Session 9 SP, ST & Intestinal Pathologies Abdominal pain (Fu tong, 腹痛 ) Abdominal Distension (Fu Zhang, 腹胀 ) Nausea / vomiting (E Xin/Ou Tu, 恶心 / 呕吐 ) Chinese Medicine Department www.endeavour.edu.au
o 2-hour lecture: abdominal pain Abdominal distension nausea/vomiting Session Content o 1-hour practical tutorial Practical hints discussion TCM examination skills practice Case study based practical skills Endeavour College of Natural Health www.endeavour.edu.au 2
Session Rationale o The aim of this session is for students to develop theoretical knowledge, critical analysis and a clinical perspective in the TCM assessment, differentiation and treatment strategies for these three disorders. o Case studies develop critical analysis skills as well as application of theory to practice, further developing clinical skills in interpreting the diagnostic meaning of signs and symptoms including tongue and pulse, in preparation for student clinic. Endeavour College of Natural Health www.endeavour.edu.au 3
Learning outcomes By the end of this session study, you are expected to be able to: o Define TCM abdominal pain, abdominal distension and nausea/vomiting and compare to bio-meds perspectives. o Compare & contrast abdominal pain and abdominal distension. o Describe TCM etiology and pathogenesis of those 3 conditions, and understand the dietary and lifestyle play an role in these three conditions. o Make accurate diagnosis and differential diagnosis. o Prescribe acupuncture treatment accordingly. o Practical: assessment, reasoning & treatment application skills practice. Endeavour College of Natural Health www.endeavour.edu.au 4
Abdominal Pain (Fu Tong, 腹痛 ) Endeavour College of Natural Health www.endeavour.edu.au 5
Endeavour College of Natural Health www.endeavour.edu.au 6
TCM terminology of Chest & abdomen regions 1. Xin Xia 心下 2. Wei Wan 胃脘 3. Da Fu 大腹 4. Xiao Fu 小腹 5. Shao Fu 少腹 6. Xie Lei 胁肋 7. Xu Li 虚里 Endeavour College of Natural Health www.endeavour.edu.au 7
Bio-meds Perspectives o Pain: The International Association for the Study of Pain (IASP) defines pain as an unpleasant sensory and emotional experience, associated with actual or potential tissue damage, or described in terms of such damage. o Abdominal pain: Subjective and unpleasant painful sensation in the abdominal region, the area from beneath the epigastrium to the suprapubic margin. *abdominal pain discussed here is intestinal in origin, not abdominal pain from gynecological or other conditions. In women, it s not easy to distinguish whether abdominal pain is of intestinal or gynecological origin, also because they may well overlap. Endeavour College of Natural Health www.endeavour.edu.au 8
Pain assessment Features of the pain history- PQRST P--provocative factors, palliative factors Q--Quality (characteristics) R--region, pattern of radiation, referral S--severity, intensity (use pain rating scales) T--Temporal factors: onset, duration, time to maximum intensity, frequency, daily variation http://www.painaustralia.org.au/ Endeavour College of Natural Health www.endeavour.edu.au 9
Bio-meds Perspectives (cont.) o Abdominal pain is a common symptom only in many digestive system diseases (i.e., Acute & chronic enteritis / Gastro-intestinal spasm / Colic/ Indigestion/ Tumour/ Impacted intestines / Pancreatitis/ Cholecystitis / Appendicitis / IBS/ IBD, etc.) o The management is based on the causes including diet, medicine and surgical treatment. o http://www.healthdirect.gov.au/abdominal-pain o http://www.rch.org.au/kidsinfo/fact_sheets/abdominal _pain/ o https://www.betterhealth.vic.gov.au/health/conditionsa ndtreatments/abdominal-pain-in-adults Endeavour College of Natural Health www.endeavour.edu.au 10
