Malnutrition is a syndrome caused by deficiency of various nutritional factors, and it displays differently in many kinds of disease.  Thinness doses not absolutely indicate malnutrition, for example, simple hypoproteinemia, if severe, may give rise to edema, and in cases of endocrine disorder, contrarily, secondary obesity may occur. But malnutrition and underdevelopment would certainly lead to an under standard condition of “body height” and “body weight”.  Therefore, a healthy figure does not actually relate to obesity, but concerns with the proportion of body weight to height, that is, the Body Mass Index.

Body Mass Index, abbreviated as BMI, is the proportion of Body Weight (kg) to Body Height (M²), see Table 1 below:

BMI = body weight  (kg)  /  body height² ( m² )

Infection of “hepatophilic virus” during infancy and childhood is the chief cause of human malnutrition and underdevelopment.

In daily life, the human body must absorb nutritious materials, such as, glucose, fat, protein, vitamins, inorganic salts and water for metabolic utilization, growth, development and activities of the body.  Deficiency of the above nutrients may be caused by diseases, hypofunction of some organs leading to poor digestion and absorption, insufficiency and imbalance of nutritional factors or over utilization due to increased necessity of the body.  Presently, due to the advance of knowledge about the pathogenic effects of “virus”, there are increasing evidences indicating that in many cases metabolic disorders, malnutrition and underdevelopment are caused by the infection of “hepatophilic virus”.

Liver is the axis of metabolism in the human body, its function is very complicated and certain functions of it, is closely related to the blood system, to glucose, protein, fat, water, electrolytes, vitamins and microelements.  If the patient was infected by hepatophilic virus during infancy, the disease would affect the child’s nutritional absorption and cause anemia and endocrine disorder and interfere with his development.  This forms “hepatogenic malnutrition and underdevelopment”.  In the later growing years, the child would be weak and subjected to frequent attacks of diseases.

It is reported that in our country as well as in South-east Asia, the infection of type B and other hepatophilic viruses is very common, and the infection during infancy, childhood and early youth may persist for several or ten more years or even throughout life.  Taking type B hepatitis as example, 70-90% of the patients would present prolonged positive reaction as “antigen carrier”, but have no clinical symptoms.  Liver function tests demonstrate no abnormality but liver biopsy showed damage in 90% of cases.  Although various types of hepatitis have different features in symptomatology, but hepatophililic virus infection invariably affects the child’s development and health.  The child cannot help himself from being infected and some are infected even before delivery and the infection is destined to exist throughout his life.  It is regretful that many parents and physicians do not pay much attention to pediatric virus hepatitis and often make misdiagnosis or miss the diagnosis in some way so that many children can not be diagnosed and treated in time.

Many chronic hepatitis patients were infected in the newborn or infantile period or during childhood, but their clinical symptoms unfortunately manifested late in the adult age and their diagnoses were suspected only at the discovery of abnormal liver function.  With the pass of time, the majority of these patients developed chronic hepatitis, cirrhosis or carcinoma of liver.  This reveals the fact that in recent years there is a tendency that victims of carcinoma of liver are becoming younger.

How to find out early that the child is suffering from hepatitis?  This is what all parents wish to know.  When there is chronic liver disease, the child has a lot of fire in the heart, liver and lung, and that heat in the large intestines is also abundant.  If water in the kidney is consumed, the function of liver and kidney is affected.  When hepatophilic virus entered the child’s body as pestilential evil, many clinical symptoms would be produced and it might lead to the formation of hepatogenic malnutrition and underdevelopment.

The TCM viewpoint is that kidney stores essence of life, regulates growth, development and fertilization.  The vital essence and energy is a basic material of the human body and is also a fundamental substance responsible for growth, development and many activities of the body.  The vital essence and energy stored in the kidney includes “the congenital essence of life” and “the acquired essence of life”.  The former occurs with the beginning of life and the latter comes from ingestion of food which is transferred into water and nutritional elements by spleen and stomache.  It intermixes with the genuine energy produced by the physiologic activities of zang and fu organs, and through metabolic regulation and balance, the remaining parts are stored in the kidney.  So, the vital essence and energy in the kidney is the basis of life activities and the physiologic effect of kidney vital essence and energy can include kidney yin (nourish and lubricate various tissues and organs of the body) and kidney yang (activate and warm various tissues and organs of the body).  The two of them rely on, restrict and take advantage of each other.  At the same time, they maintain relative balance of yinand yang of various zang and fu organs.  Therefore, it is said, in TCM, that kidney dominates bone and generates bone marrow.  In fact, the vital essence and energy within the kidney is an important component in promotion of developmental function of the body.

But, in liver disease, the dysfunction or failure of liver and kidney, provides opportunity for the evil (or virus) to damage the regular metabolic procedures.  As the TCM principle denotes, the development of bone depends on the fullness of bone marrow together with the nourishment provided by it.  When the virus evil invades and causes functional deficiency of liver and kidney, general metabolic disorder is produced, and if the condition is not treated in time, it will become serious and invariably lead to malnutrition and underdevelopment.

