A 45-year-old man with severe emaciation and chronic abdominal distension was treated using a refined herbal strategy to tonify Spleen Qi and gently regulate digestion.

Case ID: CHC-0010

Case Summary

This case describes a 45-year-old man who presented with a six-year history of chronic stomach fullness, bloating after meals, and significant weight loss. The original report documented a conventional diagnosis of chronic gastritis and a TCM assessment of Stomach Pi (Glomus/Fullness) due to Spleen and Stomach Qi deficiency. The patient was managed with a precise, gentle herbal formula designed to restore digestive function without overburdening the system.

Patient Presentation

• Patient: 45-year-old male.
• Main Complaint: Stomach fullness and distension lasting for 6 years, accompanied by physical emaciation.
• History: The patient reported a long-standing struggle with digestive issues. Any food intake would immediately trigger abdominal bloating. He experienced a loss of taste and appetite, along with frequent nausea and belching. His bowel movements were soft and occurred twice daily. Physically, he was noticeably emaciated with a sallow, lackluster complexion. His sleep was average, and urination was normal. He had no history of infectious diseases, allergies, smoking, or alcohol use.

Examination and Diagnosis

• Conventional Diagnosis: Chronic gastritis. A physical examination revealed a flat, soft abdomen with no tenderness or rebound pain. Liver and kidney percussion tests were negative, and bowel sounds were normal (5 times/minute).
• TCM Tongue and Pulse: The tongue was pale red with a white, moist coating. The pulse was weak (脉弱).

TCM Assessment

The original practitioner interpreted the presentation as Stomach Pi (Glomus) driven by Spleen and Stomach Qi deficiency (脾胃气虚).

According to the principles of Yin and Yang Chinese Medicine, the Spleen and Stomach act as the central metabolic engine, responsible for transforming food into the vital energy (Qi) and blood needed to nourish the entire body. In this patient, chronic Spleen Qi deficiency meant the digestive system lacked the strength to process food. This failure caused energy to stagnate in the epigastrium (manifesting as bloating and fullness after meals), while simultaneously starving the body’s tissues of nutrients (explaining his severe six-year emaciation, fatigue, and sallow complexion).

Treatment Approach

The primary treatment principle was to strengthen the Spleen, tonify Qi, regulate Qi, and resolve the fullness (健脾益气，理气消痞). The practitioner specifically emphasized a “refined, simple, and effective” approach, aiming for steady, gradual restoration of the digestive function rather than seeking a rapid, aggressive purge of the stagnation.

Herbal Formulas and Modifications

• Core Formula (Initial Visit): The prescription was based on a combination of Chen Xia Liu Jun Tang and Xiang Su Yin.
  • Tonifying the Spleen: A robust dose of Huang Qi (30g), Dang Shen (20g), Bai Zhu (20g), and Zhi Gan Cao (5g) was used to strongly replenish the foundational Qi of the Spleen and Stomach.
  • Regulating Qi and Resolving Fullness: Chao Xiang Fu (15g), Su Geng (15g), Jiang Ban Xia (15g), and Chen Pi (5g) were included to gently move the stagnant energy, dry dampness, and stop the nausea and belching.
  • Aiding Digestion: Ji Nei Jin (15g) was added to directly promote gastric motility and help dissolve the food stagnation.
• Modification (Second Visit): After the initial course, Mu Xiang (10g) was added to the base formula to further enhance the regulation of intestinal Qi.

Follow-Up

• Second Visit: After taking 15 doses of the initial decoction, the source reported an 80% reduction in the patient’s stomach fullness. His appetite noticeably increased, his complexion improved, and his overall energy levels recovered. The practitioner prescribed 20 additional doses of the modified formula to consolidate the healing process.

Why This Case Is Interesting (Clinical Reasoning)

A highly notable feature of this case is the practitioner’s clinical caution regarding the patient’s severe emaciation. The original report explicitly notes that when treating patients with extremely low BMI, practitioners must first rule out consumptive conditions like malignant tumors, diabetes, or hypothyroidism before proceeding with TCM pattern differentiation.

Furthermore, the case highlights the danger of over-prescribing. When faced with severe, chronic bloating, it is common to rely on heavy doses of Qi-moving or digestive herbs. However, the practitioner pointed out that using overly complex or harsh formulas on a patient with such profound underlying weakness would further damage the Spleen and increase the patient’s mental burden, potentially triggering Liver Qi stagnation. By utilizing a simple, Qi-tonifying base, the treatment successfully rebuilt the patient’s digestive engine, allowing the body to naturally clear the six-year stagnation.

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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：健脾益气，理气消痞法治疗胃痞病案]
• Practitioner: Professor Dong Mingguo (董明国)
• Publication date: November 1, 2024
• Original language: Chinese
• Source link: View original page
• ChineseHerb.org version: English translation and editorial adaptation