The 2nd Form : Gastrointestinal, dermal or lower-jiao wetness–heat Form (viral gastrointestinal disease, dermal wetness-heat)

In virus hepatitis, the virus can attack any part of the gastrointestinal tract.  In the past, people thought that the gastrointestinal symptoms were merely manifestations of the liver disease, but now, it is confirmed that the symptoms of digestive system in chronic hepatitis are caused by direct viral infiltration of gastric or intestinal mucosa or by damage of gastrointestinal mucosa following disorder of immune system evoked by virus.  Gastrointestinal mucosal biopsies of these patients show significant inflammatory changes.

The gastrointestinal symptoms and clinical manifestations of virus hepatitis usually include poor appetite, anorexia, nausea, vomiting, distension of upper abdomen, belching, borborygmus, or recurrent paroxysmal abdominal pain, diarrhea, constipation, oral ulcerations, edema, dryness, desquamation and fissures of lip mucosa, obstinate tongue coating, ozostomia and indigestion.  A small number of hepatitis patients, when associated with hepatogenic peptic ulcer may be easily complicated by hemorrhage of digestive tract or venous varicosities of colon leading to repeated hematochezia (polyps, hemorrhoids or anal fissure).  Therefore, pediatric hepatitis patients are prone to have repeated alternating constipation and diarrhea and also tenesmus, defecation right after meal, abdominal distension, anorexia, frequent farting and susceptibility to wetness-heat abdominal pain.  For infants, the common symptoms are poor appetite, indegestion, recurrent diarrhea, abdominal distension, milk regurgitation, restless sleeping, nocturnal crying and susceptibility to aphthae.  One should think of the existence of hepatic disease if these manifestations are present.  The more severe cases may be associated with thinness, malnutrition and hypoalbuminemia (such as presence of edema of the ankles).

The infants and children with the above symptoms should be examined for hepatomegaly and be ascertained whether or not suffering from hepatitis.  It should be mentioned that hepatogenic diarrhea is one of the common clinical symptoms of liver disease (including acute or chronic hepatitis, cirrhosis or carcinoma of liver).  In liver disease, sometimes hepatogenic diarrhea may be the first symptom to appear as well as the chief symptom causing the patient to seek for medical help.  According to statistics, 4% – 30% of chronic active hepatitis patients have diarrhea, so this condition should not be neglected.

Introduction of cases –

2nd Form : Gastrointestinal, dermal of lower-jiao wetness-heat form

Case 2-1: The siblings were diagnosed as hepatomegaly for investigation.  Their parents had hepatomegaly and were treated simultaneously with TCM drugs in our clinic (the mother had history of positive type B hepatitis antibodies).

The elder sister: Yang – (computer no. 1981) female, age 7 yrs.

First visit: 8^th November 1999.  The patient was thin, poorly nourished and underdeveloped for a long time; she also had poor appetite and sleepiness.  In the recent days, she experienced abdominal pain, belching, nausea and vomiting, the vomitus being food remnants.  Doctors diagnosed the disease as exopathy attacking the stomache.  WM drugs were taken but of no avail.  Physical examination revealed an enlarged tongue with thin white coating, percussion tenderness of hepatic region, hepatomegaly of 1.5 cm.  After taking TCM drugs, the abdominal pain and vomiting ceased.  Another 3 parcels of TCM drugs were taken and the appetite improved and other symptoms disappeared only for the presence of thick white tongue coating.  The liver was normal.  TCM drugs were continued for 3 weeks, the appetite was good and the tongue coating detached completely.  At the fourth week of medication, her body weight increased 1.5 kg (from 22 kg to 23.5 kg).  A total 6 weeks of TCM drugs were taken, at the end of which, she was clinically cured and was then followed up.