Clinic red flagging: When to see a medical doctor about abdominal pain https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/abdominal-pain-in-adults Go straight to your doctor or the emergency department of the nearest hospital if you have any of (related to red-flag s&s for CM clinic): severe pain pain lasting for several hours pain and/or vaginal bleeding if you are pregnant pain in your scrotum if you are a male pain and vomiting or shortness of breath pain and vomiting blood blood in your bowel motions or urine pain that spreads to your chest, neck or shoulder fever and sweats become pale and clammy unable to pass urine unable to move your bowels or pass gas Endeavour College of Natural Health www.endeavour.edu.au 11
Questions for Discussion Answer the questions below after reviewing bio-meds knowledge: o What are the common causes of abdominal pain? o List the types of abdominal pain o Outline the abdominal pain assessment strategy and demonstrate the abdominal examination skills. o What type of abdominal pain should be the red-flagged in Chinese medicine clinic and refer to a medical professional in Australia health system context? Endeavour College of Natural Health www.endeavour.edu.au 12
TCM Perspective: Abdominal Pain o Define: (Fu Tong, 腹痛 ) Fu (abdomen): the area from beneath the epigastrium to the suprapubic margin. It is a merging area for the three hand and the three foot yin mai, some hand and foot yang mai and also the Chong mai, Ren mai and Dai mai. Tong: pain. Fu Tong signifies various disorders from the internal organs (Zang fu), as well as the channels and vessels (Jing luo) o Zang-Fus/Meridians usually involved in Fu Tong: Upper abdominal pain: SP, ST Lower abdominal pain: Kidney, Bladder, Large/Small-Intestinal, Uterus Side abdominal pain: Liver & Gall-Bladder Endeavour College of Natural Health www.endeavour.edu.au 13
TCM etiology and Pathogenesis o Invasion of seasonal exterior pathogens Pain Leads to Cold, Summer heat and Damp Heat obstruction o Improper diet Food Stagnation Spleen fails to T&T o Emotional Stress Qi Stag Blood Stag Organ Dysfunction Pain due to obstruction o Constitutional yang deficiency Pain due to obstruction Yang fails to warm the internal organs Pain due to malnourishment o Miscellaneous Endeavour College of Natural Health www.endeavour.edu.au 14
TCM etiology and pathogenesis (cont.) Abdominal pain arises due to various aetiologies that either: Obstruct the qi(full conditions) Fail to warm/nourish the organs(empty conditions) Endeavour College of Natural Health www.endeavour.edu.au 15
TCM Diagnosis of Abdominal Pain Maciocia, G. (2008). There are some aspects of diagnosis that particularly apply to abdominal pain: o Nature of pain o Reaction to pressure o Reaction to food or drink o Reaction to bowel movement o Reaction to activity or rest o Reaction to heat o Tongue & pulse signs o Palpation of the abdomen-location of the pain (umbilical, central abdomen, lateral-lower abdomen, central-lower abdomen) Endeavour College of Natural Health www.endeavour.edu.au 16
Key Diagnosis of Abdominal Pain o Identification of cold, heat, excess and deficiency: Based on the etiology, the affected area, and the characteristics of pain o Differential diagnosis of similar disorders: 1) Dysentery disorder 2) Abdominal masses 3) Intestinal abscess 4) Hernia disorder Endeavour College of Natural Health www.endeavour.edu.au 17
TCM Diagnosis of Abdominal Pain Abdominal pain can be acute and short lasting or chronic and long lasting. It may be distending, vague, stabbing, twisting (colicky) or burning in quality and in different location. key points of analysis Acute or Chronic Quality of Pain (cold, heat, qi stagnation, blood stasis, Overindulgence or indigestion ) Location of Pain (hypochondrium, epigastrium, upper or lower abdomen, just below heart ) Endeavour College of Natural Health www.endeavour.edu.au 18
TCM diagnosis according to abdominal pain nature o acute (excess); o chronic/recurrent (excess/deficient); o stabbing, fixed (blood stasis); o vague, unfocalized (qi stagnation); o severe, cramping (cold); o dull, nagging (qi deficiency); o worse with pressure (excess); o worse for eating (excess); o better with pressure (deficiency); Endeavour College of Natural Health www.endeavour.edu.au 19
