A 54-year-old woman with chronic left rib-side and stomach pain driven by Liver Qi stagnation overacting on the Spleen was managed using a Liver-soothing and Spleen-strengthening herbal strategy.

Case ID: CHC-0040

Case Summary

This case describes a 54-year-old woman who presented with recurrent left hypochondriac (rib-side) pain and stomach pain for one month. The original report documented a conventional diagnosis of gastrointestinal dysfunction and a TCM assessment of Hypochondriac Pain (Xie Tong) driven by Liver Qi stagnation. The patient was managed through a dynamic herbal approach based on the classical formula Chaihu Shugan San, designed to soothe the Liver, regulate Qi, and physically restore the digestive tract’s motility.

Patient Presentation

• Patient: 54-year-old female (Surname: Dai).
• Main Complaint: Left hypochondriac pain accompanied by stomach pain for 1 month, with frequent relapses.
• History: The patient sought consultation on February 13, 2018. Over the prior month, she suffered from recurrent left-sided rib pain and epigastric (stomach) pain. She had previously sought treatment at another hospital, but the results were unsatisfactory. Associated symptoms included epigastric and abdominal fullness, distending pain, hyperactive bowel sounds (borborygmus), diarrhea, and a noticeably reduced appetite.

Examination and Diagnosis

• Conventional Diagnosis: Gastrointestinal dysfunction.
• TCM Tongue and Pulse: The tongue was pale red with a white coating. The pulse was stringy and slippery (脉弦滑).

TCM Assessment

The original practitioner interpreted the presentation as Hypochondriac Pain driven by Qi Stagnation (胁痛 – 气郁型).

According to the holistic principles of yin and yang Chinese Medicine the Liver is responsible for the smooth flow of Qi and emotions, while the Spleen and Stomach govern digestion. The original report noted that the patient’s Qi mechanism had become knotted and stagnant. When the Liver loses its free-flowing nature, its stagnant energy “rebels horizontally” and attacks the Spleen and Stomach (a classic dynamic known as “Wood overacting on Earth”).

This trapped Liver Qi caused the localized pain in her left ribs and stomach. Consequently, the attacked Spleen lost its ability to properly transport and transform food and fluids. This digestive breakdown directly resulted in her abdominal fullness, distension, hyperactive bowel sounds, diarrhea, and poor appetite. The pale red tongue with a white coating, alongside the classic stringy pulse, provided objective confirmation of this underlying Liver stagnation and Spleen weakness.

Treatment Approach

The primary treatment principle was to soothe the Liver, regulate Qi, strengthen the Spleen, and harmonize the Stomach (疏肝理气，健脾和胃). The strategy aimed to “untie” the Liver to relieve the painful spasms while simultaneously rebuilding the Spleen’s digestive capacity.

Herbal Formulas and Modifications

• Initial Formula (February 13, 2018): The practitioner prescribed a 12-herb decoction, acting as a heavily modified version of the classical Chaihu Shugan San (Bupleurum Liver-Soothing Powder).
  • Soothing Liver and Regulating Qi: Cu Bei Chai Hu (Vinegar-prepared Bupleurum, 15g), Cu Xiang Fu (Vinegar-prepared Cyperus, 15g), Cu Yu Jin (Vinegar-prepared Curcuma, 10g), and Fu Chao Zhi Ke (Bran-fried Aurantium, 20g) formed the core to aggressively soothe the Liver, unblock the Qi mechanism, and stop the rib pain.
  • Strengthening Spleen and Harmonizing Stomach: Zheng Bai Zhu (Steamed Atractylodes, 10g) and Fu Ling (Poria, 15g) fortified the digestive system to stop the diarrhea, while Jiang Shui Ban Xia (Ginger-prepared Pinellia, 10g) descended rebellious Qi, dried dampness, and dissipated the epigastric fullness.
  • Moving Blood and Collaterals: Su Mu (Sappan Wood, 10g), Tao Ren (Peach Kernel, 10g), and Niu Xi (Achyranthes, 15g) invigorated blood circulation and unblocked the collaterals to enhance pain relief.
  • Moving Qi and Relieving Stagnation: Mu Xiang (Aucklandia, 10g) and Bing Lang (Areca Seed, 10g) strongly moved Qi and guided out accumulation in the intestines.
• Second Visit (February 22, 2018): After 5 daily doses, the left rib and stomach pain were noticeably improved, along with her other digestive symptoms. The practitioner removed the downward-draining Mu Xiang and Bing Lang, and added Qing Pi (Green Tangerine Peel, 10g) to further focus on soothing the Liver and stopping pain. (4 doses prescribed).
• Third Visit (March 30, 2018): The pain and digestive symptoms continued to improve significantly. To consolidate the treatment and ensure the digestive tract was fully cleared of stagnation, the practitioner kept the previous formula but re-introduced Bing Lang at a heavy dose (20g) to strengthen Qi movement and guide out any remaining accumulation. (4 doses prescribed).

Follow-Up

• Following the third visit, a subsequent follow-up confirmed that after finishing the final course of medication, the patient’s illness was completely cured, and she experienced no further discomfort or relapses.

Why This Case Is Interesting (Clinical Reasoning)

The notable feature of this case is its classic demonstration of treating a gastrointestinal disorder through the Liver. In conventional medicine, a diagnosis of “gastrointestinal dysfunction” (often presenting similarly to Irritable Bowel Syndrome) focuses purely on the physical intestines.

However, the original practitioner recognized the strict TCM relationship between the Liver and the digestive tract. The rib-side pain was the definitive clue that the root of the diarrhea and stomach distension was actually trapped Liver Qi. By utilizing a modified Chaihu Shugan San, the treatment didn’t just forcefully stop the diarrhea; it removed the “chokehold” the Liver had on the Spleen. The dynamic addition of blood-moving herbs (Su Mu, Tao Ren, Niu Xi) also highlights the TCM wisdom that “chronic pain involves the collaterals and blood stasis,” ensuring a complete and lasting resolution.

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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: Qingyuan Maternal and Child Health Hospital / Guangdong Provincial Administration of Traditional Chinese Medicine
• Original title: 【以案说医】曾宪进：柴胡疏肝散加减治疗气郁型胁痛症案
• Practitioner: Professor Zeng Xianjin (曾宪进)
• Publication date: September 23, 2024
• Original language: Chinese
• ChineseHerb.org version: English translation and editorial adaptation