It is commonly known that chronic virus hepatitis is a generalized disease and individuals of unlike constitution, in different periods of life, may present symptoms of different systems.  In pediatric virus hepatitis, the hepatitis virus might have attacked the body early during infancy or childhood and directly or indirectly affected all the organs of the body.  Immune compounds (antigen-antibody compounds) may form and deposit on the lymph nodes, spleen, vascular endothelium, renal glomerular basal membrane, sensorial membrane and vascular networks, and produce inflammatory and degenerative changes, and in clinical practice, two kinds of hepatitis can be seen, the “chronic persisting hepatitis” and “chronic active hepatitis”.  The former is due to decrease of the child’s immune ability so that the hepatitis virus can not be eliminated causing the disease persisting and hard to be cured; the latter is formed because of defect of immunologic function and deficiency of antibodies, so that the virus can not be entirely eliminated and its replication is not inhibited.  There are still some liver cells continuously destroyed under the action of hypersensitive lymphocytes and subsequently the disease runs a prolonged uncured course, leading to damage of many systems in the body and presentation of different clinical symptoms.

Besides chronic hepatitis, patients suffering from acute nonicteric hepatitis, subclinically infected individuals or patients with concealed infections may present mild, insignificant or no symptoms.  If we can diagnose the child suffering from virus hepatitis in time, he will be treated in time.  The former standard of diagnosing chronic hepatitis (such as the existence of antigen, antibodies and liver function abnormality by blood examination, positive result by ultrasound or computer screening) is extremely inadequate and it will certainly produce large amounts of misdiagnoses and missed diagnoses.  The physician can diagnose and treat the disease in time if he is familiar with the TCM classification and symptoms of chronic hepatitis and the finding of abnormal margin of hepatic dullness.  In the 2855 cases of abnormal margin of hepatic dullness recorded in our clinic during these years, there were only 895 cases confirmed according to the diagnostic criteria of hepatitis, occupying 31.3%.  The remaining 2000 cases (about 70% of the patients) had only chronic hepatitis clinical symptoms and abnormal margin of hepatic dullness.  If they were given effective systemic TCM treatment, clinical cure should be the expected result.

Symptoms of hepatogenic malnutrition and underdevelopment

The most common symptoms in children with chronic hepatitis are thinness, dullness, fatigue, polish yellow or polish white of skin, pale mucous membrane of eyelids, lips and tongue, dryness of skin, hyperkeratosis, scaly desquamation and fissure formation.  The patient is susceptible to eczema, varicella and sweat stains.  Because of the decrease of immunologic ability, the patient is also extremely susceptible to infection.  Some pediatric patients tend to develop abnormal psychotic behavior such as anxiety, insomnia or reticence, indifference to the surroundings, retardation of memory and childish actions.  Manifestations of malnutrition in children include soft and distended abdomen, shallow and flat umbilicus (or even protruding), scarce subcutaneous fat, skin easily picked up by fingers,  If hypoalbuminemia is marked, one may find edema of the ankles and finger marks over the pretibial region (pitting after finger pressure).

Being parents, they must recognize and take preventive measures against hepatophilic virus infection during their child’s infancy and must give thorough treatment to liver disease, if present; this is the only way to ensure the child’s health.  This is also a basic method of improving the body constitution of the population in our country.  Once the development of hepatogenic malnutritition and underdevelopment has taken place, the patient’s health may be affected for a life time.

Yang (code number 0453), male, age 4 years.  He was born on 6^th November 1997 and first visited our clinic on 14^th September 1998.  His father had chronic hepatitis.  The child’s complaint was substituted by his mother who said that her son often had pruritus and dryness of the skin, nocturnal crying and had a hepatomegaly of 1.5 cm.  Because at that time the child’s age did not exceed one year, she did not dare to give him TCM drugs.

His return visit was on 30^th August 1999.  His mother said that he still had skin eruptions and repeated erythema, edema and pruritus of the skin which also showed fissures and exudative ulcerations.  He had bowel movements ever two to three days; the stools hard and bleeding occurred after defecation.  The child was dysphonic and had feeling of tiredness.

Physical examination: pallor of face, malnourished and underdeveloped, weight 22 lbs, skin dry with desquamation and infantile eczema, liver still enlarged to 1.5 cm.  Diagnosis: hepatomegaly for investigation, hepatic malnutrition and underdevelopment, rectal varicosities, anal fissure complicated with hemorrhage, virus gastrointestinal disease, xerosis cutis syndrome, eczema, rubella.

After taking 7 parcels of TCM drugs, the liver returned to normal, hematochezia stopped, but there was still constipation and fatigue. The xerodermatic lesions improved. TCM drugs were continued for 4 weeks at the end of which clinical cure was attained and medication was stopped for observation.

Wang (code number 2289) female, age 41 years.  Her first visit was in December 2000 and she complained of being a carrier of type B hepatitis virus for 10 years and had repeated exopathic coughing, nasal obstruction, copious expectoration, epistaxis and fatigue.  There were facial pigmented patches since ten more years of age.  In the recent three months, cough was more conspicuous; she often felt pain in the chest, low grade fever, headache, bowel movements 1-3 times daily, often associated with bleeding.

Physical examination: thin, malnourished and underdeveloped, thirsty, weight 40 kg, height 1.54 m,  BMI 16.8, telangiectasis over medial side of both popliteal fossa, marked hypochondriac anomaly, percussion tenderness over hepatic region, hepatomegaly of 4.5 cm.

After taking 3 parcels of TCM drugs, the liver was normal and she slept well and had no headache.  She still felt thirsty, the nasal discharge was yellowish and viscous; there was nasal obstruction, occasional coughing, fatigue, sleepiness and bowel movements twice a day with tenesmus.  The pulse was 108/min.  After another 4 parcels of TCM drugs, the common cold alleviated and coughing stopped.  There was some chest pain and examination revealed localized tenderness over the sternocostal joint.  She persisted in taking TCM drugs and during the course of treatment, cough, itching of throat, abundance of sputum, fatigue and tenesmus all gradually disappeared.  A total of 42 parcels of TCM drugs were taken.  Clinical cure was achieved and therapy was stopped.

