.Boli Zhou
The patient was a 37-year-old male from the city of Ningbo in Zhejiang province. For 3 years, he had experienced high fevers 3 to 4 times a month that persisted for 3 to 5 days each time.
Health history: he patient was plump as a child and at the age of 8 (in 1993) he was found to have a congenital choledochal cyst. A cholecystectomy was performed in hospital; the name of the surgical procedure was “choledochojejunostomy” (Roux-en-Y choledochojejunostomy).
The surgery led to changes in normal physiological structures, causing bile reflux that triggered the formation of gallstones. In 2010 (at age 25), a physical exam found hepatolithiasis. At age 34, in March 2019, inflammation of the bile ducts caused the patient to suffer from fever. He experienced both fever and chills; a CT scan and MRI at the hospital found left localized hepatolithiasis. He underwent a left hepatic lobectomy and intrahepatic bile duct lithotomy. During the surgery, it was found that reflux of bile and food at the site of the choledochojejunostomy had caused reflux cholangitis, so a lithotomy and biliary-enteric anastomosis were performed.
In August 2020 (at age 35), the patient once again experienced persistent fever due to bile duct inflammation. When he went to the hospital for a CT and MRI exam, an abscess of the left liver was found. He then underwent fine-needle aspiration of the left liver to drain the abscess and received antibiotic treatment. More than 20 days later, MRI and CT scans showed that the abscess was still present. At that point, a left hepatic lobectomy and intrahepatic bile duct lithotomy were performed. During the surgery, the doctors found a relatively large number of stones in the intrahepatic bile ducts, requiring additional extraction procedures.
In November 2020, the patient underwent PTCD (percutaneous transhepatic cholangial drainage). PTCD involves the insertion of a drainage tube through the skin, intrahepatic bile ducts, and anastomotic stoma into the jejunum. In order to extract stones, the PTCD drainage tube remained inserted in the patient’s body for nearly 14 months. In the early stages of the procedure, the bile ducts were relatively narrow and needed to be dilated, so from November 2020 to December 2021, 4 surgeries were performed to switch out the drainage tube and dilate the bile ducts. This was followed by 3 lithotomy procedures, 1 every 3 months or so. At the end of December 2021, during the last lithotomy, the doctors found that they could not extract all the stones and there was reflux of digested material. The patient and his family were deeply discouraged.
Starting in May 2022, the patient came to the clinic for TCM treatment.
Initial intake on May 22, 2022:
Health history and current symptoms: After the drainage tube was removed, the patient began to experience recurrent bile duct inflammation starting in January 2022. He experienced high fevers ranging from 37.5 to 40.2 degrees Celsius 1 to 2 times a month. Pustules often formed on his face and back, and he had frequent canker sores. At the end of February, he suffered from shingles on his head, belching after eating, excessive passing of gas, and bubbly urine, along with an occasional swelling sensation in his chest that seemed to be in the gastric region, and discomfort on the right side of his back. He had a painful expression. The tongue fur was slightly yellow but thick, and he had frequent fevers.
Disease identification: welling-abscess of the liver
Pattern diagnosis: liver-gallbladder damp-heat, qi stagnation, and blood stasis
First prescription:
Cardamom (bái kòu) 10 g, agastache (huò xiāng) 15 g, virgate wormwood (yīn chén) 60 g, talcum (huá shí) 30 g, atractylodes root (cāng zhú) 20 g, forsythia fruit (lián qiào) 20 g, scutellaria root (huáng qín) 20 g, red peony root (chì sháo) 60 g, moutan root bark (dān pí) 30 g, dried rehmannia root (shēng dì) 30 g, chuanxiong rhizome (chuān xiōng) 20 g, curcuma root (yù jīn) 20 g, bushy knotweed root (hǔ zhàng) 30 g, purslane (mǎ chǐ xiàn) 30 g, dandelion (pú gōng yīng) 30 g, lygodium spore (hǎi jīn shā) 10 g, gizzard lining (jī nèi jīn) 10 g, violet (zǐ huā dì dīng) 30 g, wild chrysanthemum flower (yě jú huā) 20 g, lonicera stem (rěn dōng téng) 30 g, gardenia fruit (zhì zǐ) 30 g, and rhubarb (dà huáng) 10 g (to be added to the decoction at the end).
The formula was to be taken as a decoction. One preparation was to be taken daily, decocted 3 times to yield a total of 800 ml of juice, which was to be divided into 4 equal portions to be consumed separately. After continuously administering 32 preparations of this formula, the prescription would be changed.