TCM diagnosis according to abdominal pain nature (cont.) o better with heat (cold); o better with rest (deficiency); o better with activity (qi stagnation); o periodic, accompanied by thirst (heat); o violent attacks, accompanied by fullness (excess) o Digestive or gynaecological: according to symptoms & signs Endeavour College of Natural Health www.endeavour.edu.au 20
TCM diagnosis according to abdominal pain nature (cont.) Identify the etiology factors of abdominal pain/fu Tong (External/internal pathogenic factors, emotional stress and improper diet): o invasion of external cold; o internal cold; o invasion of external heat; o internal heat, damp heat; o repressed emotion (frustration, anger, resentment); o blood stasis (i.e. following abdominal trauma/surgery); o dietary factors (spoiled food, excess cold, raw food, overeating). Endeavour College of Natural Health www.endeavour.edu.au 21
Basic Patterns of Fu Tong 5 patterns (set text P97): 1. Cold invasion 2. Food retention 3. Damp-heat accumulation 4. Qi stagnation & blood stasis 5. Spleen & stomach yang deficiency Endeavour College of Natural Health www.endeavour.edu.au 22
Onset Nature of Pain Worse with Better with Cold invading Stomach Acute Severe Cold Warmth Food retention Acute Dull, full feeling which radiates to the epigastrium Pressure and food Vomiting Damp heat accumulation Acute Dull and a feeling of fullness/ stuffy sensation in epigastric/ hypochondriac area Pressure and greasy fried foods Qi stagnation & blood stasis Chronic Distending, migrating or sharp stabbing fixed At night, with pressure and eating Slight exercise Sp/St yang xu Chronic Intermittent, Vague and dull In the morning and with hunger Warmth, pressure, meals, rest
TCM Treatment of Fu Tong o Treatment Principles: Pain due to obstruction: Regulate the flow of qi, harmonize the blood, dispel the cold, relieve food stagnation, drain accumulation downward to un block obstruction Pain due to malnourishment: Fortify yang qi to warm internal organs o Chinese herbal formula treatment (optional for students) o Acupuncture treatment based on pattern diagnosis (see next slide) Endeavour College of Natural Health www.endeavour.edu.au 24
Cold invasion Damp Heat Food stagnation Qi and Blood Stagnation Spleen & Stomach Yang deficiency Sudden/urgent onset, severe abdominal pain, alleviated by warmth. Treatment principle: Warm the interior, dispel Cold and stop pain. Points: CV12, CV8, ST36, SP4, moxa applicable Intermittent/continuous abdominal distension & fullness, aggravated by pressure, stifling sensation worse in PM & after eating, abdomen feels firm and may look swollen Treatment principle: clear heat-dampness, relieve stagnation and stop pain. Points: LI4, LI11, BL25, ST37, ST25 Upper abdominal distension &/or discomfort better for belching/passing wind, aggravated by pressure, worse for overeating Treatment principle: relieve stagnation, regulate Qi and stop pain. Points: CV12, ST25, CV6, ST36, ST44 Chronic epigastria & abdominal distension worse with stress radiating to the flank (if qi stag dominates) or sharp stabbing and fixed pain if blood stag. Treatment principle: regulate qi and blood, mobile the blood Points: CV17, LR3, PC6, CV10, GB34 Intermittent/unrelenting abdominal dull distension that gets progressively worse throughout day, abdomen may look swollen, worse with eating, cold and tiredness, likes pressure and warmth. Treatment principle: Warm the middle-jiao, augment Qi and strengthen the spleen to stop pain. Points: BL20, BL21, CV12, LR13, CV6, ST36
Discussion: Practical hints for Fu Tong o Rule out all possible non-medical diagnosis before treatment o Red-flagging s&s of abdominal pain in CM clinic. Endeavour College of Natural Health www.endeavour.edu.au 26
Abdominal Distension (Fu Zhang/Pi Man) See: Maclean W. & Lyttleton J., 2002. Vol. 2 pp2-42 Endeavour College of Natural Health www.endeavour.edu.au 27