Lin  (code number 2031), female, age 18 years. Her first visit was on 1^st January 2000 with the chief complaint of having a history of repeated gastritis and enteritis associated with repeated nausea, vomiting and loss of appetite.  She now became thin and suffered frequently from cough, with large amount of sputum, headache, chest pain, liver pain and generalized pain of the bones.  She had occasionally cold and fever and nocturnal perspiration.  She was diagnosed as pulmonary tuberculosis and treated by western medicine.  But during the anti-tuberculosis treatment, blood examination revealed a high ferment, so that, for two times, the therapy was stopped.  Now she asked for TCM to treat her liver illness.

Physical examination: lean, body weight 40 kg, height 1.52m., BMI 17.3, skin color polish, anemic looking, female secondary sexual characteristics under-developed, tongue reddish, coating thin and yellow, pulse 104/ min, abdomen navicular, percussion tenderness over hepatic region, hepatomegaly of 3 cm.  After taking TCM drugs, she experienced abdominal pain, diarrhea and flatulence, burning pain of anus, abundance of sputum and coughing.  The liver returned to normal after taking 3 parcels of TCM drugs, and the pulse was 112/min.  She totally took 14 parcels of TCM drugs and then stopped the therapy for 11 days.  She visited again because of asthma and cough, abundant sputum, abdominal distention nocturnal perspiration.  Physical examination revealed an enlarged liver of 1.5 cm which formed the first relapse.  Six parcels of TCM drugs were required to bring the liver to normal.  During the course of systemic TCM treatment, the symptoms disappeared gradually.  The course of treatment was 6 week; clinical cure was achieved and the patient was followed up.

Chan (code number 2038), female, age 17 years.   His first was on 10^th January 2000.  She complained of repeated wetness-heat abdominal pain since childhood and also constipation, bowel movements every three or four days with hard stools.  She had to defecate right after meal, and frequently suffered from wetness-heat, abdominal pain and tenesmus.  Her menstruation had a lag of about 10 days every time, the amount not large and the color bright red; pain was present.  For a long time, she had acne over the face, being more marked in the period before and after menstruation.

Physical examination: limbs long, thin, poorly nourished and developed, skin dry, numerous sweat stains, hairy lower limbs, toque reddish, prominent taste buds, toque enlarged with teeth prints, thick yellowish coating, finger nails pale, secondary sexual characteristics underdeveloped, hypochondriac anomaly, hepatomegaly of 1.5 cm, percussion tenderness over hepatic region, body weight 43 kg, height 1.64 cm, BMI 15.98.

After taking 4 parcels of TCM drugs, the liver returned to normal.  She took totally 3 weeks of TCM drugs and stopped the medication by herself, although the course of systemic treatment was not ended.  She returned to the clinic two months later complaining of sorethroat, coughing for several days with chest pain and constipation.

Physical examination revealed hepatomegaly of 1.5 cm. which was the first relapse.  She was given 3 parcels of TCM drugs, after which the margin of hepatic dullness became normal.  She had again systemic TCM treatment for 6 weeks and it resulted in clinical cure.  She was followed up and was advised to take hormone replacement therapy which gave her prominent changes of secondary sexual characteristics and improvement of nutrition and development.

Zhang (code number 2152), female, age 33 years.  First visit: June 2000.  She was thin since childhood and ate little, body weight being 35 kg, height 1.5 cm and BMI 15.5.  She suffered from neurosis, anorexia and failed to increase body weight in spite of receiving information from a nutritionist.  For a long time, her appetite was poor and she often had tiredness and insomnia and because of the latter, she was given hypnotics and anti-allergic agents.  She was susceptible to headache and sorethroat.  In recent years, she often had belching, distensive pain of abdomen, diarrhea and stomache ache which aggravated half a year ago and required gastroscopy but the result revealed no abnormality.  She had irregular menstruation (once in about 30-40 days), lasting for 6-10 days with clots and dysmenorrheal which required calling for emergency once.

Physical examination : polish yellow color of face, wan and sallow looking, anemic and lean, underdeveloped, tongue enlarged with marginal teeth prints, mild percussion tenderness over hepatic region, hepatomegaly of 4.5 cm, mild edema of lower extremities, prominent veins and mild venous varicosities of lower limbs.  The diagnosis was chronic hepatophilic virus disease, hepatomegaly for investigation, hepatic malnutrition and underdevelopment, hepatic anemia, anorexia, hypotension, hepatic neurosis, sexual hormone disorder, hypertension of inferior vena cava, venous varicosity, hepatogenic peptic ulcer, virus gastrointestinal disease, menstrual disorder, dysmenorrheal, hepatic edema, hepatophilic upper respiratory tract infection.

After taking two parcels of TCM drugs, bowel movements were smooth but the amount of stools was small.  Her appetite improved, and sleeping was good but could be easily awaked.  Her hepatomegaly shrank to 1.5 cm; the blood pressure ⁸²/₅₀ mmHg; lower extremities edema (+).  After another 3 parcels, the liver was normal.  The menses appeared two weeks after the medication and the amount had a decrease of one third.  On the fourth day of menstrual flow, the amount reduced (in former months, it needed 6-7 days); there were no clots but dysmenorrheal still existed which required analgesics for 5 times in the first two days.  Clinical cure was obtained after taking 48 parcels of TCM drugs.

