Name of Student clinician: Minjung Shin Name of supervisor: Mei
Age : 50 years Gender : Female
Chief Complains : Acid reflux for over 1 year
Description (4 diagnostic methods)
Accompanying symptoms are stiffness of shoulder ( tenderness on the Jianjing – both side ), nape ( Fengchi ), anxiety and nausea. Also, she is infected with a Hepatitis C virus for a long time and the side effect symptoms that are suspected to be related with the HCV are orange color urination and hair falling down.
- Present Symptoms : Good appetite, No chill and fever, No abnormal
sweating, No feels thirst and prefers warm drink ( Mixed for cold and hot water ), Sleeping is good with vivid dreams ( dreams about busy things, feels tired after wakes up, sleeping 7 hours – 11pm~6am ), Urine ( normal amount, orange color of urine without foam, fish smell ), Loose stool ( 1~2 times per day, strong smell without indigested food, no abdominal pain ), Myopia, Nausea, Acid reflux, Cold foot and hands, Stressful, Emotional, Irritability, Depression, Tinnitus ( right side ), Dry eyes.
- Past history : Currently infected with Hepatitis C Virus
- Life style : Smoking, No drinking, Fast eating, Stressful
- Family history : Mother : stroke, high blood pressure
Father : high blood pressure
- Menstruation, marital & obstetrical history : Menopause 6 years, married, have two sons and three daughters. – all natural childbirth.
7 days
13 years-------- ( Menarche at 13 years old, 28 days cycle, 7 days
28 days duration, Menopause 6 years )
Scanty menses, dark color, watery ( light menses ), sore back and lower abdominal pain before menarche.
B) Inspection
General : Sallow complexion, 6/10 vitality, normal movement
Tongue : Purplish tongue body with thick yellow coating, and crack on the middle
C) Auscultation / Olfaction
Sound : Speak clearly, breath is normal
Odor : NAD
D) Palpation
Pulse : Right side – deep and thready
Left side – deep and taut
Body areas : Tenderness on the both side of Jianjing and Fengchi
CASE SUMMARY
DIAGNOSIS
A) Diagnosis : Acid reflux
B) Syndrome Differentiation : Liver Qi stagnation invades Middle-jiao
C) Explanation
She has suffered from the acid regurgitation due to stress.
This pattern is usually caused by emotional problems that affect such as stress and depression. These emotions, over a long period of time, cause Liver Qi to stagnate and this interferes with Spleen function.
The Liver’s function of ensuring the smooth flow of Qi has a deep influence on the emotional state. If this function is impaired, the circulation of Qi is obstructed, Qi becomes restrained giving rise to emotional stress and anxiety, accompanied by such stiffness of shoulder and nape, irritability, anxiety, depression, purplish tongue body, sleeping with vivid dreams, and taut pulse.
Long term of Liver Qi stagnation can generate heat (yellow tongue coating) to consume of Yin such as blood. If Liver blood is deficient, there may by myopia, dry eyes, and hair falling down.
Hepatitis virus infection usually refers as Liver related problems and blood stasis which may lead to impairment of Spleen Qi. If it invade the Spleen, it obstructs the transformation and transportation of food and prevents Spleen Qi from flowing upwards and resulting in loose stool, acid reflux aggravated by over taken greasy or oily foot, cold four limbs, feels tired after wakes up in the morning, sallow complexion, low voice, and deep-thready pulse.
If stagnation of Liver Qi invade the Stomach preventing the downward movement of Stomach Qi and resulting in nausea, and acid regurgitation.Heat in the Stomach burns the fluids, hence odour in the mouth (foul breath), thick yellow coating, and crack on the middle of tongue.
She Kidney Qi is also deficient due to various factors such as from ageing, using drugs for long term and smoking when she was young. These long term factors damage the Kidney. The deficient of Kidney Qi will leads symptoms of tinnitus, urine disorder (orange color of urine without foam, fish smell), and deep-thready pulse.
TREATMENT
A) Treatment Principles :
- Sooth Liver Qi, promotes circulation of Qi, activate Qi, remove stasis, strengthen Middle-jiao and tonify Kidney to stop acid reflux.