In the following 3 months when medication was stopped, she received monthly examination and the liver was found to be normal.  But after the Spring festival, she took unclean food and felt tired, sleepy and listless.  By the middle of March 2000, she had sorethroat and western medical examination discovered tonsilitis but the administration of anti-inflammatory drugs was not effective.  She returned to our clinic on 19^th March and looked thin, listness and tired.  Her tongue coating was thin, yellowish; the margin of hepatic dullness increased 1.5 cm and percussion tenderness was present.  After taking 3 parcels of TCM drugs, her sorethroat disappeared, appetite improved, coating of tongue disappeared and the color of tongue deep red.  The liver was normal but her expectoration was still abundant.  Systemic TCM therapy was administered for 4 weeks and clinical cure was obtained.  The patient was followed up.

The brother: Yang – (computer no. 1983) male, age 3 yrs.

No apparent discomfort was complained.  He was examined because of hepatomegaly found in his parents and elder sister.  Physical examination revealed a hepatomegaly of 3 cm.  He took the same TCM drugs as his sister and during treatment he had vomiting and diarrhea.  After 3 parcels of drugs, the liver was normal.  His systemic therapy was similar to that of his sister.  After that, hepatomegaly did not relapse.  His sister had a relapse several months later but the patient’s liver was shown to be normal by physical examination.

Case 2-2:

Zhang – (computer no. 1580) female, age 11 yrs.

First visit: 10^th August 1999.  Her mother said that the child had a poor constitution and a habit of taking food irregularly and experienced abdominal pain and distension, diarrhea, listlessness and occasional constipation.  In the recent days, she had nausea, vomiting, vertigo, poor appetite, abdominal distension, vomiting right after food intake, loose, watery stools, being two or three times a day.  WM drugs were not effective.  Physical examination: poorly nourished, underdeveloped, skin pale yellow, lean, tongue enlarged without coating, percussion tenderness over hepatic region, hepatomegaly of 3 cm.  After taking 2 parcels of TCM drugs, nausea and vomiting ceased.  She had apparent feeling of hunger, and her appetite recovered.  Bowel movements were 1-2 times a day with loose stools, percussion tenderness was still present but the liver was normal.  Systemic therapy continued for 4 weeks and she obtained clinical cure.  She was followed up.

Case 2-3:

Lee – (computer no. 3262) male, age 14 yrs.

First visit: 18^th March 2003.  The patient suffered from nasal hypersensitivity for a long time and was susceptible to aphthae.  He was restless, had grinding of teeth at night and history of abdominal pain.  He was diagnosed as stomache disease but the taking of “gastric drugs” did not show effectiveness.  He also had frequent attacks of common cold, fever, occasional coughing, edema fissure and desquamation of lip mucosa, and enlarged tongue with apparent thin white coating.  Physical examination revealed hepatomegaly of 3 cm.

After taking 3 parcels of TCM drugs, the liver was normal.  He was sleep well and restlessness decreased.  The tongue coating was thinner and partly detached.  He had manifestations of a mild degree of common cold.  Administration of TCM drugs was continued during which time there were repeated aphthae, epistoxis and occasional nasal hypersensitivity.  In the third week, nasal hypersensitivity was not seen and at the fourth week these was no oral ulceration.  Clinical cure was obtained at the end of the sixth week of TCM therapy.  The patient was followed up.

One year later (7^th March 2004), the first relapse occurred.  On visiting, he complained of fatigue, sleepiness, facial acne and edema of lip mucosa.  His bowl movements were normal.  Physical examination revealed hepatomegaly of 3 cm.  After taking 3 parcels of TCM drugs, the liver was normal.  After another week of medication, the acne disappeared and edema of lip mucosa gradually subsided.  No other discomfort was found.  Another week of TCM therapy was administered and then he stopped the medication.

Case 2-4:

Huang – (computer no. 3840) female, age 5 yrs.

