A 45-year-old woman with a five-year history of chronic Hepatitis B, presenting with severe fatigue, rib pain, and highly elevated liver enzymes, was successfully managed using a Spleen/Kidney-tonifying and Damp-Toxin-clearing herbal strategy.

Case ID: CHC-0078

Case Summary

This case describes a 45-year-old woman who presented with severe fatigue, poor appetite, and right rib pain due to an acute flare-up of chronic Hepatitis B. Her liver enzymes were highly elevated (ALT 258 U/L), indicating active liver inflammation. The original report documented a conventional diagnosis of chronic viral hepatitis B and a TCM assessment of Liver Attachment (Gan Zhuo) driven by Liver and Kidney Deficiency, Spleen Qi Deficiency, and Damp-Toxin Accumulation. She was managed by Professor Hu Shiping using a highly strategic approach based on his academic thought of “regulating Yin and Yang as the key, supporting Yang as the root.” By utilizing a complex herbal decoction to rebuild her foundational Spleen and Kidney energy while simultaneously clearing the viral damp-toxin, she achieved a rapid normalization of her liver enzymes and complete clinical recovery in under a month.

Patient Presentation

• Patient: 45-year-old female (Surname: Jiao).
• Main Complaint: Fatigue and weakness since June 2014; severe exacerbation of generalized weakness and exhaustion for 1 week.
• History: The patient sought her initial consultation on October 27, 2019. In 2014, she developed fatigue and tested positive for Hepatitis B (HBsAg positive). She had not undergone regular monitoring, viral load testing, or routine antiviral treatment. One week prior to the visit, she felt mentally exhausted and experienced generalized severe weakness that was not relieved by rest.
• Associated Symptoms: Pale and lusterless complexion, tired limbs, reluctance to speak, shortness of breath, fatigue (worsening with movement), right hypochondriac (rib) pain, abdominal distension, occasional lower back ache, poor appetite, nausea, aversion to greasy food, sticky stools, and foul-smelling urine. Her sleep was normal.

Examination and Diagnosis

• Imaging & Labs: Liver function tests showed active and significant inflammation: Alanine Aminotransferase (ALT) 258 U/L, Aspartate Aminotransferase (AST) 93 U/L. Hepatitis B serology showed HBsAg (+), Anti-HBe (+), and Anti-HBc (+) (indicating the chronic carrier state transitioning to active hepatitis).
• Conventional Diagnosis: Chronic viral hepatitis B.
• TCM Tongue and Pulse: The tongue body was dark and pale with a thin, yellow coating. The pulse was sunken, fine, and weak (脉沉细无力).

TCM Assessment

The original practitioner interpreted the presentation as Liver Attachment (Gan Zhuo) driven by Liver/Kidney Deficiency, Spleen Qi Deficiency, and Damp-Toxin Accumulation (肝着 – 肝肾不足，脾气亏虚，湿毒蕴结).

According to the holistic principles of Chinese Medicine, a chronic illness lasting five years deeply damages the Spleen and Kidneys. The Liver lost its smooth flow, rebelled, and attacked the Spleen. Because the weak Spleen failed to transport clear Qi upward, the patient experienced severe fatigue, shortness of breath, and a pale complexion. Simultaneously, the Spleen failed to transport turbid fluids downward, resulting in the sticky stools and foul urine (classic signs of Damp-Heat).

The trapped Liver Qi and blood stasis directly caused the rib pain and abdominal distension. Furthermore, the chronic drain exhausted her Kidney essence, leading to the lower back ache. The dark pale tongue, thin yellow coating, and sunken-fine-weak pulse provided textbook objective confirmation of this profound systemic deficiency complicated by an active, trapped damp-heat toxin (the hepatitis virus).

Treatment Approach

The primary treatment principle was to tonify and benefit the Liver and Kidneys, strengthen the Spleen and boost Qi, and clear and resolve damp-toxin (补益肝肾，健脾益气，清利湿毒). The strategy utilized a sophisticated “treat the root to fight the branch” approach: heavily fortifying the patient’s innate immune system and Yang energy so the body could tolerate the specific cold, toxin-clearing herbs needed to suppress the active liver inflammation.