B) Treatment Method
1. Needling
Prescription : Taichong LV-3 (-), Zhongwan Ren-12 (+), Sanyinjiao SP-6 (+),
Zusanli ST-36 (+), Qihai Ren-6 (+), Taixi KD-3 (+),
Tianshu ST-25 (+)
Explanation : Filiform needling (reinforce and reducing methods applied) technique chosen to regulating meridians for sooth Liver Qi, promotes circulation of Qi, activate Qi, remove stasis, strengthen Middle-jiao and tonify Kidney to stop acid reflux.
► Taichong (LV-3 ) (reduce) ; is the Yuan – ( Source ) Point of Liver
Meridian, it used sooth Liver and regulate flow of Qi..
► Zusanli (ST-36) (reinforce) ; the He-(Sea) Point of the Stomach
Meridian, is promote Qi an blood to maintain health and Zhongwan
(CV-12) is the Front (Mu) points of Stomach and Converging point of
the Fu-Organs to regulate Stomach and strengthen Spleen.
► Sanyinjiao (SP-6) (reinforce) ; is the Crossing Points of Three Yin
Meridians such as Kidney, Liver and Spleen, it used for strengthen
Spleen, Liver and Kidney.
► Tianshu (ST-25) (reinforce) ; Front (Mu) point of Large intestine,
it important point for regulate to Middle-jiao of Spleen and Stomach.
► Qihai (CV-6) (reinforce) ; for dysfunction of Spleen to tonify Spleen.
► Taixi ( KD-3) (reinforce) ; the Yuan-(Source) and Shu-(Stream) Point of the Kidney Meridian, is reinforce method to tonify Kidney.
6. Life Style Advice
► Eat smaller, more frequent meals.
► Limit your intake of acid-stimulating foods and beverages.
► Don't eat within two to three hours before bedtime.
► Elevate your head a few inches while you sleep.
► Maintain a reasonable weight.
► Don't wear belts or clothes that are tight fitting around the waist.
► Don't smoke.
► Don't drink alcohol.
► Relax.
► Keep a heartburn record.
Acid Reflux
DEFINITION
Acid reflux, commonly called heartburn, is a condition in which the liquid contents of the stomach flow upward into the esophagus, the muscular canal that connects the throat to the stomach. This causes a burning sensation that can damage the inner lining of the esophagus.
TCM ETIOLOGY and PATHOGENESIS
The common causes of acid reflux are immoderate eating and drinking, emotional upsets, psychic trauma, overstrain affection of cold, etc. However, these causative factors lead to acid reflux only when the Spleen and Stomach are dysfunction. Although the Spleen and Stomach are the organs chiefly involved in this disorder, other organs may also be affected, particularly the Liver.
Diet - Sweet/greasy/hot & spicy or bad quality food
Exterior pathogen invasion - Cold invade Middle-Jiao
– Deficient Yang Qi turns to turbid dampness causing acid
Emotion - Liver attacks Stomach (sour flavour)
- Spleen creates damp/phlegm which creates acid
Deficiency Middle Jiao - Congenital dysfunction, retention of food, can’t transform or transport which creates acid
WMS – Acid Reflux
DEFINITION
This is common condition and abnormal one. In which acid in the stomach rises up into the esophagus. This occurs because the valve separating the contents of the stomach from the esophagus does not function properly.
CAUSE
A number of factors may contribute to the appearance of acid reflux. Obesity, smoking, pregnancy and the consumption of certain types of foods (such as spicy foods) may all be involved. Genetic factors may also predispose a person to getting acid reflux. The condition develops when the passage of food from the throat, through the esophagus and into the stomach is disrupted. One cause of this disruption may be a hiatal hernia, a condition in which the upper part of the stomach projects upward into the esophagus. Another possible cause of acid reflux is a malfunctioning esophageal sphincter, the valve between the esophagus and stomach that controls the flow of food from the mouth into the digestive system.
TREATMENT
Physicians normally recommend lifestyle modifications, whether or not recommending drugs to treat GERD.
