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