A 63-year-old woman with a six-month history of frequent stomach pain, belching, and acid reflux triggered by family stress was managed using a Liver-soothing and Stomach-harmonizing herbal strategy.

Case ID: CHC-0029

Case Summary

This case describes a 63-year-old woman who presented with a six-month history of dull, unfixed stomach pain accompanied by acid reflux and belching. The original report documented a conventional diagnosis of chronic gastritis and a TCM assessment of Stomach Pain driven by Liver and Stomach Disharmony. The patient was managed through a dynamic herbal approach designed to soothe her emotional stress, physically regulate her digestive tract’s motility, and gently strengthen her foundational energy.

Patient Presentation

• Patient: 63-year-old female (Surname: Gong).
• Main Complaint: Dull stomach pain with an unfixed location, accompanied by frequent belching and acid reflux.
• History: Over the prior six months, the patient experienced frequent emotional fluctuations due to numerous trivial family matters. These stressors directly triggered her stomach pain. Initially, the pain was tolerable, but it gradually worsened over time. Associated symptoms included a bitter taste in her mouth and a dry throat. She had previously taken conventional Western medications, but the results were unsatisfactory.
• Initial Visit Date: January 23, 2024.

Examination and Diagnosis

• Conventional Diagnosis: Chronic gastritis.
• TCM Tongue and Pulse: The edges of the tongue were red with a thin, yellow coating. The pulse was stringy (脉弦).

TCM Assessment

The original practitioner interpreted the presentation as Stomach Pain driven by Liver and Stomach Disharmony (胃痛 – 肝胃不和).

According to the holistic principles of yin and yang Chinese Medicine the Liver is responsible for the smooth flow of emotions and Qi, while the Stomach governs the downward descent of digested food. The original report noted that the patient’s chronic frustration over family matters caused her Liver Qi to stagnate.

This trapped, stagnant energy eventually “overacted” on or attacked her Stomach, disrupting its natural downward rhythm. Consequently, the Stomach Qi rebelled upward, causing her frequent belching and acid reflux. Furthermore, the trapped Liver Qi generated localized internal heat, which manifested objectively as the red edges on her tongue, the thin yellow coating, the bitter taste in her mouth, and the dry throat. The stringy pulse is the classic hallmark of Liver pathology and pain.

Treatment Approach

The primary treatment principle was to soothe the Liver, harmonize the Stomach, regulate Qi, and stop pain (疏肝和胃，理气止痛). The strategy required clearing the emotional stagnation while physically addressing the excess acid and digestive spasms.

Herbal Formulas and Modifications

• Initial Formula (January 23, 2024): A highly structured, 14-herb decoction combining classic Qi-regulating, heat-clearing, and pain-stopping botanicals.
  • Soothing the Liver and Clearing Heat: Bei Chai Hu (10g) and Huang Qin (10g) act as a classic pair to vent stagnant Liver Qi and clear the trapped heat from the middle jiao.
  • Regulating the Torso’s Qi Dynamic: Jie Geng (15g, which ascends Qi) and Zhi Shi (10g, which descends Qi) were paired to physically re-establish the vertical energy flow of the respiratory and digestive tracts.
  • Harmonizing the Stomach and Regulating Qi: Mu Xiang (10g, added near the end of decocting), Jiang Ban Xia (10g), Jiang Hou Po (10g), and Jiang Zhu Ru (15g) were utilized to strongly move stagnant Qi in the abdomen, harmonize the Stomach, and stop the belching.
  • Strengthening the Spleen and Draining Dampness: Bai Zhu (15g), Fu Ling (15g), and Ze Xie (10g) fortify the digestive system to prevent further stagnation.
  • Stopping Pain and Neutralizing Acid: Chao Bai Shao (10g) nourishes blood and softens the Liver, pairing with Gan Cao Pian (10g) to strongly relieve smooth muscle spasms and alleviate pain. Hai Piao Xiao (Cuttlefish Bone, ground into powder and taken with the decoction) was added specifically to physically neutralize the stomach acid and stop the reflux pain.
• Modification (Second Visit – January 30, 2024): With the acute pain and reflux controlled, the practitioner shifted the focus toward her underlying age-related weakness. Dang Shen Pian (20g) was added to the original formula to powerfully strengthen the Spleen and tonify Qi.

Follow-Up

• January 30, 2024 (Second Visit): After consuming seven doses of the initial decoction, the source reported a marked reduction in the patient’s stomach pain. Her belching and acid reflux were also significantly improved, though mild discomfort remained. The practitioner adjusted the formula to consolidate the results, and the patient was prescribed an additional nine doses.

Why This Case Is Interesting (Clinical Reasoning)

The notable feature of this case is its precise demonstration of treating a structural digestive disease (gastritis) through the lens of emotional regulation. Chronic gastritis with acid reflux is exceptionally common in older adults. However, the original practitioner prioritized the clear trigger: emotional fluctuations.

By utilizing Chai Hu and Huang Qin to “untie” the Liver, the treatment removed the mechanical pressure on the Stomach. Furthermore, the inclusion of Hai Piao Xiao (Cuttlefish Bone) highlights a pragmatic integration of TCM with physical symptom relief—this substance is high in calcium carbonate, acting as an immediate, natural antacid while the herbal decoction fixes the underlying functional motility. Finally, the strategic addition of Dang Shen during the second visit demonstrates the classical wisdom of first clearing the excess (the Liver stagnation) before tonifying the deficiency (the weakened Spleen of a 63-year-old patient).

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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: Guangdong Provincial Administration of Traditional Chinese Medicine / Beijing University of Chinese Medicine Shenzhen Hospital (Longgang)
• Original title: 【以案说医】王进东：肝胃同治效显著，病愈人安胃复宁
• Practitioner: Professor Wang Jindong (王进东)
• Publication date: October 13, 2024
• Original language: Chinese
• ChineseHerb.org version: English translation and editorial adaptation