Second prescription: ant lion larva (jīn shā niú) 4 g, lysimachia klattiana Hance (huáng kāi kǒu) 4 g, subcapitate hemiboea (jiàng lóng cǎo) 4 g, and caragana root (jīn què gēn) 4 g. The doses listed are the daily dose. All ingredients were ground into powder to be taken 3 times daily. After meals, 5 g of powder was to be taken mixed with warm water. One course of treatment was 32 days. Greasy and rich food and drink were contraindicated.
The patient was instructed to take both formulas at the same time. The western medical diagnosis was “liver abscess” and “inflammation due to a short bowel with a tendency to reflux”, or “inflammation due to reflux of bile and intestinal contents”. The prognosis estimated that he would recover in 50 to 60 days. If there were stones, he would need more than 3 months to recover.
The patient came for his second visit on June 26. Since his first visit, he had an average of 2 bowel movements a day, the swelling sensation in his chest had diminished, and he experienced excessive passing of gas with a foul odor. For the past few days, he had felt good overall. The frequency of bowel movements had decreased; over the past 5 days, he had 1, 1, 3, 3, and 3 bowel movements a day respectively, and on the day of the second visit, he had 2 bowel movements. He was prescribed 2 formulas again.
First prescription:
Cardamom (bái kòu) 10 g, mint (bò hé) 15 g, virgate wormwood (yīn chén) 20 g, paris root (cǎo hé chē) 20 g, talcum (huá shí) 30 g, atractylodes root (cāng zhú) 20 g, forsythia fruit (lián qiào) 20 g, scutellaria root (huáng qín) 20 g, red peony root (chì sháo) 60 g, moutan root bark (dān pí) 30 g, dried rehmannia root (shēng dì) 30 g, chuanxiong rhizome (chuān xiōng) 20 g, curcuma root (yù jīn) 20 g, bushy knotweed root (hǔ zhàng) 30 g, lygodium spore (hǎi jīn shā) 10 g, dandelion (pú gōng yīng) 30 g, raw gizzard lining (shēng jī nèi jīn) 10 g, violet (zǐ huā dì dīng) 30 g, wild chrysanthemum flower (yě jú huā) 20 g, semiaquilegia root (tiān kuí zǐ) 20 g, gardenia fruit (zhì zǐ) 30 g, fish poison yam (bì xiè) 20 g, acorus root (shí chāng pú) 20 g, areca husk (dà fù pí) 20 g, officinal magnolia bark (hòu pò) 20 g, and unripe tangerine peel (qīng pí) 10 g.
The formula was to be taken as a decoction. One preparation was to be taken daily or every other day. After continuously administering 12 preparations of this formula, the prescription would be changed.
Second prescription: ant lion larva (jīn shā niú) 4 g, jumping spider (yán hǔ) 4 g, thladiantha fruit (chì páo) 4 g, and gendarussa stem and leaf (bó gǔ dān) 4 g. The doses listed are the daily dose. All ingredients were ground into powder to be taken continuously for 24 days, after which the formula would be changed.
The patient took these formulas until July 6, at which point he had experienced no fevers for 22 days. On July 13, his mother called to report that he had a fever of 38.2 degrees Celsius, which had reached 39.1 degrees at its highest. I replied that this was not a fever caused by liver and gallbladder issues; it was external contraction. I instructed the patient to take 2 packets each of Nine-Ingredient Notopterygium Granules (jiǔ wèi qiāng huó kě lì) and Minor Bupleurum Granules (xiǎo chái hú chōng jì), to be soaked in warm water. By the next morning, his body temperature had returned to normal.
Starting on July 8, the patient’s condition was good while taking the formulas. He had 1 bowel movement daily, which was normal, and there was basically no belching. The passing of gas had become less frequent than before, his sleep was essentially normal, and there were no more bubbles in his urine.
Decocted prescription:
Pro formula pinellia rhizome (fǎ bàn xià) 30 g, white atractylodes root (bái zhú) 20 g, lygodium spore (hǎi jīn shā) 10 g, moneywort (jīn qián cǎo) 10 g, raw gizzard lining (shēng jī nèi jīn) 10 g, bupleurum root (chái hú) 10 g, scutellaria root (huáng qín) 10 g, poria (fú líng) 20 g, licorice root (gān cǎo) 10 g, codonopsis root (dǎng shēn) 15 g, jujube (dà zǎo) 20 g, dried ginger (gān jiāng) 20 g, chuanxiong rhizome (chuān xiōng) 15 g, Yunnan aristolochia root (yún mù xiāng) 20 g, and officinal magnolia bark (hòu pò) 15 g. Add 20 g of fresh ginger (shēng jiāng) and decoct together. One preparation should be taken daily. The formula may be changed after continuously administering more than 12 preparations. The patient fully recovered after continuously taking 18 preparations of this variation.