First visit: 7^th March 2004.  Her grandmother died of cirrhosis of liver.  When she was 4 years old, she suffered from repeated abdominal pain and was diagnosed as appendicitis and so operation was performed.  Postoperatively, her appetite was poor and she had frequent abdominal distension and pain, wetness-heat stools, repeated vomiting and poor sleeping.  Physical examination revealed edema and desquamation of lip mucosa, distension of abdomen, a slant incision mark on skin of right lower abdomen and a hepatomegaly of 3 cm.  After taking 3 parcels of TCM drugs, the mother came saying that the patient had nasal obstruction, poor sleeping and loose stools.  She took 4 parcels of drugs.  After the medication, the patient’s abdominal distension alleviated and her bowl movements were more smooth, being once a day.  She slept well but dreamful and her liver returned to normal.  A total 4 weeks of TCM drugs were taken and clinical cure was achieved.  During the course of treatment, she farted frequently with stinking smell; the stools were loose, dark in color, 1-3 times a day, but gradually it became normal in shape and once a day.  She had no abdominal distension and pain and she slept well.

Physician’s comment:

The patient had the typical gastrointestinal wetness-heat symptoms of “chronic hepatitis” and it is not difficult to find from the history that her gastrointestinal wetness-heat symptoms were rather obstinate.  The diagnosis of appendicitis and its operative treatment is not under evaluation in our article, but at least, it can be ascertained that the operation was not able to cure the disease from the fundamental.  Furthermore, it did not relieve the clinical symptoms such as repeated vomiting, abdominal distension and pain and abnormal stools.  Clinical cure and disappearance of symptoms were accomplished only after thorough TCM therapy.

Chan – (computer no. 3474) female, age 9 yrs

First visit: 12^th July 2003.  Her father was a carrier of type B hepatitis virus.  The child’s complaint was substituted by the mother who said that the patient had repeated intestinal pain, poor appetite, dysuria, hard stools and often bleeding from anal fissure following defecation since infancy.  The patient also experienced repeated aphthae which caused difficult swallowing; she slept badly and dreamfully.  She had enuresis, nocturia and difficulty in enduring a distended bladder so that her panties got wet easily.  Physical examination: lean, pale looking, tongue, thin white coating at posterior part, hepatomegaly of 1.5 cm.  After taking 3 parcels of TCM drugs, the aphthae healed up; tongue coating clean, urination smooth and liver normal.  TCM treatment continued; she had no more abdominal pain and her bowl movements were smooth, the stools in shape.  After 2 weeks medication, the tongue coating detached completely, the tip of tongue was red, the stools not hard and in rod shape.  Her urination was smooth, but her panties were wet occasionally and nocturia reduced to 0-1 time a night.  During treatment, she had incontinence of urination occasionally, but nocturnal enuresis ceased.  Aphthae occurred occasionally and the stools were loose.  TCM drugs were taken for 4 weeks totally and clinical cure was obtained.

Physician’s comment:

This patient had typical symptoms of the gastrointestinal wetness-heat form of “chronic hepatitis” associated with lower–jiao wetness-heat.  In the latter condition, the mucosal tissues of the genitourinary system show viral inflammation in which can induce respective urinary symptoms or vulvitis.  TCM therapy given in time may accomplish clinical cure.

Case 2-6:

Wong – (computer no. 3580) female, age 12 yrs.

First visit: 2^nd October 2003.  The girl took soy beam milk 15 days ago, after that she had vomiting and diarrhea.  She was given anti-diarrhea drugs but she still had vomiting repeatedly and also gastric distension and poor sleeping.  One week after the onset of illness, she was admitted to a local hospital.  She had fluid infusion for 2 days and was then discharged.  She vomited after in take of food recently.  Her menstruation was frequently delayed, the color of blood deep red, with many clots.  The last menstrual period was half a month ago and she had occasional dysmenorrhea.

Physical examination: poor nourishment and under developed, lean, long limbs, hary lower extremities, edema of lip mucosa, tongue enlarged with teeth prints and thin white coating, hepatomegaly of 3 cm.  After taking 3 parcels of TCM drugs, gastric distension and vomiting disappeared.  She had short time diarrhea and she passed loose stools twice a day.  Sleeping was well and the liver became normal.  TCM drugs were taken for another week by which time the edema of lip mucosa subsided; she did not vomit but her appetite was still not so good.  Her bowl movements were normal, being once daily.  TCM therapy continued for 6 weeks, after which she was cured clinically and was followed up.