Abdominal Distension (Fu Zhang 腹胀 / Pi Man 痞满 ) o Fu Zhang: refers to a sense of bloating, fullness, discomfort, blockage or obstruction across the either the upper or lower abdomen, or across the abdomen as a whole. o Pi Man: is distention specially in the epigastric area. o However, Fu Zhang & Pi Man can be dealt with as a single TCM defined disease symptom, hencefore abdominal distension. Endeavour College of Natural Health www.endeavour.edu.au 28
TCM mechanism of Abdominal distension o There are 4 main mechanisms that can produce abdominal distension, each of them can occur separately or in combination. 1) Obstruction of the Qi mechanism 2) Fluid retention 3) Constipation 4) Pathogenic accumulation (usually phlegm and/or dampness) Endeavour College of Natural Health www.endeavour.edu.au 29
TCM Aetiology & pathologies Aetiology: o Diet-food stagnation: overeating, irregular eating o Emotion: Liver Qi stagnation is common & dysfunction of Lungs o SP & ST Xu: the common root cause Pathogens: o Both internal and external pathogens contribute Constipation: a common contributing factor in abdominal distension. Constipation and Qi-obstruction can interact as both cause and effect/result. Endeavour College of Natural Health www.endeavour.edu.au 30
o Key diagnostic Points With constipation/sluggish bowels-excess, blockage to the Qi mechanism o Worse for pressure-excess o Worse for eating-excess o Worse when tired or evening-deficiency o Alleviated by belching/passing gas/ defecation-food stagnation o Distension with emotional component-liver Qi stagnation o Associated with an upper respiratory tract disorder-lung Qi accumulation o Associated with puffy eyes, chronic fatigue and loose bowel- Spleen deficiency See Box 1.2 on P5 Endeavour College of Natural Health www.endeavour.edu.au 31
TCM Differential Diagnosis Compare and contrast to these TCM diagnosis diseases: o Abdominal distension (Fu Zang/Pi Man) VS Abdominal pain (Fu Tong) o Abdominal distension (just below the heart-pi Man/ Wan Pi) VS Epigastric Pain (Wei Wang Tong) VS Xiong Bi (chest painful obstruction) Endeavour College of Natural Health www.endeavour.edu.au 32
TCM Treatment of Abdominal o Food stagnation: distension (pattern based) Treatment principle (TP): relieve food stagnation and harmonise the ST Acu-points, rationales and techniques? o Phlegm Damp: TP: dry dampness and transform phlegm Acu-points, rationales and techniques? o LR Qi stagnation TP: soothe LR-qi Acu-points, rationales and techniques? o SP & LU qi Xu TP:? Acu-points, rationales and techniques? * All Chinese herbal formula treatment, please refer to the text (optional). Endeavour College of Natural Health www.endeavour.edu.au 33
Nausea/ Vomiting E xin 恶心 / Ou Tu 呕吐 Endeavour College of Natural Health www.endeavour.edu.au 34
Bio-meds perspective to Nausea / Vomiting: o Characteristics o Possible causes o Types and diagnosis o Differentiating diagnosis o Management o Useful links: http://www.healthdirect.gov.au/what-causes-vomiting http://www.healthdirect.gov.au/diarrhoea-and-vomiting-in-children https://www.health.qld.gov.au/nutrition/resources/oncol_nausea.pdf Endeavour College of Natural Health www.endeavour.edu.au 35
TCM Perspective to: Nausea/Vomiting (Ou Tu) o Define: it s called Ou Tu in TCM. Vomiting is the ejection of the stomach s contents via the mouth due to a disharmony of the stomach and rebellion of the stomach Qi. Vomiting with the ejection of emesis accompanied by sound is called Ou 呕 ; the vomiting without any sound is called Tu 吐 ; Gan Ou (retching) refers to the involuntary effort to vomit accompanied by the sound of vomiting without actual emesis. Ou Tu is viewed and treated as one dis order as the sound and emesis are usually present simultaneously. Endeavour College of Natural Health www.endeavour.edu.au 36
TCM Aetiology and Pathogenesis o Exterior Pathogens Wind, cold, dampness and epidemic pathogens have a direct influence on the Stomach. By hindering the descending function of the St qi, those factors provoke rebellious qi and cause vomiting o Improper Diet Raw, cold, greasy or contaminated food injure St and SP= food stagnation o Emotional Stress Anger and frustration = Wood attacks the Earth Pensiveness and worry = Spleen Def o St and SP deficiency Endeavour College of Natural Health www.endeavour.edu.au 37
