Journal of Acuherb in Medicine


Hepatitis

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Hepatitis

Traditional Chinese medicine (TCM) does not have a term or definition that specifically refers to the current understanding of hepatitis. In modern medicine, hepatitis is often caused by different viruses, which result in acute or chronic liver problems. Infection of the hepatitis A, B and C viruses are the most common forms of viral hepatitis. The disease is characterized by fever, dry mouth, poor appetite, nausea, vomiting, weakness and skin that appears yellow in color (jaundice).

Despite the fact there is no specific classification of hepatitis in TCM, the clinical features of viral hepatitis share similarities to TCM syndromes including “jaundice,” “liver-stagnation,” “hypochondria pain,” “abdominal distention” and “abdominal mass.” “Jaundice” is when the skin and eyes develop a yellow appearance “Hypochondria pain” is caused by a depletion of vital energy (qi) and stagnation of blood flow in the meridians of the liver and gallbladder. “Abdominal distention” is characterized by distention of the abdomen with visible superficial veins covering the skin’s surface.

As early as the Han Dynasty (206-220A.D.), these syndromes were already mentioned in TCM medical texts. For example, “liver-stagnation syndrome” and “abdominal mass” were first described in the famous Chinese medical book Yellow Emperor’s Internal Classic . This book defined “liver-stagnation syndrome” as a disease caused by stagnation of vital energy (qi) and blood in the liver, and “abdominal mass” was defined as a formation of a mass in the abdomen accompanied by distention or pain.

According to TCM theory, the liver is mainly responsible for regulating the flow of qi as well as storing and regulating the amount and flow of blood. It is also linked to part of the central nervous system, and the autonomic nervous system (the part of the nervous system over which a person does not have voluntary control), the circulatory system and eyes. Moreover, the liver controls emotions, digestion, tendon movement, and female menstruation. As a result, symptoms or signs of liver problems will occur in these related organs when a person falls ill. 

Causes

As stated earlier in the definition section, viral hepatitis shares similar symptoms with particular TCM syndromes such as jaundice, abdominal distention or hypochondria pain.

1. The cause of jaundice: occurs during the acute phase of the disease.
Over consumption of food and alcohol leads to spleen and stomach malfunction. In TCM, these organs transform food and drink into qi, and transport the qi to the lungs where it can be distributed throughout the body. When the spleen and stomach malfunction, dampness evils accumulate internally and transform into heat evils. If the evils cannot be removed, they exert negative influences on the body. When external seasonal evils such as dampness and heat attack the body at the same time, they interact with each other, become hyperactive and cause the malfunction of the triple-burner. This creates liver qi and blood stagnation, and results in bile leakage from the gall bladder, which eventually gives rise to the yellow color of skin and eyes known as jaundice.
2. The cause of abdominal distention or hypochondria pain (or chronic phase).
When the individual’s immunity to illness is weak or there is retention of dampness and heat evils from being inadequately treated, the remaining evils can trigger symptoms such as poor appetite, abdominal discomfort and fatigue. Consequently under these pathological conditions, the internal organs such as the lungsspleen and kidneys malfunction and lose their moistening and nourishing functions. As a result the flow of blood and qi becomes impaired. In severe cases of qi stagnation and blood stasis, abnormal metabolism of fluid occurs and gives rise to symptoms like ascites, an accumulation of fluid in the abdominal cavity.
3. The cause of multiple organ failure. 
Factors such as pestilential evils, also known as poisonous agents or plagues, can trigger serious contagious diseases. In TCM, these evils are characterized by a sudden onset of symptoms, strong infection potential and ability to spread rapidly. When these evils infect the body, the internal organs and qi and blood movement become seriously impaired and give rise to fatal symptoms like bleeding and convulsions.

Symptoms

At present, western medicine distinguishes viral hepatitis by its acute and chronic forms. According to TCM‘s viewpoint, jaundice, regional pain over the liver area, fatigue and poor appetite are characteristic of acute hepatitis. Chronic hepatitis is characterized by symptoms of with nausea, regional pain over the liver, abdominal distension and fatigue. 