► Foods
- Eating within 2-3 hours before bedtime.
- Coffee, alcohol, and excessive amounts of Vitamin C supplements stimulate gastric acid secretion. Taking these before bedtime especially can cause evening reflux.
- Foods high in fats and smoking reduce lower esophageal sphincter competence, so avoiding these may help. Fat also delays stomach emptying.
- Acidic foods: tomatoes and tomato-based preparations; citrus fruits and citrus juices.
► Drug treatment
- Proton pump inhibitors (such as omeprazole, pantoprazole, lansoprazole, and rabeprazole) are the most effective in reducing gastric acid secretion. These drugs stop acid secretion at the source of acid production, i.e., the proton pump.
- Gastric H2 receptor blockers (such as ranitidine, famotidine and cimetidine) can reduce gastric secretion of acid. These drugs are technically antihistamines. They relieve complaints in about 50% of all GERD patients. Compared to placebo (which also is associated with symptom improvement), they have a number needed to treat of eight (8).
- Antacids before meals or symptomatically after symptoms begin can reduce gastric acidity (increase pH).
- Prokinetics strengthen the lower esophageal sphincter (LES) and speed up gastric emptying. Cisapride, a member of this class, was withdrawn from the market for causing Long QT syndrome.
- Sucralfate (Carafate) is also useful as an adjunct in helping to heal and prevent esophageal damage caused by GERD, however it must be taken several times daily and at least two hours apart from meals and medications.
► Posture and GERD
In adults, a slouched posture is an important factor contributing to GERD. With a slouched posture there is no straight path between the stomach and esophagus; muscles around the esophagus go into a spasm. Gas and acidity get blocked in the spasm, causing coughing and other asthma-like symptoms.
PREVENTION
People with heartburn should avoid or reduce consumption of foods and beverages that contain caffeine, chocolate, peppermint, spearmint, and alcohol.
Both caffeinated and decaffeinated coffee increase acid secretion.
· All carbonated drinks increase the risk for GERD.
· Although physicians often advise patients with GERD to cut down on fatty foods, studies are finding no evidence that a low-fat or high-fat meal make any difference in symptom exacerbation. Better studies are needed to confirm this. In any case, as a rule, it is always wise to avoid saturated fats (which are from animal products), and cut down on all fats if one is overweight.
· Increasing protein may help strengthen muscles in the muscle valve. Patients should choose low-fat or skim dairy products, poultry, or fish, in such cases.
· Whole grain products rich in selenium may have some protective role against dangerous cells changes in Barrett's esophagus.
· Patients should have a diet rich in fruits and vegetables, although avoid acidic vegetables and fruits (e.g., oranges, lemons, grapefruit, pineapple, tomatoes).
Follow up Consultations
Date: 01 / 09 / 2008 , 13 / 09 / 2008
Treatment Number : 2, 3
TCM Disease : Acid reflux
TCM Type / Pattern : Liver Qi stagnation invades Middle-jiao
Current Condition/changes:
- After 1st treatment, acid reflux and nausea are much getting improved than before. Suggest to her stop taking medication during the acupuncture treatment.
- Tongue : Purplish tongue with thick white coating, crack.
- Pulse : Right - deep and thready Left – deep and taut
Treatment Adjustment: Sooth Liver Qi, promotes circulation of Qi, activate
Qi, remove stasis, strengthen Middle-jiao to stop acid reflux.
Prescription Adjustment: Jianjing GB-21 (-), Fengchi GB-21(-),
Jingbailao EX-HN-15 (-)Ganshu BL-18 (+), Pishu BL-20 (+),Geshu BL-17 (+)
Explanation:
► Jingbailao ( EX-HN-15 ) (reduce) ; It located on the nape, reducing methods to promote circulation of Qi and blood in local area to reduce nape pain.
► Jianjing ( GB-21 ) (reduce) ; The Crossing Point of Sanjiao Meridian, Gallbladder Meridian, Stomach Meridian and Yang Link Vessel, it used reduce method for promote circulation of Qi and blood in the local area to treat shoulder pain.