Symptoms induced by metabolic disorder commonly seen in liver disease

When infection of hepatophilic virus has led to parenchymatous hepatic changes, various metabolic disorders may be evoked; the following are the ones usually encountered.

•            Hypoalbuminemia

Children with chronic hepatophilic virus disease are usually infected through the mother-child pathway or by close contact, therefore infantile hepatitis causes malnutrition and the development of some children may be affected.  The hepatic metabolic function of children is weaker than adults, its protein synthetic function is lower and when the liver is injured, there is synthetic insufficiency of albumin, fibrinogen and coagulative factors.  Therefore, children with chronic hepatitis often have hypoalbuminemia, disturbance of calcium absorption and bleeding tendency.  In there is decrease of growth hormone in the blood due to endocrine disorder, the diseased child would have calcium deficiency and form bone malnutrition.  The cause lies on the fact that chronic liver disease induces nausea, vomiting, poor appetite and gastrointestinal disturbance, affecting absorption of various nutrients.  Inflammation can also cause decrease number of hepatic cells and lowering of hepatic function, inadequate food intake and decrease of synthetic ability.  All these can easily lead to hypo-albuminemia and production of nutritional disturbance and subsequently to malnutrition and underdevelopment.

Clinically, the pediatric patient’s abdominal wall is soft and distended, and it shows prominent venous collateral circulation and telangiectasis.  The patient’s liver is usually enlarged; right hypochondriac pain can be shown in larger children and during examination hepatic percussion tenderness can be detected.  The child may have bleeding tendency and present repeated epitasis, hematochezia, bleeding of the gums and history of spontaneous or postcontusion ecchymosis.

At present, it can often be found clinically that if one was attacked by hepatitis during infantile and childhood, he may show by examination, during the school age, young or middle adult age, asymmetry of the hypochondria, the left hypochondria slightly depressed or protruding like an angle, the right hypochoridrium full, extending outwards or even bulging.

In medical practice, there is a formula for calculation of a child’s body weight to know whether it is up to standard or not; it under standard, it means the body weight is insufficient.  This formula is:

Age in year x  2  +  7  =  body weight of child in kg.

•            Hepatogenic osteal malnutrition and underdevelopment

It is a series of bone pathologic changes induced by metabolic disturbances of calcium, phosphorus of Vitamin D in liver disease, including chiefly diseases like osteoporosis, rickets and osteomalacia.  A small number of cases may develop into “hepatic dwarfism”.  The diseased child’s face is lack of luster; he is smaller than general, lean, growing much more slowly and the inadequate calcification of bones leads to rickets.  In severe cases, there are costal moniliformis, chicken breast; anomaly of spinal column, chest and feet.  This is due to endocrine disorder in chronic hepatitis which causes lowering of the level of growth hormone and also calcium deficiency; this subsequently results in osteal malnutrition.  When anomaly has taken place, the result of operative correction is usually not ideal.  If the patients’ chronic hepatitis can not be treated thoroughly with systemic TCM method and not cured clinically, operative treatment can only be “a measure for the superficial and not for the fundamental”.

•            Hepatogenic hypoglycemia.

Hepatogenic hypoglycemia often aggravates progressively in its degree of severity and frequency of attack.  It tends to attack before breakfast, the meal time is then delayed and fasting may be induced.  Its manifestations include getting hungry easily, palpitation, perspiration, tremor of hands, pallor of face and anxiety.  The more serious cases may have dizziness, headache, blurring of vision, slowness of response or even hypoglycemic encephalopathy such as psychosis.

•            Hypokalemia

In liver disease, metabolic disturbance of potassium presents as hypokalemia, which is caused by inadequate absorption, vomiting or diarrhea.  Clinically, these are myasthenia oliguria, anuria, bitter taste, loss of appetite, distention of abdomen, hypotension and, in severe cases, restlessness, emotional instability and sleepiness.

•            Hyponatremia

The clinical symptoms of this entity include haggard looking, weakness, indifference, loss of appetite, thirst, anxiety, dizziness, distensive feeling of head, headache, anorexia, nausea, vomiting, paleness and coldness of limbs.  In severe cases, these are painful spasm of muscles, blurring of vision, hypotension and postural collapse.

•            Hepatogenic diabetes

An early symptom of pediatric diabetes is infantile nocturia which is acute in onset and once discovered it is usually quite serious.  It is often associated with thinness, polydipsia, polyuria, polyphagia, hunger, fatigue and unlively behavior.  The patient is susceptible to infections.  If the disease is prolonged, the child may present xeroderma, scaly desquamation, pruritus or hairiness.

Soup recommendation

“Large snail meat and pork calf yin nourishing soup”

TCM theory acknowledges that food and medicine are of the same origin.  In addition to systemic TCM therapy, during the course of treatment or after clinical, hepatophilic virus disease patients are advised to take the “nourish yin and supplement kidney” soup from time to time.  It renders the kidney to hold plenty of water so as to suppress the initiation of heart fire, liver fire and lung fire.  The body constitution of the hepatophilic virus disease patient belongs to the category that is deficient but not suitable to be supplemented; therefore, the soups with dryness heat or with coldness character should not be taken,

[Materials]      

One large snail or frozen snail head half lb, pork calf 500g, Poria, Semen Eurgales, Rhizoma Dioscoreae, Peeled white Semen Nelumbinis in small amounts, mushroom, 6-8 pieces, one piece of raw ginger, a bit of table salt.