1. Fever, aversion to heat, fatigue and soreness of limbs 
Initially heat and dampness evils impair the protective-qi, which is one kind of yang-qi. Food and drink are digested in the stomach and spleen and converted into protective-qi. This kind of qi keeps skin intact of skin as well as regulates perspiration. This function prevents the evils from invading the body and causing illness. Therefore when protective qi cannot function properly, heat symptoms, also known as an exterior disease pattern, will result.
   
2. Poor appetite, nausea, vomiting, fatigue, abdominal fullness, and weak limbs
These symptoms occur when the evils such as dampness and heat accumulate in the middle burner, which is where the spleen and stomach are located. This affects the absorption, digestion, transformation and transport of nutrients leading to the above symptoms.
   
3. Yellow coloring of skin and eyes (jaundice), dark color urine, or itchy skin
When dampness and heat evils are dominant, the liver and gall-bladder can become damaged, leading to liver qi and blood stagnation. This causes bile to leak out from the gall-bladder (located under the liver), and eventually gives rise to dark yellow colored skin, eyes and urine also known as jaundice.
   
4. Bleeding tendencies such as nasal bleeding, restlessness or unconsciousness 
When strong contagious evils such as poisonous agents attack the internal organs that affect blood circulation, bleeding occurs. If the evils invade the upper part of the body they can disturb the brain’s mental activities.
   
5. Depression, anxiety, emotional instability, pain that distends into the upper lateral region of the abdomen, and abdominal mass
These symptoms occur when the liver cannot regulate the flow of blood and qi, which leads to chest discomfort and affects the emotions. Stagnation of blood and qi for a long period obstructs the gall-bladder meridian and the liver meridian , which can cause regional pain over the liver area or the development of an abdominal mass.
   
6. Pale complexion, malaise, fatigue, and muscle spasms 
When dampness and heat evils damage the liver or spleen for a prolonged amount of time, the liver and spleen become dysfunctional and the ability to absorb nutrients declines. As a result, the production of essence stored in the kidney decreases along with blood, and the muscles lose nutrients and develop spasms.
   
7. Abdominal distention
In the final stage of the disease, not only do the liver and spleen become impaired, but the kidney is also affected. The resulting qi stagnation, bloodstasis and metabolic imbalance gives rise to symptoms like ascites.

 

In addition to the above symptoms, TCM practitioners will also diagnose individuals with a particular disharmony pattern which is discussed under the diagnosis section.

Diagnosis

Through the four techniques a variety of symptoms and signs will be used to identify the individual’s disharmony pattern. This is crucial because at the various stages of a disease, a variety of disharmony patterns are present which require different types of therapy. This is why individuals with the same disease may be treated very differently by their TCM practitioner.

As described earlier in the definition section, hepatitis is not directly diagnosed using TCM methods. Instead its symptoms will be grouped according to the disharmony pattern the individual displays. The following describes the disharmony patterns most commonly seen in person’s with viral hepatitis.

1. Stagnation of dampness-heat evil in middle-burner
  This condition causes fever, bright yellow coloring on the face, eyes and skin, as well as poor appetite, vomiting, nausea, and yellow or dark-colored urine. Additional symptoms may include constipation, and a feeling of oppression over the central abdomen after eating meals. The tongue is red and coated with greasy and yellow fur. The pulse is faint and stringy 
   
2. Stagnation of liver-qi and spleen deficiency
  Symptoms are not always obvious, but can be seen by poor appetite, nausea, dark yellow urine, a dry mouth, discomfort over the central abdomen after meals, and distended pain in the upper lateral region of the abdomen. However these symptoms are less obvious than the symptoms listed in the above type. The tongue appears red or pink, and is covered with a thin coating of fur and appears greasy. The pulse sign is small, faint and thready.
   