Analysis:The patient suffered from damp-heat in the center burner, as well as congestion and blockage of damp-heat in the spleen, stomach, liver, and gallbladder, which caused frequent discomfort in those areas. The multiple factors involved were qi, damp, heat, stasis, and vacuity.
Treatment requirements: There were 6 inflammatory factors in this case. The drainage procedure required dilation of the intrahepatic bile ducts, and once they were dilated they could not easily return to their original form, which made them prone to inflammation. Post-surgical scarring was vulnerable to inflammation, as was the chronic left liver abscess. Inflammation was triggered by reflux of bile and intestinal contents, and there was chronic inflammation in the bile ducts and intestines. After the choledochojejunostomy, the qi ［or gas］ in the intestines moved upward to gather in the upper cavity that remained after surgery, which also caused inflammation. The treatment was intended to stop the reflux, descend the accumulated qi, enable the dilated bile ducts to shrink, reduce scarring, disperse the abscess, and address the chronic inflammation in the bile ducts and intestines.
The pattern diagnosis was liver-gallbladder damp-heat, qi stagnation, and blood stasis. For liver-gallbladder damp-heat, cardamom (bái kòu), mint (bò hé), virgate wormwood (yīn chén), paris root (cǎo hé chē), talcum (huá shí), atractylodes root (cāng zhú), forsythia fruit (lián qiào), scutellaria root (huáng qín), bushy knotweed root (hǔ zhàng), dandelion (pú gōng yīng), gardenia fruit (zhì zǐ), fish poison yam (bì xiè), acorus root (shí chāng pú), violet (zǐ huā dì dīng), wild chrysanthemum flower (yě jú huā), and thladiantha fruit (chì páo) were used. For qi stagnation and blood stasis, curcuma root (yù jīn), areca husk (dà fù pí), officinal magnolia bark (hòu pò), and unripe tangerine peel (qīng pí) were used.
For blood stasis and stones, red peony root (chì sháo), moutan root bark (dān pí), dried rehmannia root (shēng dì), chuanxiong rhizome (chuān xiōng), lygodium spore (hǎi jīn shā), raw gizzard lining (shēng jī nèi jīn), semiaquilegia root (tiān kuí zǐ), ant lion larva (jīn shā niú), jumping spider (yán hǔ), and gendarussa stem and leaf (bó gǔ dān) were used.
In combination, these formulas treat welling-abscess of the liver.
Clearing heat and cooling blood can address dilation and inflammation of the bile ducts, for which mint (bò hé), virgate wormwood (yīn chén), paris root (cǎo hé chē), talcum (huá shí), atractylodes root (cāng zhú), forsythia fruit (lián qiào), scutellaria root (huáng qín), bushy knotweed root (hǔ zhàng), dandelion (pú gōng yīng), gardenia fruit (zhì zǐ), fish poison yam (bì xiè), acorus root (shí chāng pú), violet (zǐ huā dì dīng), wild chrysanthemum flower (yě jú huā), thladiantha fruit (chì páo), and lygodium spore (hǎi jīn shā) were used. It was necessary to quicken the blood and soften hardness to treat post-surgical scarring, so forsythia fruit (lián qiào), bushy knotweed root (hǔ zhàng), thladiantha fruit (chì páo), curcuma root (yù jīn), unripe tangerine peel (qīng pí), red peony root (chì sháo), moutan root bark (dān pí), chuanxiong rhizome (chuān xiōng), raw gizzard lining (shēng jī nèi jīn), semiaquilegia root (tiān kuí zǐ), ant lion larva (jīn shā niú), jumping spider (yán hǔ), and gendarussa stem and leaf (bó gǔ dān) were used.