[Method]         

1.        Large piece of pork calf placed in boiling water for a very short time.

2.        One piece of fresh snail, remove, the shell and viscera together with the dirty attacked parts.  Clean with water.  If the snail is refrigerated defrost and clean it.  Remove water for preparation.

3.        Put all materials in cooler, add adequate amount of boiled water, increase intensity of fire to boiling degree, then use moderate or small fire to maintain boiling 2-3 hours, add some table salt for flavoring.

[Effect] 

• Large snail meat tastes sweet, salty slight cold, can nourish yin, brighten the vision, facilitate urination and increase body fluid.
• Pork calf nourishes yin and supplements muscle moistens intestines and nourishes stomache; it has great nutritious value.
• Poria can facilitate water excretion, decrease wetness, strengthen spleen and tranquilize emotion; Semen Euryales can supplement spleen, eliminate wetness tonify kidney and arrest sportaneous emission.
• Rhizoma Dioscoreae has the ability of nourishing qi and yin, supplementing spleen, lung and kidney; Semen Nelumbinis has the ability of strengthening spleen and stopping diarrhea, supplementing kidney, arresting spontaneous emission and nourishing heart and calming the mind.

Published on 30th May 2002

Translated by Professor Zheng in November 2004

Chronic hepatophilic virus disease inevitably gives rise to “deficiency of blood and weakness of qi“because liver is the axis of metabolism in the human body and also is an organ indispensable to the maintenance of life.  Liver function is very complicated, and certain functions are closely related to the blood system.  So, in liver disease, there are often hematological changes which may be simple abnormality of blood cells or mild coagulopathies (but in serious liver diseases, severe coagulopathies are quite common and they are often the main causes of death in patients with hepatic disease).  In addition, there may be decrease of all blood cells or generalized hemorrhages in the whole body, or even failure of the entire bone marrow such as in fulminant hepatic failure and the patient’s death can be caused by the complication of disseminated intravascular coagulation.

“Hepatogenic anemia” is very common, and it is reported in the literature that anemia, in liver diseases of various causes, reaches 77.3%.  Although hepatogenic anemia occurs commonly, but often times, it remains unnoticed due to the undefined diagnosis of hepatitis or concealed under the cover of symptoms of liver disease.  Up to the present, not few physicians still consider “hepatogenic anemia” as anemia of unknown etiology and the result is probably long term misdiagnosis.  In fact, the principle of treating hepatogenic anemia is treatment of liver disease in the first step and increase of nutrition to improve liver function and subsequently the blood disease may also improve.

If chronic liver disease is not detected and confirmed early and not treated in time with systemic TCM therapy to achieve clinical cure, the course of disease would continue, the functions of internal organs are continuously impaired and the extra-hepatic complications such as anemia would increase day by day, and recovery is more difficult.

We have received 2787 chronic hepatophilic virus disease patients; in this group there were 457 patients (16.4%) who presented symptoms and signs of hepatic anemia.  In these patients, male were 997, in which only 46 patients had hepatic anemia, being 4.61%, which in 1790 female patients, anemia occurred in 411 patients, reaching 22.96%.

Etiology and pathoginesis of hepatogenic anemia

From the TCM point of view, virus, the pestilential evil, on entering the human body, can hide itself as in “evil” in the blood and attack the internal organs – five zang-organs and six fu-organs.  The “evil” not only hurts the body energy and resistance, but also disturbs the qi and blood.  If here is dysfunction of the zang and fu organs, the blood would inevitably flow in the adverse direction and leave the body and the body would become more susceptible to deficiency and to damage of qi and blood.  If treatment is not proper or if there are depression of qi, menorrhagia, mental consumption, fatigue of heart and kidney, large amount of blood loss and little blood regeneration, the pathological conditions of deficiency of both qi and blood would gradually occur.  With the advance of science, the knowledge about hepatophilic virus disease has been much increased and it is known that the etiologic factors of hepatogenic anemia may act singly or in a complex manner, such as:

1. Malnutrition and decrease of storage of hepatic hemopoictic factors:

Loss of appetite and decrease of absorption in the intestinal tract in chronic hepatitis patients can directly cause protein metabolic disorder and hypoproteinemia, affecting not only the synthesis of plasma albumin by hepatic cells, but also the production of hemopoietic factors like folic acid, leading to deficiency of iron and finally to the formation of anemia.  The liver stores vitamin B₁₂, folic acid and iron, so liver disease would definitely lead to decrease storage of these hemopoietic factors and subsequently to anemia.  Alcohol can directly interrupt the absorption, metabolism, hepato-intestinal circulation and usage of folic acid; therefore, liver disease patients must stop drinking.

2. Chronic blood loss:

Liver disease may be associated with clotting defect and therefore it provides a high risk to hemorrhage. According to statistics, 85% of liver diseases have at least one item of coagulation abnormality and 15% present a bleeding tendency.  Therefore, hypodermic purpura, epistaxis, hemoptysis, menorrhagia, gastrointestinal bleeding, rupture of hemorrhoid and esophageal veins, parturient and postpartum periods may all cause hemorrhagic anemia.