Physician’s comment:

The patient had gastrointestinal wetness-heat symptoms induced by virus gastroenteritis.  Despite WM treatment and fluid infusion in hospital, she was not cured.  According to her history, symptoms and physical signs, one should consider wetness-heat of chronic hepatitis.  The patient in this case was poorly nourished and underdeveloped, thin, had long limbs and hairy lower extremities (due to decrease of female sex hormones) and the association of lip mucosal edema, enlarged tongue with teeth prints and thin white coating and hepatomegaly of 3 cm.  The impression of hepatophilic virus disease is reasonable.  On the administration of TCM drugs, the symptoms disappeared and clinical cure was obtained.  Systemic treatment was of advantage to the improvement of liver function and therefore, helped to correct her sexual hormone disorder and to regulate her menstruation.

Case 2-7:

Gao – (computer no. 2422) male, age 7 yrs.

First visit: 21^st March 2001.  His parents suffered from chronic active hepatitis.  His complaint was substituted by his father, saying that the child had repeated common cold for a long time and had been operated for congenital urethral stricture, but after the operation, he still suffered from unsmooth urination and yellowish urine with occasional tea like color.  The tongue coating was white and thick in the centre and the hepatomegaly was of 3 cm.  After taking 3 parcels of TCM drugs, the liver was normal.  He did not feel any discomfort and the stools were loose, being twice a day.  There was still thin whitish coating at the centre of tongue.  Another 4 parcels were taken but there was still wetness-heat stools, being 1-3 times a day.  The tongue coating had detached and the liver normal.  Two weeks later, he stopped the medication for 2 days because of common cold.  His expectoration was abundant.  Another week of TCM drugs was given and the child’s bowl movements were 3-4 times a day, his urination was smooth, color of urine clear and the amount was large.  He had no more cough, his appetite good and sleeping was well.  He continued to take another week of TCM drugs, making a total of 4 weeks of systemic therapy.  The patient was followed up.  Two weeks later, a return visit was made.  The patient was found to have slightly thin white tongue coating, good appetite, smooth urination, normal stools and the liver was also normal.

Physician’s comment:

The patient had liver stagnation and lung dryness and wetness-heat of lower-jiao since infancy.  His repeated exopathic symptoms were in fact manifestations of liver stagnation and lung dryness.  The postoperative urination should be smooth and the reason that it was not was due to wetness-heat of lower-jiaofrom chronic hepatitis.  Therefore, he suffered from prolonged unsmooth urination, voiding of yellowish or even tea-like urine with frequent interruption.  Systemic TCM therapy was administered and after 3 parcels of TCM drugs, the liver was normal, the wetness-heat of stomache, intestines and lower-jiao was gradually expelled and clinical cure was achieved after 4 weeks of therapy.

Case 2-8:

Lau – (computer no. 3691) female, age 14 yrs.

First visit: 25^th December 2003.  Her father was a carrier of type B hepatitis virus and had abnormal liver function.  Her mother had a history of type A hepatitis. She had repeated gastrointestinal discomfort and abdominal distension since infancy.  She had also frequent constipation (once in 2-3 days), the stools hard and in the shape of lumps.  She frequently suffered from common cold and cough.  Menarche came at the age of 10 and thereafter, she had irregular menstruation and in one episode the menstrual blood persisted for nearly a month.  Her left ear lost hearing ability since infancy but examination by specialist did not reveal abnormality.  Physical examination: nutritional state and development satisfactory, forehead showing red macules and multiple acne, abdomen distended, hepatomegaly of 1.5 cm.