To treat the inflammation caused by the reflux of bile and intestinal contents as well as the accumulation of qi, cardamom (bái kòu), mint (bò hé), virgate wormwood (yīn chén), paris root (cǎo hé chē), gardenia fruit (zhì zǐ), acorus root (shí chāng pú), thladiantha fruit (chì páo), curcuma root (yù jīn), areca husk (dà fù pí), officinal magnolia bark (hòu pò), unripe tangerine peel (qīng pí), lygodium spore (hǎi jīn shā), raw gizzard lining (shēng jī nèi jīn), semiaquilegia root (tiān kuí zǐ), ant lion larva (jīn shā niú), jumping spider (yán hǔ), and gendarussa stem and leaf (bó gǔ dān) were used.
To make the accumulated qi descend and shrink the dilated bile ducts, one should cool the qi, reduce body weight, quicken the blood, and fortify the spleen using mint (bò hé), virgate wormwood (yīn chén), paris root (cǎo hé chē), talcum (huá shí), scutellaria root (huáng qín), red peony root (chì sháo), moutan root bark (dān pí), dried rehmannia root (shēng dì), chuanxiong rhizome (chuān xiōng), curcuma root (yù jīn), bushy knotweed root (hǔ zhàng), raw gizzard lining (shēng jī nèi jīn), acorus root (shí chāng pú), unripe tangerine peel (qīng pí), ant lion larva (jīn shā niú), thladiantha fruit (chì páo), and gendarussa stem and leaf (bó gǔ dān). In this way, one can prevent recurrence after the patient has recovered.
Author information:
Boli Zhou: Doctor of Chinese medicine Ren Shou County, Meishan City, Anhui Province
多因肝膿腫案
周伯禮
男，37歲。浙江省寧波市人。每個月高燒3~4次，每次持續3~5天3年。
病史：小時候體胖，8歲（1993年）檢查出先天性膽總管囊腫，在醫院做了膽囊囊腫切除術，手術名稱是膽總管空腸吻合手術（Roux-en-Y膽總管空腸吻合術）。
手術導致正常生理結構改變，膽汁逆行引起結石，至2010年（25歲）體檢發現有肝內膽管結石。34歲的2019年3月膽管發炎引起發燒，出現發熱寒戰，經醫院CT和核磁共振檢查，發現左肝結石，做了左肝肝葉切除和肝內膽管取石術，手術時發現是因為膽總管空腸吻合處有膽汁、食物反流，引起反流性膽管炎，做了取石手術並膽腸吻合術。
2020年（35歲）8月又膽管發炎發燒，一直不退，到醫院住做CT和磁共振檢查時發現左肝膿腫，隨即做了左肝穿刺引流膿腫加抗生素治療，20餘天後通過磁共振和CT檢查發現膿腫仍在，於是做了左肝肝葉切除和肝內膽管取石術，手術時醫生發現肝內膽管結石比較多需要另外取石。