3. Hemalysis:

In liver disease, the life time of the patient’s red blood cells is shortened; this indicates hepatic anemia is related to hemolysis.  It is commonly considered that in liver disease, the increase of cholesterol and phospholipids deposits on the cell membrane of red blood cells and the decrease of GSH inside red blood cells are related to splenic hyperfunction.

4.  Increase of plasma volume:

In liver disease, there is significant increase of plasma volume due to hepatic edema and cirrhotic ascites and it subsequently induces dilution of the blood.

5.   Decrease of hemopoietic function of bone marrow:

Hepatic dysfunction causes decreased production of prodromal substances of red blood cell genesis and therefore affects bone marrow hemopoiesis.  (Alcohol can also directly inhibit bone marrow red cell generation, so liver disease patients must stop drinking).

Symptoms of hepatogenic anemia

Due to the complicated clinical symptoms of liver disease, the symptoms and signs of hepatogenic anemia often belong to different forms TCM classification.  For example, anemia may be caused by chronic hepatitis, and although chronic hepatitis may not be confirmed by blood examination, ultra-sound or computer screening, it is still possible to discover signs such as abnormal margin of hepatic dullness during physical examination.

The causes of anemia from liver diseases are many, and through statistical data, one can also find that hepatogenic anemia often includes various clinical kinds of anemia, such as, megaloblastic anemia, occupying 32.6% (mainly folic acid deficiency), normoblastic anemia 30.3% (mainly due to hemolysis), microcytic hypochromic anemia, 14.4% (mainly due to iron deficiency) and aplastic anemia, 0.06%.

In hepatic anemia, there are also some manifestations commonly seen in anemia, such as vertigo, dizziness, palpitation, insomnia, dreaminess, sleepiness, fatigue, coldness of limbs, sluggishness in speaking, pallor of face and headache due to deficiency of blood.  If there is prolonged deficiency of yang, entrapment of wetness and hepatic edema, secondary obesity may occur. 

Introduction of cases

Case 1.  

Zheng (code no. 2126) female, age 44 years.  First visit: May, 2000.

Her chief complaint was that she was a carrier of type B hepatitis virus for 10 years.  She was puffy since childhood and often experienced fatigue, nasal hypersensitivity and shortness of breath.  The menstruation was irregular with occasional dysmenorrhea and the blood amount was extremely large, the bleeding rapidity may cause a menstrual pod soaked up thoroughly in 1-2 hours.  Because of this, she dared not move much during menstruation to avoid excessive bleeding.  In the postmenstrual period, she often had repeated headache and common cold.

During the visit, she was having sorethroat and hoarseness of voice for a week, associated with cough and viscous sputum.  Her figure belongs to the obese type, weighing 140 lbs, height 5 feet 2 inches.  Her tongue was enlarged with teeth prints, lower extremities pitting edema (+), percussion tenderness over hepatic region, hepatomegaly of 3 cm.  The diagnosis was active chronic hepatitis, liver stagnation and lung dryness, with TCM classifications of deficiency of blood and weakness of qi, blockage of channels and stasis of blood, hepatic edema, secondary obesity.

After taking 3 parcels of TCM drugs, the liver was normal.  Hoarseness and coughing improved, there was no sputum, but the passing out of flatus was frequent.  The tongue was still dry with red margin and thin coating; edema of lower limbs disappeared.  She took another 4 parcels and the sorethroat and coughing disappeared.  There was mild diarrhea; the stools were loose and copious.  After one week of TCM medication, the menses appeared and its amount significantly decreased, but the color was bright with little clot and no dysmenorrhea.  The liver was still normal and the lower extremities showed mild edema.

During the course of TCM therapy, there was occasional sneezing and nasal discharge.  Abdominal pain before defecation was still present; and bowl movements appeared every other day.  The tongue was still enlarged and edema over the lower limbs was (+).  Systemic TCM therapy lasted for 4 weeks and the patient did not feel any discomfort.  Edema of the lower extremities was minimal.  Clinical cure was attained and TCM therapy was stopped for observation.  Menstruation reappeared after stoppage of treatment and its color was brownish red, the amount of blood decreased markedly.  It lasted for 3 days without dysmenorrhea and blood clots.

Yi (code no. 472) male, age 43 years.  First visit: October 1996.

He complained of suffering from acute type A hepatitis 20 years ago and was treated in hospital.  He had a history of stomache illness since childhood and was once hospitalized because of bleeding and received blood transfusion.  In the recent 2 years, he often had palpitation, vertigo, tremor, feeling of weakness and insomnia.  He was diagnosed as anemia and neurosis.  Physical examination revealed anomaly of hypochondria, percussion tenderness of hepatic region and hepatomegaly of 3 cm.  His lower extremities showed (+) pitting edema.

He was treated with systemic TCM, resulting in disappearance of symptoms and clinical cure.

He was reexamined in September 1997 and his liver was normal and he did not feel any discomfort.

Lee (code no. 061) female, age 26 years.  First visit: July 1998.

She had a history of Mediterranean anemia, and urinary system infection.  She often had vertigo, abdominal distention and diarrhea.  Her menstruation was regular, the color bright red, large in amount with many blood clots.  Physical examination: color of face palish fellow, anemic, thin, wan and sallow looking, tongue enlarged and pale with marginal teeth prints, abdomen soft and distended, protuberance of right hypochondrium and depression of left hypchondrium, hepatomegaly of 3 cm, mild edema of lower extremities.  She was diagnosed as hepatomegaly for investigation, hepatopathic upper respiratory tract infection, hepatogenic peptic ulcer, virus gastrointestinal disease, hepatogenic anemia, menstrual disorder, urinary system infection.