3. Yin deficiency in liver and kidney
  Individuals feel fullness or dull pain in the upper lateral region of the abdomen. They also experience dizziness, ringing in the ear, fatigue and soreness in the limbs. The skin complexion appears yellow in color, and the skin especially around the eyes and throat appears wrinkled and dry. Mental depression and insomnia may arise and lead to malaise and fatigue. Poor appetite and abdominal distention can also occur. Males may suffer from premature ejaculation, and females may have irregular menstruation. The tongue is pale and covered with thin greasy fur, and the pulse is faint.
   
4. Obstruction of the meridians by blood stasis
  Symptoms include lassitude, soreness of limbs, poor appetite, dull pain in the upper lateral region of the abdomen, and abdominal distention. The face appears gray or dark gray, the skin complexion yellow, palms appear dark red and there is nasal bleeding. Dilatation of small blood vessels may find on the face, chest or upper part of body. The tongue appears dark red and is covered with pettechaie that are small pinpoint purple bruised looking spots or appears greasy. The pulse sign is faint or thready and slight.
   
5. Excessive heat and toxins
  This type of syndrome occurs suddenly or results from persistent hepatitis. The individual suddenly becomes feverish, and the yellow coloring of the skin steadily deepens. Subsequent symptoms include drowsiness, confusion, swelling, body fluid that leaks into the abdominal cavity (ascites), passing bloody stool, and nasal bleeding. Finally, the individual vomits blood and slips into a coma. Death is usually the ultimate result. The tongue is dark red and is covered with fur that appears filthy and greasy or scaled. The pulse sign is thready and rapid or thready and rolling.

Note: If a TCM practitioner suspects there might be a serious problem that Chinese medicine alone cannot treat, he or she will recommend the individual see a western doctor for further follow up.

Western Medicine Diagnosis

Hepatitis A
Hepatitis A is diagnosed by testing blood for the presence of the virus. After an acute infection with the hepatitis A virus, most people recover uneventfully with no long-term effects but recovery generally takes a long time. Once a person recovers from the infection, the person develops immunity to the virus and cannot be infected again.

Hepatitis B
Hepatitis B virus infection can result in an acute or chronic condition. The disease is diagnosed by testing blood for the presence of the virus. A person is usually diagnosed with hepatitis B virus if they have had the virus present in their blood for more than six months. The severity of liver disease can be determined from A liver biopsy – a procedure used to obtain a small amount of liver tissue that is examined under a microscope. 

 

A fasting plasma glucose (FPG) of 140 mg/dl (7.8 mmol/l) or greater
A 2-hour plasma glucose (2-h PG) post 75-gm of oral glucose tolerance test (OGTT) level of 200 mg/dl (11.1 mmol/l)
Both of the above

Hepatitis C
As with hepatitis A and B, diagnosis of hepatitis C can be made by testing blood for the presence of the virus. The severity of liver disease can be determined from performing a liver biopsy.

However, the latest American Diabetes Association (ADA) expert committee finds that there is a greater degree of hyperglycemia amongst patients who have FPG of 140 mg/dl or higher than those who have 2-h PG of 200 mg/dl or higher. Almost all patients with FPG 140 mg/dl or higher have 2-h PG levels of 200 mg/dl or higher. However, not all patients with 2-h PG of 200 mg/dl or higher have FPG of 140 mg/dl or higher. Therefore, the ADA currently recommends the diagnosis of diabetes be based on a lower level of FPG.
A patient is diagnosed with diabetes if he has typical hyperglycemic symptoms with a random plasma glucose of 200 mg/dl (11.1 mmol/l) or greater, confirmed on a subsequent day by one of the following criteria: 

Typical symptoms of diabetes plus a random plasma glucose of 200 mg/dl (11.1 mmol/l)
A fasting (at least 8 hours of no caloric intake) plasma glucose of 126 mg/dl (7 mmol/l) instead of 140 mg/dl
A 2-hour post load glucose level of > 200 mg/dl (11.1 mmol/l) after a 75-gram anhydrous glucose load.