2020年11月做PTCD（經皮經肝穿刺取石術），經皮經肝穿刺取石術就是把引流管通過皮膚和肝內膽管、經過吻合口一直插到空腸位置。 為了取石，PTCD膿腫引流管在身上插了近14個月。插管前期因膽管較細需要擴張，2020年11月底到2021年12月底先後為了擴張膽管做了4次手術换引流管，後面3次取結石，每次大約間隔3個月。2021年12月底最後一次去取石，醫生發現結石取不乾淨還有消化物反流的現象， 病患及其家屬失望之至。
自2022年5月就診接受中醫治療。
2022年5月22日初診：病史與現在症：取引流管後，在2022年元月起反復膽管發炎每月高燒37.5~40.2度1~2次，臉及背容易長膿痘，口腔易潰瘍。今年2月底患頭部帶狀皰疹，食後打嗝，排氣較多，尿中泡沫， 偶爾胸口疑似胃部頂脹感 ，右背部不適感。痛苦貌，舌苔微黃但厚，常常發燒。
辨病：肝癰
辨證：肝膽溼熱，氣滯血瘀。
處方一：
白蔻10g、藿香15g、茵陳60g、滑石30g、蒼朮20g、連翹20g、黃芩20g、赤芍60g、丹皮30g、生地30g、川芎20g、鬱金20g、虎杖30g、馬齒莧30g、蒲公英30g、海金沙10g、雞內金10g、紫花地丁30g、野菊花20g、忍冬藤30g、梔子30g、大黃（後下）10g。
煎服。每天服1劑。
煎3次共取汁800ml，均分4次服完。連服32劑轉方。
處方二:
金沙牛4g、開口4g、降龍草4g、金雀根4g。每天量。打粉。每天吃3次。
飯後溫開水拌服5g。32天為一個療程。禁忌油膩飲食。
醫囑：兩方同吃。 西醫確診是“肝膿腫”，“腸短容易反流致炎症”，或者是“膽汁和腸內容物反流引起的發炎”，預後估計50~60天可愈。有結石，則需要3個月以上。
6月26日二診：就診後，每天大便平均2次，胸口頂脹感減輕，排氣多且臭，最近幾天整體感覺尚可，大便頻率有所下降，前五天分別是1、1、3、3、3次，今天排便2次； 仍然開具2方。
處方一：
白蔻10g、薄荷15g、茵陳20g、草河車20g、滑石30g、蒼朮20g、連翹20g、黃芩20g、赤芍60g、丹皮30g、生地30g、川芎20g、鬱金20g、虎杖30g、海金沙10g、蒲公英30g、生雞內金10g、紫花地丁30g、野菊花20g、天葵子20g、梔子30g、萆薢20g、石菖蒲20g、大腹皮20g、厚朴20g、青皮10g。
煎服。每天或每2天吃1劑，連服12劑轉方。
處方二：
金沙牛4g、蠅虎4g、赤瓟4g、駁骨丹4g。
每天量，打粉連服24天轉方。
服至7月6日，已經22天沒有發高燒了。7月13日其母親電訴發燒38.2度，最高達39.1度。我回復：不是肝膽問題發燒，是外感，叫服九味羌活顆粒加小柴胡沖劑，每樣一次吃2包，溫開水泡服。次日早晨體溫正常了。
7月8日開始，患者服藥整體情況尚可，每日大便一次正常，基本無打嗝情況，排氣次數較之前有所下降，睡眠基本正常，小便泡沫消失。
煎服處方：
薑半夏30g、白朮20g、海金沙10g、金錢草10g、生雞內金10g、柴胡10g、黃芩10g、茯苓20g、甘草10g、黨參15g、大棗20g、乾薑20g、川芎15g、雲木香20g、厚朴15g。加生薑20g。同煎。
每天1劑。連服12劑以上轉方。
此方化裁，連服18劑治愈。
分析：素有中焦溼熱，脾、胃、肝、膽溼熱壅堵，致此處常常不適。多因有：氣、溼、熱、瘀、虛。
治療要求：有6種發炎因素：引流要擴張肝內膽管，擴張了就擴張着不易回復，此易發炎；手術後疤痕要發炎；左肝慢性膿腫要發炎；膽汁和腸內容物返流要引起發炎；膽管—腸慢性炎症發着炎；膽管-空腸吻合術後，腸中之氣往上聚於手術後的上段空腔內要引起發炎。
治療要不讓再反流，積氣要下降，要讓擴張了的膽管回縮，要消疤痕，要消膿腫，要治療膽管—腸慢性炎症。
辨證為肝膽溼熱，氣滯血瘀。
肝膽溼熱用白蔻、薄荷、茵陳、草河車、滑石、蒼朮、連翹、黃芩、虎杖、蒲公英、梔子、萆薢、石菖蒲、紫花地丁、野菊花、赤瓟；氣滯用鬱金、大腹皮、厚朴、青皮；血瘀及結石用赤芍、丹皮、生地、川芎、海金沙、生雞內金、天葵子、金沙牛、蠅虎、駁骨丹。
全方合治肝癰。
清熱涼血可治膽管擴張發炎，用薄荷、茵陳、草河車、滑石、蒼朮、連翹、黃芩、虎杖、蒲公英、梔子、萆薢、石菖蒲、紫花地丁、野菊花、赤瓟、海金沙。
治療手術後疤痕發炎要活血軟堅，用連翹、虎杖、赤瓟、鬱金、青皮、赤芍、丹皮、川芎、生雞內金、天葵子、金沙牛、蠅虎、駁骨丹。
治療膽汁和腸內容物返流和積氣發炎，用白蔻、薄荷、茵陳、草河車、梔子、石菖蒲、赤瓟、鬱金、大腹皮、厚朴、青皮、海金沙、生雞內金、天葵子、金沙牛、蠅虎、駁骨丹；積氣要下降，要讓擴張了的膽管回縮，應涼氣減肥、活血健脾，用薄荷、茵陳、草河車、滑石、黃芩、赤芍、丹皮、生地、川芎、鬱金、虎杖、生雞內金、石菖蒲、青皮、金沙牛、蠅虎、赤瓟、駁骨丹。故治愈後可預防復發。
作者簡介:
周伯禮,中医师，安徽省眉山市，仁壽郡周禮伯診所