After taking 6 parcels of TCM drugs, the liver returned to normal and symptoms also disappeared.  During the course of systemic treatment, the liver was enlarged to 1.5 cm in the postmenstrual period in August and it became normal after taking another 3 parcels of TCM drugs.  When the systemic treatment ended, clinical cure was attained and the patient was followed up.

Four months later, she was hospitalized for 5 days because of fever and urinary system infection.  She received oral cephalosporin and anti-inflammatory drug injections.  Physical examination after discharge from hospital revealed hepatomegaly of 4.5 cm, which was the first relapse of liver enlargement.  Three parcels of TCM drugs brought the liver to normal.  Systemic TCM therapy was given and clinical cure was attained afterwards.

Thereafter, the patient received persistently TCM therapy before each menstrual period and was followed up uninterruptedly.  Anemia was corrected and she felt no discomfort.  During the four years of observation, hepatomegaly relapsed for 6 times (once after taking durian and shousi, once after uncooked lobster, once after traveling to Korea for 5 days, the remaining two times cause not clear), but all were cured by systemic TCM therapy.

Chan (code no.527) female, age 18 years.  Her first visit was in June 1994.

She complained chiefly of marked thinness recently, the body weight dropping from 96 lbs to 89 lbs within several months and also insomnia and yellowish urine for half a year.  In the recent 10 days, she had repeated vaginal and the menstrual blood was red or brownish and large in amount.  She also experienced vertigo, nausea, perspiration, palpitation and a pulse rate of 100/min.

Physical examination: thin and anemic, pale color of face, tired looking, hepatomegaly of 4.5 cm with percussion tenderness.  After taking 6 parcels of TCM drugs, the menstrual blood amount decreased and color became red.  The liver shrank to the costal margin.  Another 3 parcels of TCM drugs brought the liver to normal.  Her menstruation was normal; her sleeping and mental condition was good.

After 9 parcels of TCM drugs, her menses appeared but the liver was enlarged to 3 cm and another 3 parcels of TCM drugs brought it to normal.  Her menses lasted for 6 days and TCM drugs were taken every month before and after menstruation since the termination of the TCM therapeutic course.  Thereafter, the menses were regular and no hepatomegaly or clinical discomfort occurred during menstruation.  Her last return visit was on 12 June 1996, at which time them was no hepatomegaly, her anemic condition improved and the menstruation was normal.

The Leung sisters.

Their body build were of the weak type; they were examined and suspected to have Mediterranean anemia and treated with WM drugs.  Their mother had a history of positive type B hepatitis antibodies by blood examination,

Leung (code no: 545) female, age 25 years.  Her first visit was in June 1996 with the complaint of getting tired easily, especially during the menstrual period.  She experienced headache post-menstrually.

Physical examination: marked anemic appearance, polish color of mucous membrane of lips, tongue and eyelids, blood pressure 90/50 mmHg, abdomen soft, hepatomegaly of 3 cm.

After taking 6 parcels of TCM drugs, the liver shrank to the costal margin and after another 3 parcel, the liver was normal.  Sometime TCM therapy lasted for 6 weeks and medication was stopped when clinical cure was attained.

A return visit was made 8 months after cessation of medication and it was found that the anemia was corrected significantly.  No clinical symptoms appeared and liver was normal.
Leung (code no: 550) female, age 22 years.  She first visited the clinic in April 1996 with the chief complaint of insomnia for more years.  She could hardly fall into sleep and was dreamful.  She felt tired and experienced repeated nasal hypersensitivity and common cold.  She frequently had headache, vertigo, palpitation, shortness of breath, constipation hard stools, once in 2-3 days.  Her menstrual interval was 25 days, the amount moderate, lasting for 7 days, with clots, some pain and abdominal distention.  She lost about 10 lbs last year and had operative resection of fibroma of left breast several weeks ago.  She was diagnosed as chronic hepatitis complicated with hepatic anemia and neurosis.

Physical examination revealed a marked anemic figure; the mucous membrane of eyelids, lips and tongue pale like paper, the tongue enlarged with teeth prints, the lower extremities slowing (+) pitting edema.  After taking 9 parcels of TCM drugs, she could sleep but wakeful and her liver became normal.  The visit happened to be the 2^nd day of menstruation, the color was bright red, the clots were few and no pain was present.  TCM treatment continued for three months; during this period, there was occasional vertigo, repeated ulceration of the mouth and pharynx.  The stools were of the wetness-heat character.  In each premenstrual period, she felt distention of the breasts, but no dysmenorrhea.  The menstrual blood was bright red, the amount less and without clots.  At the stoppage of medication, she was well, her sleeping was good, her appetite was normal and her anemia had been corrected significantly.  Her lips were red and she felt no discomfort.  In the following months, she received TCM therapy during thee premenstrual days and she felt no discomfort, the liver was also normal,

Six months later, she made a return visit because of exapathy for 3 days.  She was afraid of relapse of the liver disease.  Physical examination revealed a hepatomegaly of 1.5 cm.  She was treated by systemic TCM therapy which was stopped at the attainment of clinical cure.

 Hepatitis aplastic syndrome

A small number of hepatitis cases (especially acute icterohepatitis) may develop aplastic anemia, also called “hepatitis aplastic syndrome”, during the course of the disease or in the period of convalescence.  The incidence is higher in pubescent and young people. And about 90% occur in the year following onset of the disease.  According to statistics, hepatitis aplastic syndrome occupies 1.07% – 5.8% of aplastic anemia and those complicated by aplastic anemia account for 0.34% – 0.4% hepatitis cases.  There are about 0.06% – 0.07% of children with hepatitis complicated by aplastic anemia.