Treatment

From the viewpoint of TCM, the greatest harm that viral hepatitis causes is the retention of dampness and heat evils, which results in liver and gall bladder damage, stagnation of liver-qi, or liver and spleen malfunction. Therefore treatment depends on the clinical stages and disharmony patterns an individual displays. The therapeutic goals include clearing away heat and dampness evils, eliminating toxic materials, dispersing the liver-qi, relieving the blood stasis, invigorating the spleen, regulating stomach function for proper digestion, restoring proper liver function and nourishing yin. Below lists some examples of treatment options for the disharmony patterns most associated with viral hepatitis.

Stagnation of dampness-heat evil in middle-burner


Prescription:
 yinchenhao decoction plus addition or deduction with erchen decoction and sanhuang decoction

yin chen oriental wormwood
shan zhi cape jasmine fruit
huang qin baical skullcap root
huang lian golden thread
huang bai amur cork-tree
cang shu atracylodes root
ban xia pinellia tuber
chen pi dried tangerine peel
gan cao liquorice root
chuan qun rhubarb
che qian zi plantain seed

In this prescription, oriental wormwood and cape jasmine fruit expels yellow coloring; baical skullcap root, Chinese goldthread and amur cork-tree clears away damp-heat evils in the triple burner; atractylodes root, pinellia tuber and tangerine peel removes dampness evils and regulates stomach function; liquorice root coordinates the actions of the drugs in the prescriptions; rhubarb and plantain seed expels disease and toxins from the body.

Stagnation of live-qi and spleen deficiency


Prescription: xiaoyao powder plus addition or deduction with jinhua power

huang qin baical skullcap root
huang lian golden thread
huang bai amur cork-tree
tian ji huang hyperici japonici herb
chai hu Chinese tororwax root
zhi qiao orange fruit
mi yan coix seed
che qian zi plantain seed
chuan qun rhubarb
gan cao liquorice root

In this prescription, baical skullcap root, Chinese goldthread, amur cork-tree and hyperici japonici herb clear away damp-heat evils in the triple burner; Chinese thorowax and orange fruit regulate the circulation of liver-qi; coix seed invigorates the spleen and dispels dampness evils; plantain seed and rhubarb expel heat-toxin evils from the body. Liquorice root coordinates the actions of the drugs in the prescriptions.

Yin deficiency in liver and kidney

Prescription: xiaoyao powder plus zishui qinggan drink

chai hu Chinese tororwax root
zhi qiao orange fruit
sha shen fourleaf ladybell root
mai dong dwarf lilyturf tuber
sheng di dried rehmannia root
gui ban tortoise shell
shan yu rou cornus fruit
sang shen zi mulberry fruit
shou wu fleece flower root
nu zhen zi glossy privet fruit

In addition, for individuals who suffer from shortness of breath and weakness:

huang qi milkvetch root
bai zhu large head atractylodes rhizome
shan yao common yam root

In this prescription, Chinese thorowax and orange fruit regulate the circulation of liver-qi; fourleaf ladybell root, dwarf lilyturf root, rehmannia root and tortoise shell nourishes yin and clears away heat evils; taro pulp invigorates the spleen; mulberry, fleece flower root and glossy privet fruit nourish the kidney. Milkvetch root, largehead atractylodes and Chinese yam can replenish qi. 

Obstruction of the collaterals by blood stasis

Prescription: Yiguan decoction plus addition or deduction with Huayu decoction 

shi hu dendrobium stem
sha shen coastal glehnia root
bai zhi large head atractylodes rhizome
ji jin chicken’s gizzard skin
fu ling Indian bread
mi yan coix seed
bai shao white peony root
xiang fu nutgrass flatsedge root
xia ku cao spike of prunella
bie jia turtle shell
dan shen red sage root
hai zao seaweed

In this prescription, dendrobium and coastal glehnia root nourishes yin and clears away heat evils; large head atractylodes, chicken’s gizzard skin, Indian bread and coix seed invigorates the spleen and disperses dampness evils; white peony root and nutgrass flatsedge disperses liver-qi and relieves pain; spike of prunella, turtle shell, red sage root and seaweed activates the blood circulation and dissipates blood stasis. 