Interventions and Herbal Formulas

• Initial Herbal Formula (October 27, 2019): A 16-herb decoction modifying the concepts of Chaihu Shaoyao Liujunzi Tang, Siwu Tang, and Erzhi Wan.
  • Tonifying Kidneys and Supporting Yang (The Root): Ba Ji Tian (Morinda, 30g) and Tu Si Zi (Dodder Seed, 10g) strongly warm and boost Kidney Yang. Zi He Che (Placenta, 15g), Nu Zhen Zi (15g), and Mo Han Lian (Eclipta, 20g) deeply nourish Kidney Yin to consolidate the congenital root.
  • Strengthening Spleen and Boosting Qi: Dang Shen (15g), Bai Zhu (15g), and Cang Zhu (15g) strengthen the Spleen’s digestive capacity and rebuild energy.
  • Clearing Damp-Toxicity: Ye Xia Zhu (Phyllanthus urinaria, 15g) and Chui Pen Cao (Sedum, 30g) are highly specific, modern classic herbs used to clear hepatitis viral heat/dampness and aggressively lower elevated liver enzymes.
  • Soothing Liver and Moving Blood: Chai Hu (Bupleurum, 15g) and Qing Pi (Green Tangerine Peel, 10g) soothe Liver Qi. Bai Shao (White Peony, 30g) softens the Liver. Dang Gui (15g) and Chuan Xiong (10g) nourish and move blood. Zhi Gan Cao (5g) harmonizes. (7 doses, water decocted, taken warm after breakfast and dinner).
• Second Visit (November 3, 2019): The patient’s complexion improved. Fatigue, abdominal distension, and backache were significantly reduced. The rib pain disappeared, her appetite returned, and the nausea stopped. Liver enzymes dropped dramatically: ALT 192 U/L, AST 80 U/L. Recognizing that her Righteous Qi was recovering but the pathogenic heat remained, the heavy tonic Zi He Che was removed and Huang Qin (Scutellaria, 15g) was added to clear Liver heat. (7 doses).
• Third Visit (November 10, 2019): The patient was in good spirits with only occasional fatigue. The formula was adjusted to remove Qi-breaking and heavy nourishing herbs, adding Spleen-drying/damp-resolving herbs: Chen Pi (15g), Fu Ling (15g), and Cao Dou Kou (10g) to further promote middle Jiao transportation. (7 doses).
• Fourth Visit (November 17, 2019): The patient’s symptoms progressively resolved with no remaining discomfort. Liver enzymes (ALT, AST) fully returned to normal levels. Chuan Xiong was removed, and Dan Shen (Salvia, 30g) was added to gently regulate and nourish the Liver to consolidate the cure. (7 doses).

Why This Case Is Interesting (Clinical Reasoning)

The notable feature of this case is Professor Hu Shiping’s application of “supporting Yang” in the treatment of active viral hepatitis.

Standard treatments for active hepatitis B flare-ups (characterized by highly elevated ALT/AST) often rely heavily on bitter, cold, damp-heat clearing herbs to “attack” the virus. However, Professor Hu recognized that this 45-year-old patient’s core issue was five years of chronic exhaustion. If he had only used cold herbs, he would have destroyed her already weak Spleen (digestive) and Kidney Yang. Brilliantly, he anchored the formula with heavy Kidney Yang tonics (Ba Ji Tian, Tu Si Zi) and deep essence builders (Zi He Che). This protected and rebuilt her core vitality, providing the physical stamina necessary for specific virus-clearing herbs (Ye Xia Zhu, Chui Pen Cao) to successfully purge the inflammation and normalize her liver enzymes in less than a month.

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Source Original source: Shenzhen Hospital of Beijing University of Chinese Medicine (Longgang) / Traditional Chinese Medicine Bureau of Guangdong Province Original title: 【以案说医】胡世平：固本培元重脾肾，体用俱荣肝病痊 Practitioner: Professor Hu Shiping (胡世平) Publication date: August 15, 2024 Original language: Chinese