The aplastic anemia cases following hepatitis are usually severe ones, and their conditions may aggravate rapidly.  Their clinical manifestations include the three major categories: anemia, bleeding and infection, and the main causes of death are intra-cranial hemorrhage and septicemia.

To avoid hepatitis aplastic anemia, when hepatitis is confirmed, it is necessary to administer at once systemic TCM therapy to achieve clinical cure.  This can prevent direct injury to the hemopoietic stem cells by hepatitis virus, inhibition of hemopoieses by immunologic reactions and decrease of hepatic detoxification function.

Published on 25th April 2002

Translated by Professor Zheng in October 2004

Zhao X (computer number 2123), female, 51 years old.

First visit was made in April 2000. Her chief complaints were: She suffered ailment from childhood, born two boys and one girl, got induced abortion twice and natural abortion four times.  She has had amenorrhea since last year, often in perturbation.  She had her menstruation once this year soon after taking traditional Chinese medicine. She got chest pain, short breath, and “foreign body sensation in throat” five years ago and had undergone physical examination. Lupus erythematosus cells were found in blood test and computer scanning showed phlyctena at left kidney. She has not received western medical treatment so far. She got stomach and intestine sensitiveness and fever easily and had chronic astriction, erosion and desquamation of the lips, overmuch skin chromatosis at neck, face and forearm, and senile plaque. She still had agitation, bad sleep, dreaminess, listlessness, eye dryness, and chest pain.

Physical examination showed that rhagas and desquamation were found at lips, adnexal thickening and tenderness of sternal rib joint, fixed tenderness points at the connection of breastbone to costal margin of 6th to10th ribs (left) and 9^th to 10th ribs (right). Abdomen was soft and swollen, hepatic region got percussion tenderness, and liver located 1.5cm down prime rib. Edema of lower extremities, finger indentation (+), lower extremities vena emergent, capillary vessel dilatation was at limited region beside left knee.

In the return visit after 4 copies of traditional Chinese medicine, liver deflated to be normal level. She herself thought to have gotten dull pain at abdomen, headache, cough, dark urine, and dryness heat after taking the Chinese medicine. Desquamation at lips, adnexal thickening and tenderness of sternal rib joint. After using the Chinese medicine one week, headache and dark urine disappeared. To go on taking the Chinese medicine, stomachache, paralysis at the limbs and trunk, overmuch phlegm, bad sleep, dreaminess and hypopiesia (80/50 mmHg) occurred reiteratively. But they all disappeared while the patient went on taking the Chinese medicine.

Observing with suspension of the drug after usage of 42 copies of the medicine, sneeze occurred during the suspension. Gentle fixed tenderness was still at breast joint of 9^th left rib. Slight desquamation at lips, little phlegm, white face, no edema at lower limbs, no other abnormity. It was cured clinically. To observe with quit of the medicine.

Liang X (computer 2261), female, 42 years old. First visit at October 2000. She herself said that she had been sickly since childhood, with repeating skin pruritus and skin rash in the past years. Last November, she got erythema itch around the right eye socket, on the back and extremities. Biopsy at health center proved it to be cazenaves lupus. Blood and urine test showed no abnormity. There was no effect after repeating treatment of Chinese and western medicine and special treatment. Patient appeared listlessness, drowsiness, eye cloudiness (vitreous opacity at left eye), disturbance of menses, and vermeil abundant menses with little sludge. And she had chronic migrant skin rash and drastically skin pruritus.

Physical examination: Measles pimple could be found at the skin of top right internal canthus. At left back, palm-large ecchymosis and scratch mark appeared. Beat of pulse was 80 times per minute. Costal regions were malformed. Hepatic region got percussion tenderness and liver located 1.5 cm down prime rib. After taking 3 copies of the Chinese medicine, bilious headache broke out acutely, patient got aversion to wind and cold, pulse was 72 times per minute. Erythema was apparent on the face, and erythematous edema occurred at skin of right internal canthus, but liver located normally 1.5 cm top of prime rib.

When patient went on taking the Chinese medicine three copies, headache got relief. She herself thought to be skin pruritus. Patient got watery diarrhea, and the quantity was large. Another usage of three copies of the Chinese medicine stopped headache, alleviated skin pruritus. Accounting in her own words, she needed no western antipruritic or daub drug for exterior use. Erythema at right internal canthus retreated, and presented as brown pigmentation spot. Erythema at top right eyelid subsidized, attenuated and reduced apparently. After 9 copies of the Chinese medicine in all, physical examination showed that hepatic dullness area was still normal, and edema on the lower limbs disappeared.

When it was two weeks after beginning to take the Chinese medicine, erythema on the right eyelid subsidized apparently, and teeth prints in the tongue abated. Going on to take treatment with the Chinese medicine everyday till one month, patient seldom felt skin pruritus at down right eyelid, could go back to work, seldom felt headache, and got no hypersensitivity when contacting with abluent. Additionally, menses was vermeil and in normal quantity, with slight sludge.

Patient totally took 87 copies of the Chinese medicine, and that caused no discomfort, no skin rash, some listlessness, while stomach inhalement was ok. After clinic cure, we stopped Chinese medical treatment and switched to observation.