A 45-year-old man suffering from a three-year history of chronic stomach pain, bloating, and acid reflux was managed using a prolonged, dynamically adjusted Liver-soothing and Spleen-strengthening herbal strategy.

Case ID: CHC-0041

Case Summary

This case describes a 45-year-old man who presented with a three-year history of recurrent epigastric pain and severe bloating. The original report documented a conventional diagnosis of chronic gastritis and a TCM assessment of Epigastric Fullness (Wei Pi) driven by Spleen Qi deficiency and Liver Qi stagnation. Over the course of two months and seven consultations, the patient was managed through a highly adaptive herbal approach that ultimately resolved his condition by tonifying the Spleen, soothing the Liver, and deeply warming the middle jiao.

Patient Presentation

• Patient: 45-year-old male (Surname: Liang).
• Main Complaint: Stomach pain that worsened after meals, accompanied by stomach bloating and acid reflux.
• History: The patient sought initial consultation on February 6, 2018. He reported a three-year history of chronic, recurrent stomach distension and pain. Despite the chronic pain and acid reflux, his appetite remained relatively normal (胃纳尚佳). He had been continually seeking TCM treatment at the hospital for his condition.

Examination and Diagnosis

• Conventional Diagnosis: Chronic gastritis.
• TCM Tongue and Pulse: The tongue was pale and puffy (舌质淡胖) with a white coating. The pulse was stringy (脉弦).

TCM Assessment

The original practitioner interpreted the presentation as Epigastric Fullness driven by Spleen Qi Weakness and Liver Qi Stagnation (胃痞 – 脾气虚弱，肝气郁滞).

According to the core principles of yin and yang Chinese Medicine prolonged illness directly damages the Spleen and Stomach. Over his three-year illness, the patient’s digestive system became chronically weakened, resulting in a state of deficiency and cold in the middle jiao (digestive center). Because the Stomach lacked proper warming and nourishment, it lost its smooth function, resulting in the localized pain (“where there is no free flow, there is pain”).

Concurrently, the Spleen’s failure to properly transport fluids and food caused Liver Qi to stagnate, creating the persistent sensation of stomach bloating and distension. When the Spleen and Stomach are weak, the normal downward descent of Stomach Qi is reversed; this turbid Qi rebelled upward, physically manifesting as his severe acid reflux. The pale, puffy tongue with a white coating, paired with the stringy pulse, provided clear objective confirmation of the combined Spleen deficiency (pale/puffy) and Liver stagnation (stringy pulse).

Treatment Approach

The primary treatment principle was to benefit Qi and strengthen the Spleen, soothe the Liver, and harmonize the Stomach (益气健脾，疏肝和胃). The strategy was based on modifying the classical formula Xiangsha Liujunzi Wan to simultaneously rebuild the digestive engine while actively untangling the stagnant Liver Qi.

Herbal Formulas and Modifications

Given the chronic and stubborn nature of the disease, the practitioner guided the patient through seven distinct phases of herbal modification over two months:

• Initial Formula (February 6, 2018): A 15-herb decoction focused on regulating Qi and settling acid.
  • Strengthening Spleen: Dang Shen (30g), Zheng Bai Zhu (15g), Fu Ling (15g), Guang Shan Yao (30g), and Chao Bai Bian Dou (15g) formed a massive core to tonify Qi and rebuild the Spleen.
  • Soothing Liver and Regulating Qi: Mu Xiang (10g), Zheng Fo Shou (15g), Zheng Chen Pi (10g), Qing Pi (10g), and Fu Chao Zhi Ke (15g) were combined to aggressively soothe Liver constraint, move stagnant Qi, and stop the bloating.
  • Neutralizing Acid and Descending: Hai Piao Xiao (30g) and Wa Leng Zi (20g) are shell-based herbs used to physically neutralize stomach acid. Wu Zhu Yu (5g) and Zi Su Geng (10g) directed rebellious Qi downward.
• Dynamic Adjustments (Visits 2 to 6; Feb 14 – Mar 25): The patient’s bloating improved, but the pain and acid reflux fluctuated. The practitioner made highly active changes based on real-time feedback:
  • Added Jiang Shui Ban Xia and Sha Ren to dry dampness.
  • Added Bei Chai Hu and Cu Xiang Fu to further target the Liver meridian.
  • Introduced Jiao Shan Zha and Jiao Shen Qu to aggressively digest food stagnation.
  • Added Shi Di (Persimmon calyx) to forcefully stop the upward rebellion of stomach acid.
• Final Breakthrough (Visit 7 – April 18, 2018): The stomach distension and pain were significantly reduced, but the patient developed loose stools (大便烂), a clear sign that the underlying deep cold of the Spleen had surfaced. The practitioner retained the Spleen-tonifying and Liver-soothing herbs but made a critical addition: Hei Shun Pian (Processed Aconite, 15g) and Gao Liang Jiang (Galangal, 10g). These highly warming botanicals were introduced to powerfully ignite the “Mingmen Fire” and dispel the deep middle jiao cold.

Follow-Up

• Following the seventh visit and the final course of deep-warming herbs, a subsequent follow-up confirmed that the patient was completely settled and comfortable. He did not require any further visits, marking the successful resolution of his three-year chronic gastritis.

Why This Case Is Interesting (Clinical Reasoning)

The notable feature of this case is the practitioner’s long-term clinical persistence and precise differential diagnosis of a refractory digestive disorder.

As the original commentary notes, treating Liver-Stomach disharmony requires a delicate balance: one must soothe the Liver without forgetting to harmonize the Stomach. Furthermore, because regulating Qi often involves using acrid, drying herbs (like Qing Pi, Mu Xiang, and Zhi Ke), the practitioner was careful to balance them with Yin-nourishing Spleen herbs (like Shan Yao and Bai Bian Dou) so as not to exhaust the patient’s fluids. Finally, the true clinical breakthrough occurred on the seventh visit. When the patient’s loose stools revealed a deep, underlying internal cold (中焦虚寒), the practitioner boldly introduced Hei Shun Pian (Aconite). By finally warming the root of the digestive system, the chronic pain and spasm were completely cured.

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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 / Qingyuan Maternal and Child Health Hospital
• Original title: 【以案说医】曾宪进：疏肝和胃法治疗脾虚气滞型胃痞案
• Practitioner: Professor Zeng Xianjin (曾宪进)
• Publication date: September 23, 2024
• Original language: Chinese
• ChineseHerb.org version: English translation and editorial adaptation