A 69-year-old man with chronic upper abdominal fullness and discomfort was managed using a modified Xiang Sha Liu Jun Zi Tang to strengthen the Spleen and regulate Qi.

Case ID: CHC-0006

Case Summary

This case describes a 69-year-old man who presented with a one-month history of upper abdominal distension and a “noisy” discomfort in the stomach, exacerbated by eating. The original report documented a conventional diagnosis of chronic gastritis and a TCM assessment of Stomach Pi (Stomach Glomus/Fullness) driven by Spleen deficiency and Qi stagnation. The patient was managed with a classical herbal approach designed to simultaneously tonify the digestive system and unblock stagnant energy.

Patient Presentation

• Patient: 69-year-old male.
• Main Complaint: Upper abdominal pain and distension lasting for over one month.
• History: The patient reported that one month prior, without any obvious trigger, he began experiencing upper abdominal fullness and distension that worsened significantly after eating. He described a “noisy” or unsettled sensation in his abdomen (嘈杂感), but had no acute pain, no acid reflux, and no nausea or vomiting. His bowel movements occurred once every two days, urination was normal, and his general appetite was fair. He sought treatment due to the fluctuating but persistent nature of these symptoms.

Examination and Diagnosis

• Conventional Diagnosis: Chronic gastritis.
• TCM Tongue and Pulse: The tongue was pale and dark with a white, greasy coating. The pulse was stringy and fine (弦细).
• Physical Examination: General physical examination was largely unremarkable regarding the abdomen (soft, no tenderness or rebound tenderness, negative Murphy’s and McBurney’s signs). Mild symmetrical, pitting edema was noted in the lower extremities, though not the primary focus of the chief complaint.

TCM Assessment

The original practitioner interpreted the presentation as Spleen deficiency and Qi stagnation (脾虚气滞), categorizing the condition under the traditional disease name of Stomach Pi (胃痞).

In TCM theory, the Spleen and Stomach operate as the central hub of digestion. The Spleen is responsible for ascending clear energy, while the Stomach governs the descending of turbid matter. According to the principles of yin and yang Chinese Medicine, a healthy digestive system relies on the dynamic, frictionless balance of these ascending and descending forces. In this patient, the underlying Spleen deficiency meant the digestive system lacked the vital energy to process food effectively. This weakness led to an accumulation of dampness (evidenced by the white greasy tongue coating) and stalled the flow of Qi. The resulting stagnation trapped energy in the central abdomen, manifesting as the feeling of fullness and distension that reliably worsened after meals.

Treatment Approach

The primary treatment principle was to regulate Qi and strengthen the Spleen (理气健脾). Because the patient presented with both a deficiency (weak Spleen) and an excess (stagnant Qi and dampness), the treatment required a balanced approach: moving the stagnant energy without further exhausting the patient, and tonifying the digestive system without creating more blockage.

Herbal Formulas and Modifications

• Initial Formula (December 21, 2020): The practitioner based the prescription on a modified version of Xiang Sha Liu Jun Zi Tang (Six Gentlemen Decoction with Aucklandia and Amomum).
  • Strengthening the Root: Dang Shen, Fu Ling, Bai Zhu, and Gan Cao (the foundational Si Jun Zi Tang) were used to supplement Qi and fortify the Spleen.
  • Moving Qi and Resolving Dampness: Xiang Fu and Wu Yao were added to strongly soothe the Liver and move stagnant Qi. Sha Ren, Chen Pi, and Ban Xia were employed to regulate the Stomach, dry the dampness, and dissipate the fullness. Chao Mai Ya (Stir-baked Malt) was included specifically to aid digestion and harmonize the stomach.
• Formula Adjustment (December 28, 2020): At the second visit, the practitioner modified the formula significantly. While maintaining Spleen-fortifying and Qi-regulating herbs (Dang Shen, Bai Zhu, Fu Ling, Chen Pi, Ban Xia), specific herbs like Huang Qin and Huang Lian (which are bitter and cold) alongside Gan Jiang (which is pungent and warm) were introduced. In TCM clinical practice, this specific combination is often utilized to harmonize complex cold-heat interplays in the stomach and directly address lingering gastric inflammation or a “noisy” stomach sensation.

Follow-Up

(Note: The original source documented the adjusted prescription for the second visit on December 28, 2020, but did not explicitly detail the symptomatic changes or long-term clinical outcomes following this adjustment.)

Why This Case Is Interesting (Clinical Reasoning)

The notable feature of this case is the classical demonstration of “treating both the root and the branch.” When a patient presents with severe abdominal bloating and distension, there is a temptation to use heavy, aggressive herbs to force the digestive tract moving (treating the branch). However, the original practitioner recognized from the pale tongue and fine pulse that the underlying engine—the Spleen—was weak (the root).

By utilizing a variation of Xiang Sha Liu Jun Zi Tang, the practitioner successfully paired Spleen-tonifying herbs with Qi-moving herbs. This clinical reasoning ensures that as the stagnation is cleared, the digestive system is simultaneously rebuilt to prevent the fullness from recurring. The subsequent introduction of hot and cold herbs (Gan Jiang and Huang Lian/Huang Qin) at the second visit further highlights the dynamic nature of TCM prescribing, adapting to subtle shifts in the gastric environment.

---

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 (广东省中医药局)
• Original title: 【以案说医】董明国：理气健脾治疗慢性胃炎案
• Practitioner: Professor Dong Mingguo (董明国)
• Publication date: November 6, 2024
• Original language: Chinese
• Source link: View original page
• ChineseHerb.org version: English translation and editorial adaptation