TCM Viewpoint: Nausea/vomiting Nausea (e xin, 恶心 ): from stomach qi ascending counter-flow (stomach deficiency and cold, heat, dampness, phlegm, food stagnation in stomach). Damp or phlegm SP/ST involvement Vomiting (ou tu, 呕吐 ): Stomach qi rebelling or other disorders affecting the stomach and can be a sign of hepatic, renal, eurological, biliary and other diseases SP, ST & LR involvement Endeavour College of Natural Health www.endeavour.edu.au 38
TCM Diagnosis & Differential Diagnosis A. Identification of excess and deficiency Excess patterns are usually acute onset and severe Deficient patterns chronic and prolonged course B. Differential Diagnosis of similar disorders Vomiting, gastric reflux and hiccough are disorders of rebellious Stomach Qi See set text p84 Endeavour College of Natural Health www.endeavour.edu.au 39
Diagnosis based on the contents of emesis o clear water (spleen/stomach empty cold, phlegm, food stagnation, worms); o with copious clear phlegm (cold phlegm patterns, e.g. malaria); o vomiting long after eating or on exposure to cold (stomach full or empty cold, excessive cold, raw food, external pathogen); o immediate vomiting of food or at the sight of food (spleen/stomach heat or heat invading stomach); o periodic nausea and vomiting of clear phlegm (phlegm ascending counter-flow); Endeavour College of Natural Health www.endeavour.edu.au 40
Diagnosis based on the character of vomiting o with fullness and oppression in stomach duct (food accumulation, dietary irregularities, emotions or external pathogen); o with distension and fullness in the chest and diaphragm (qi deficiency, vomiting from emotional disturbance); o bitter vomitus (liver/gallbladder fire obstructing or being obstructed by damp heat); o sour vomitus (food stagnation, phlegm fire, liver qi invading stomach, spleen/stomach qi deficiency); immediate vomiting of water (deep-lying phlegm). Endeavour College of Natural Health www.endeavour.edu.au 41
Vomit Slight nausea With loud sound With low sound Soon after eating Some time after eating Food Thin fluids Sour vomiting Vomiting blood Differentiation Deficiency Excess Deficiency Excess Deficiency Excess Deficiency Liv invading St Heat
Basic patterns: 1) Excess patterns: Exterior pathogens attacking the stomach Food retention Accumulation of congested fluids Stagnant Liver qi overacting on the stomach 2) Deficiency patterns: Deficient cold in the spleen & stomach Stomach Yin deficiency Endeavour College of Natural Health www.endeavour.edu.au 43
Exterior pathogens attacking the Stomach Food Stagnation Accumulation of congested fluids Stagnant Liver Qi overacting on Stomach Deficient cold Spleen & Stomach Stomach Yin deficiency Sudden urgent episodes of vomiting & external pathogenic attack S/S with white greasy tongue coat & soft slow pulse Vomiting with sour and foul smelling vomitus, worse for eating, relieved by vomiting with thick greasy tongue coat & slippery forceful pulse Nausea and vomiting of clear fluids, coughing up white or yellow sputum with white greasy tongue coat & slippery pulse Vomiting of sour and bitter tasting vomitus, relieved by belching with red tongue & thin greasy coat & wiry slippery pulse Recurrent vomiting with clear vomitus brought on by improper diet or tiredness with pale tongue with thin white coat & deep, thready and weak pulse Recurrent vomiting with dry heaves with dry red tongue with scanty coat & rapid thready pulse
Acu-Treatment of Nausea / Vomiting CV12, ST36, PC6, SP4 Plus the following points according to pattern differentiation Endeavour College of Natural Health www.endeavour.edu.au 45
Exterior pathogens attacking the Stomach Food Stagnation + GB20, LI4 reduce + CV12, CV21 reduce Accumulation of congested fluids + CV17, ST40 reduce Stagnant Liver Qi overacting on Stomach + LR3, GB34 reduce or even method Deficient cold Spleen & Stomach + BL20, LR13 reinforce & moxa Stomach Yin deficiency + SP6, BL 20, BL21 reinforce