Excessive heat and toxin

Prescription: Anying niuhuang pill plus lingyangjiao powder for emergency treatment. 

It is recommended that an individual with this type of disharmony pattern be treated with a blend of both TCM and Western medicine.

Prevention

Individuals should be well rested. When yellow coloring appears on the skin and eyes (jaundice), strict bed rest is recommended. After the acute stage of the disease has passed, gradual exercise to promote rehabilitation can be undertaken. 
   
Diet should be light. For example, avoid seafood and greasy and spicy food.
   
Alcohol should be completely eliminated during recovery and post recovery because it can cause a relapse or worsen the liver condition.
   
Individuals should pay particular attention when consuming medications since the liver plays a special role in their metabolism. When liver function is damaged, these medications may not be broken down properly and can cause harmful side effects. Your doctor should advise you on which medications are safe to take if you have hepatitis. 

Western Medicine prevetion

Hepatitis A, B, and C virus are a common cause of liver disease worldwide. While hepatitis A infection is relatively benign in most cases, the effects of hepatitis B and C can have serious consequences. More importantly, since there is no cure for hepatitis B and C, prevention is the most important strategy to contain the spread of disease. While hepatitis B virus is the most common cause of chronic liver disease in Asia, hepatitis C is the most common cause of chronic liver disease in the U.S. Hepatitis C remains the most common cause of liver disease in the U.S. because of the chronic nature of the disease and the lack of effective vaccine. Although liver transplantation has become an accepted form of therapy in life-threatening cases, the new liver is not immune to re-infection by the hepatitis B or C. Until we find a cure for hepatitis, we must continue to educate the public about the risk factors and lifestyles changes to prevent hepatitis from spreading. Below lists some important prevention strategies for hepatitis. 

Hepatitis A
The best strategy for prevention is to practice good personal hygiene and maintain proper sanitation. There are also two drugs used to prevent hepatitis A virus infection: hepatitis A vaccine andimmune globulin 
Hepatitis A vaccine provides the best long-term protection against hepatitis A. The vaccine is intended for persons two years of age and older who are at risk for infection and for persons with chronic liver disease. Because it takes about four weeks for the vaccine to provide protection against hepatitis A, it should not be given after exposure to hepatitis A virus. 

Immune globulin can be given before exposure and is taken for short-term protection (three to six months) against hepatitis A. Patients who have already been acutely exposed to hepatitis A virus can also use it, because it helps to prevent them from re-developing hepatitis.
In order for the drug to work, it must be administered within 14 days after exposure. Lastly, the drug is highly recommended for travelers headed to high-risk areas who need short-term protection against hepatitis A. People who have already developed hepatitis A are immune against the virus for life.

Hepatitis B
Because there is no cure for hepatitis B infection, and the disease may lead to chronic liver disease, which can cause cirrhosis and liver cancer, prevention is critical in managing hepatitis B infection.Hepatitis B vaccine and hepatitis B immune globulin are two drugs that used to prevent hepatitis B infection.

Hepatitis B vaccine provides the best long-term protection against hepatitis B virus and should be given to all babies at birth, all children up to 18 years of age who have not been vaccinated, health care personnel, hemodialysis patients, persons who are at increased risk because of sexual practices, drug users who share needles, and people who have been accidentally exposed to blood infected needles with the virus.

Note: All individuals who are exposed to infected needles should receive both the hepatitis B vaccine and hepatitis B immune globulin immediately after they are exposed. 

Hepatitis B immune globulin is indicated for persons acutely exposed to the hepatitis B virus, infants born to infected mothers, and any individuals at increased risk of infection. Immune globlulin may prevent a person who is exposed to the virus from developing the disease. 

 

Hepatitis C
Unlike hepatitis A and B, there is no vaccine or immune globulin currently available to prevent hepatitis C transmission. Therefore, the only preventative measure is screening blood, organ, and tissue donors for the presence of the hepatitis C virus, and educating the public by counseling them to reduce or alter high-risk behaviors associated with hepatitis C infection.

 

 

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