A 42-year-old man with a five-year history of moderate ulcerative colitis and chronic diarrhea was managed with a customized herbal formula to tonify the Spleen and Kidneys.

Case ID: CHC-0009

Case Summary

This case describes a 42-year-old man who presented with a five-year history of chronic diarrhea and was previously diagnosed with moderate ulcerative colitis. The original report documented a TCM assessment of Spleen and Kidney deficiency. The patient was managed using a complex herbal prescription designed to simultaneously warm the Kidneys, boost Qi, strengthen the Spleen, and astringe the intestines to stop the fluid loss.

Patient Presentation

• Patient: 42-year-old male.
• Main Complaint: Chronic diarrhea, presenting as yellow, loose stools 3 to 5 times a day for over five years.
• History: The patient reported that his chronic diarrhea began more than five years ago without a clear trigger. The loose stools occasionally contained mucus and were sometimes accompanied by mild abdominal pain, though he experienced no bloating. His appetite was slightly poor, while his sleep and urination were normal. He had no history of infectious diseases, allergies, smoking, or alcohol consumption.

Examination and Diagnosis

• Conventional Diagnosis: Ulcerative colitis (moderate). Physical examination showed a flat, soft abdomen with no tenderness or rebound tenderness. Bowel sounds were normal (5 times/minute).
• TCM Tongue and Pulse: The tongue was pale and dark with a white, greasy coating. The pulse was stringy and fine (弦细).

TCM Assessment

The original practitioner interpreted the presentation as Diarrhea driven by Spleen and Kidney deficiency (脾肾亏虚).

Within the framework of Yin and Yang Chinese Medicine, chronic depletion of Spleen Yang (the digestive fire) over many years will eventually drain Kidney Yang (the body’s foundational metabolic heat). The practitioner noted that the patient’s five-year history of diarrhea had exhausted both organ systems. The pale, dark tongue with a white, greasy coating indicated that this lack of internal Yang energy was failing to properly transform fluids, causing damp-turbidity to accumulate and leak downward as chronic loose stools, while also resulting in chronic fatigue.

Treatment Approach

The primary treatment principle was to tonify the Kidneys, boost Qi, strengthen the Spleen, and stop the diarrhea (补肾益气，健脾止泻). The strategy required a careful balance: strongly warming the interior to rebuild metabolic heat, while simultaneously deploying astringent herbs to halt the chronic loss of fluids.

Herbal Formulas and Modifications

• Formula Prescribed (September 10, 2020): The practitioner crafted a highly customized prescription blending warming, tonifying, and astringing botanicals.
• Action and Composition:
  • Warming the Kidneys and Spleen: Shu Fu Zi (Prepared Aconite, decocted first) and Gui Zhi (Cinnamon Twig) were used to strongly warm the Kidney and Spleen Yang, driving out internal cold.
  • Boosting Qi: Zhi Huang Qi (Astragalus), Shu Dang Shen (Prepared Codonopsis), and Bai Zhu (Atractylodes) were included to heavily tonify Qi and strengthen the digestive system’s ability to process food and fluids.
  • Astringing the Intestines: Wu Mei (Mume/Dark Plum) at a heavy dose of 20g, paired with Ma Huang Gen (Ephedra Root), was utilized to astringe the intestines and physically reduce the frequency of bowel movements.
  • Balancing Localized Heat: Because ulcerative colitis often involves localized intestinal inflammation, small amounts of Huang Bo (Phellodendron) and Huang Lian (Coptis) were added to clear any lingering damp-heat without overriding the primary warming nature of the formula.

Follow-Up

• September 17, 2020 (Second Visit): After taking seven doses of the decoction, the source reported a clear clinical improvement. The frequency of his diarrhea decreased to 2 to 3 times a day. Furthermore, his overall sense of fatigue was alleviated, and his appetite increased. The practitioner continued the foundational formula with minor modifications to consolidate these therapeutic gains.

Why This Case Is Interesting (Clinical Reasoning)

The notable feature of this case is the sophisticated application of traditional diarrhea treatment principles. In the original report’s editorial notes, the practitioner cited the “Nine Methods for Treating Diarrhea” (治泄九法) from the Ming Dynasty classic text Yizong Bidu (医宗必读).

Instead of relying solely on heavy anti-inflammatory herbs for ulcerative colitis, the original practitioner recognized that a five-year disease course ultimately roots itself in Spleen and Kidney deficiency. By combining powerful Yang-warming herbs (Fu Zi) with targeted intestinal astringents (Wu Mei), the treatment addressed both the systemic metabolic weakness (the root) and the exhausting daily fluid loss (the branch symptom) simultaneously, leading to rapid improvements in both bowel frequency and energy levels.

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What This Case Can — and Cannot — Tell Us

This is an individual case report, not a controlled clinical trial. It documents the reasoning, treatment, and outcome reported for one patient and should not be interpreted as evidence that the same approach will produce the same result in another person.

Source

• Original source: Dongguan Hospital of Traditional Chinese Medicine (东莞市中医院) / Guangdong Provincial Administration of Traditional Chinese Medicine
• Original title: [【以案说医】董明国：补肾益气，健脾止泻法治疗泄泻案]
• Practitioner: Professor Dong Mingguo (董明国)
• Publication date: November 2, 2024
• Original language: Chinese
• Source link: [View original page]
• ChineseHerb.org version: English translation and editorial adaptation