Hepatogenic malnutrition and underdevelopment (One of the common symptoms of “deficiency of blood and weakness of qi”

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