► Fengchi ( GB-20 ) (reduce) ; The Crossing Point of Gallbladder Meridian and Yang Link Vessel, used reduce method for promote circulation of Qi and blood in the local area and release nape pain.
► Ganshu ( BL-18 ) (reinforce) ; the Front-(Mu) Point of the Liver, it used for strengthen Liver.
► Pishu ( BL-20 ) (reinforce) ; the Front-(Mu) Point of the Spleen, it used for strengthen the Spleen.
► Geshu ( BL-17 ) (reinforce) ; the Front-(Mu) Point of the Geshu, it used for nourishing blood to treat dizziness.
Lifestyle Advice (if any adjustments): Same as before
Name of Student Clinician: Minjung Shin
Name of Supervisor: Xing Mei Xie
Follow up Consultations
Date: 20 / 10 / 2008
Treatment Number : 4
TCM Disease : Acid reflux
TCM Type / Pattern : Liver Qi stagnation invades Middle-jiao
Current Condition/changes:
- Loose stool is improved. Hot sensation of 5 centers, sometimes has night sweating. Tongue body is change purplish to dim, but tongue coating is change to yellow again
- Tongue : Dim tongue with thick yellow coating, crack.
- Pulse : Right - deep and thready Left – deep and taut
Treatment Adjustment: Sooth Liver Qi, promotes circulation of Qi, activate
Qi, remove stasis, strengthen Middle-jiao to stop acid reflux.
Prescription Adjustment : Zhaohai KD-6 (+),Quchi LI-11 (-)
Explanation:
► Zhaohai ( KD-6 ) (reinforce) ; the One of the Eight Confluent Points of the Kidney Meridian, this point linking with the Yin Heel Vessel, it reinforce method to nourishing Yin to treat hot sensation in the five centers and night sweating.
► Quchi ( LI-11 ) (reduce) ; the He-(Sea) Point of the Large intestine Meridian,
It regulates nutritive Qi and blood, and clear away heat.
Lifestyle Advice (if any adjustments): Same as before
Name of Student Clinician: Minjung Shin
Name of Supervisor: Xing Mei Xie
Follow up Consultations
Date: 03 / 11 / 2008, 10 / 11 / 2008, 17 / 11 / 2008, 24/ 11 / 2008
Treatment Number : 5, 6, 7, 8
TCM Disease : Acid reflux
TCM Type / Pattern : Liver Qi stagnation invades Middle-jiao
Current Condition/changes:
- She’s symptoms are much improved. Less stress, a bit form in the stool, no
more acid regurgitation, nausea, no hot sensation in the 5 centers and night
sweating. But some tinnitus is still there. And she’s tongue coating changed
thick-yellow to thin-white without crack
- Tongue : Dim tongue with thin white coating.
- Pulse : Right - deep and wiry Left – deep and weak
Treatment Adjustment: Sooth Liver Qi, promotes circulation of Qi, activate
Qi, remove stasis, strengthen Middle-jiao to stop acid reflux.
Prescription Adjustment: Same as before
Explanation: Same as before
Lifestyle Advice (if any adjustments): Same as before
Name of Student Clinician: Minjung Shin
Name of Supervisor: Xing Mei Xie
Case Conclusion
She has acid reflux and nausea due to Liver Qi stagnation invades Middle-jiao from stress, and she received 8 treatments in total. My treatment principle was sooth Liver Qi, promotes circulation of Qi, activate Qi, remove stasis, strengthen Middle-jiao and tonify Kidney to stop acid reflux.
She was keep taking the medication while the acupuncture treatment. I had to make sure that the effectiveness of the acupuncture treatment by asking her to stop taking the medication during acupuncture treatment after 2nd treatment, otherwise I couldn’t know my treatment make to improve the symptoms or medication is help to her release the symptom. After quitting the medication, she assures that the symptoms really have improved with the acupuncture treatments. She is very happy with the results and that she could quit medication with the acupuncture treatment. She is very relaxed and can feel her stress is relieved day by day with the treatments as well as long term problems of acid reflux and nausea has improved very quickly.