Practical Hints o In-class group discussion: Practical hints on set text p88 Endeavour College of Natural Health www.endeavour.edu.au 47
Nausea / vomiting Acupuncture research o Numerous reports support the use of PC6 (neiguan) for nausea/vomiting. Do some literature research and find a relevant literature review regarding PC6 effectiveness in acupuncture treatment. o May share your research information with your peer students in practical tutorial or via the LMS forum. Endeavour College of Natural Health www.endeavour.edu.au 48
Break Endeavour College of Natural Health www.endeavour.edu.au 49
Practical Tutorial
Practical o Compare and contrast epigastric pain and abdominal pain. o Review pain assessment strategy and pain scale. o Practise TCM abdominal palpation and meridian identification. Endeavour College of Natural Health www.endeavour.edu.au 51
Case study Case1: 76 years old female presented with intermittent dull pain in the abdomen for many years. The pain used to be dull with preference for warmth and pressure, getting worse by hunger, exertion and stress. She has a few foods intolerance, easily gets bloated and exhausted, and feels fullness or distention in the whole abdomen area especially after meal. Usually loose stool. Pale tongue with white think coating, deep and slow pulse. Endeavour College of Natural Health www.endeavour.edu.au 52
Case study Case 2: The patient was a 66 years old male, who came to the clinic due to a sudden onset of periumbilical pain. The pain was aggravated by food and pressure. No nausea or vomiting. Defecation and urination were normal. The tongue coating was thin and greasy, and the pulse deep and taut. Stool examination did not show any parasitic ova. Endeavour College of Natural Health www.endeavour.edu.au 53
Case study questions o What is the TCM diagnosis (Disease and Pattern)? Explain your answer. o What are the TCM treatment principles? o What TCM treatment methods will you choose to combine in the management for the patient s condition? o Choose at least five acu-points for your acupuncture prescription to treat this condition based on your diagnosis. o Give the rationale for the above acupuncture points & demonstrate your appropriate needling techniques and WH&S knowledge and skills. o Recommend suitable lifestyle/dietary advice for this condition based on Chinese Medicine theory. o How might be the progress of the patient s condition after a course of appropriate treatment has been applied? Endeavour College of Natural Health www.endeavour.edu.au 54
Practical o Demonstration and practice of the assessment, diagnosis and treatment for the patient in case study o Lets treat each other according to the diagnosis and treatment. * Campus lecturers can provide more case studies for your students learning in the practical section. Endeavour College of Natural Health www.endeavour.edu.au 55
Main References Shi, A. (2011). Essentials of Chinese medicine: Internal medicine. (2nd ed.). Walnut, CA: Bridge Publishing Group. Maciocia, G. (2008). The practice of Chinese medicine: Treatment of disease with acupuncture and Chinese herbs(2nd ed.). Edinburgh, Scotland: Elsevier Churchill Livingstone. [ebook available] Maclean, W., & Lyttleton, J. (1998). Clinical handbook of internal medicine: The treatment of disease with traditional Chinese medicine, volume one, lung, kidney, liver, heart. Sydney, NSW: University of Western Sydney. Maclean, W., & Lyttleton, J. (2002). Clinical handbook of internal medicine: The treatment of disease with traditional Chinese medicine, volume two, spleen and stomach. Sydney, NSW: University of Western Sydney. Maclean, W., & Lyttleton, J. (2010). Clinical handbook of internal medicine: The treatment of disease with traditional Chinese medicine, volume three, blood, fluid and channel disorders. Ulladulla, NSW: Pangolin Press. Endeavour College of Natural Health www.endeavour.edu.au 56