea. The prescription is Ge Gen Scutellaria Tang Plus Decrease, which contains: Ge Gen, Scutellaria Baicalensis, Huang Lian, Roasted Licorice, Poria, Atractylodes Macrocephalae, Xian Ling Spleen, Xian He Cao, Hooked Vine, and water decoction.
1 week re-diagnosis: Mr. Luo’s symptoms did not decrease, the pain remained the same, diarrhea existed, sometimes pus and blood stool, the original formula added Wu Ling Li and Pu Huang.
1 week 3 consultation: Mr. Luo’s stool frequency decreased to 2-4 times, abdominal pain reduced, mucus decreased, external hemorrhoid pain, more vector gas, add Citrus aurantium and Atractylodes macrocephala in front.
1 Thursday consultation: Mr. Luo’s abdominal pain disappeared, night sleep improved, stool still diluted mainly, more frequent, weakness existed, tongue lighter, add Radix Codonopsis and Poria with additional amount.
2 Friday consultation: Mr. Luo’s spirit improved significantly, abdominal pain was relieved, sleep improved, diarrhea slightly when eating carelessly.
After continuing to take the front for 1 month, no abdominal pain and diarrhea occurred again in 2 months of follow-up.
III. Treatment effect
Mr. Luo has been ill for a long time, his spleen and stomach have been damaged for a long time and his spleen qi is weak. At the fourth consultation, Mr. Luo’s spleen qi weakness is particularly obvious, plus ginseng, Poria increase the amount to help the spleen transport 2 weeks after the spirit improved significantly, there is no obvious weakness, lethargy. Pueraria lobata, Xian Ling Spleen, Xian He Cao, Scutellaria Baicalensis and Huang Lian clear heat and dry dampness, and the damp-heat dysentery will stop. At the third consultation, Qi stagnation was obvious, adding Citrus aurantium and Atractylodes to regulate Qi and move stagnation. During the fourth consultation, the stagnation of Qi was no longer obvious. During the treatment, Mr. Luo’s anxiety was diagnosed and psychological guidance was given to relieve Mr. Luo’s unnecessary worries about the disease. As the disease is prone to recurrence, attention should be paid to regular colonoscopy during treatment. In conclusion, Mr. Luo’s abdominal pain and diarrhea disappeared and the treatment effect was good.
IV. Notes
We are glad that Mr. Luo’s abdominal pain and diarrhea are relieved after treatment. However, if there is any adverse reaction during taking the medicine, you can choose to take it after meal to reduce the irritation to the gastric mucosa. If enema is used for treatment, the hip should be raised as much as possible to prolong the retention time of the drug to enhance the efficacy. Currently, with the improvement of people’s living standard, high-fat, high-protein and high-sugar diet has more and more influence on the human body, and the incidence of chronic colitis has gradually increased, especially the excessive intake of meat, protein, etc., and fried foods rich in trans fat and saturated fat, which have a close relationship with the development of chronic colitis. Therefore, Mr. Luo should have a high dietary fiber diet and consume more fresh vegetables and fruits, which are rich in soluble fiber and can reduce the incidence of the disease by scavenging oxygen free radicals, such as fresh yam, adzuki beans, white lentils, gorgonian rice and poria, etc. to strengthen the spleen and resolve dampness. After the occurrence of the disease, Mr. Luo should promptly adjust his diet, living and life pattern, and control his emotions to make his spirit happy, so that his condition can be improved as soon as possible through good control.
V. Personal Insight
Modern research has also shown that psychological stimulation can aggravate gastrointestinal symptoms by changing gastrointestinal dynamics and visceral sensitivity, and that prolonged negative emotions can aggravate inflammatory activities and symptoms, and that the onset of chronic colitis is related to mental stress, and long-term treatment is generally required, so the necessary psychological intervention is more important. In this case, Mr. Luo’s lack of understanding of the disease and his anxiety about the disease, timely disease education and psychological counseling effectively enhanced Mr. Luo’s awareness of health care, which was helpful for the improvement of symptoms and prognosis.
For patients with early intestinal polyps, they should undergo regular colonoscopy. For patients with ulcerative colitis with constipation, they should not only rely on enemas for symptom relief, but also go to the hospital for comprehensive treatment.