After taking 3 parcels of TCM drugs, her bowl movements were smooth and of large amount; the liver was normal.  After another 3 parcels, she still had abdominal distension and pain, poor appetite and large amounts of loose stools; she also had chilliness, sleepiness and fatigue.  She was given another five parcels, at which time she experienced gastric discomfort, nausea poor appetite, scanty amount of stools, nasal discharge, scanty expectoration, insomnia and pain of upper thigh.  The liver was still normal.  At the 10^th day of drug administration, menstruation appeared, it was normal, without pain and blood clots and persisted for 7 days associated with poor appetite and gastric discomfort.

TCM drugs were continued for 4 weeks, during which time, she had occasional abdominal distension and pain, scanty stools, tenesmus, nasal discharge, abundant expectoration, shortness of breath which required deep breathing, coldness of limbs, poor appetite, small amount of food intake, fatigue, paroxysmal abdominal pain but acne disappeared and sleeping was well.  TCM drugs were taken for 6 weeks altogether, and clinical cure was obtained.  The patient was followed up.

Since infancy, the patient had liver stagnation, lung dryness and heat of large intestines (common cold, cough, constipation, hard stools) and repeated gastrointestinal wetness-heat of “chronic hepatitis” (gastrointestinal discomfort, abdominal distension, suppressive sensation on stomache, nausea, poor appetite, paroxysmal abdominal pain) and dermal wetness-heat (dermal erythema of face, acne) symptoms.

Female pediatric patients at the post-adolescent period are prone to develop menstrual disorders, leading to symptoms of deficiency of qi and blood.  (In this case, there were menstrual disorder, menorrhagia, prolonged menstrual bleeding, dysmenorrhea, fatigue, insomnia, coldness of limbs, vertigo).  Therefore, in female pediatric patients with chronic hepatitis, it is important to pay attention to early diagnosis and to give timely TCM treatment.  If early diagnosis and treatment is neglected, the patient is prone to develop liver disease complications like sexual hormone disorder and anemia at the post-adolescent period and these conditions would affect development and body constitution seriously.  In this case, after treatment of the liver disease, the patient still suffered from prolonged menstruation which was examined to be caused by progesterone deficiency and drugs were given to control the bleeding.

Case 2-9:

Zhang – (computer no. 4240) male, age 9 yrs.

First visit: 16^th October 2004.  His mother had history of carrier of type A and B hepatitis virus.  The patient was fat and short in height since infancy; his height was 1.29 m, weight 38.5 kg, BMI = 23.2 (normal 15).  The mother said that her child suffered from prolonged nasal hypersensitivity, fatigue, sleepiness and occasional cough.  Recently he had belching, repeated desquamation of lips, post-auricular dermal itching and erosion.  There were eczema on the back and oral ulcers.  The patient stature was fat and short; his lips showed fissures and erosion; the lower limbs showed slight pitting edema; the abdomen was highly distended; development of genital organs satisfactory, the penis circumcised and hepatomegaly was of 3 cm.

After taking 3 parcels of TCM drugs, the regurgitation ceased but belching, occasional cough and lip desquamation was present.  Edema of lower extremities subsided, splenic dullness was present and the liver was normal.  Another 3 parcels were taken, the belching and coughing ceased; sleeping was well, there was no sputum, but headache was present.  Bowl movements were once a day, the stools hard.  Splenic dullness was not detected and the liver was still normal.  TCM drugs were continued, fissuring of lip mucosa decreased and the post-auricular dermal eczema or eruptions completely disappeared.  The stools were passed smoothly at times, being loose and of the wetness-heat character.  A total of 6 weeks TCM therapy was administered and clinical cure was achieved.  The patient was followed up.

This pediatric patient possessed typical symptoms of liver stagnation and lung dryness and wetness-heat vaporization forms of “chronic hepatitis” including gastrointestinal wetness-heat, viral lip mucosal pathologic changes and dermal wetness-heat leading to chronic generalized eczema and secondary obesity.  It was fortunate that the patient responded well to the TCM therapy and the liver was normal after 3 parcels of TCM drugs.  All of the symptoms disappeared rapidly and the eczema was well in two weeks.