The patient Lee (code number 292) mentioned in the previous article, had hepatophilic virus disease, presenting wetness-heat vaporization, deficiency of blood and energy and blockage of channels and stasis of blood. She was followed up for 8 more years and had numerous return visits. Up to the present, her hepatomegaly relapsed for thirteen times, in which the eighth episode was on May, 1997 when she was hospitalized by emergency because of acute pain at the back of the sternum and left side of the chest. She was observed for 3 days in hospital and diagnosed as acute pneumonia and acute pleuritis, but EKG and chest X-ray did not reveal any significant abnormality and she had no ascribable symptoms nor fever. So she was discharged from the hospital and came to our clinic when her chest pain was somewhat relieved. She told us that she had left side chest pain, loss of appetite, nausea, belching, distensive pain of abdomen and wetness-heat stools.
Physical examination revealed distention and tympanites of abdomen as well as hepatomegaly of 3 cm. The primary diagnosis was gastro-esophageal regurgitation causing esophagogenic chest pain (that is obstructive globus hystericus of TCM). After 5 parcels of TCM drugs, the liver retracted to costal margin, but pain was still present at the back of left chest although the severity had markedly gone down. Her skin was still palish yellow and she felt tired and her sleeping was not satisfactory. Another 5 parcels of TCM drugs were taken and the margin of liver dullness became normal. There was only some vague pain in the left hypochondrium and wetness-heat of stools. Three weeks later, the pain in the chest and hypochondrium disappeared. TCM drugs were given to complete the systemic treatment, after which clinical cure was obtained.
In fact, when gastro-esophageal regurgitative disease occurs in chronic liver disease patients, it is called “gastro-esophageal regurgitation disease” which includes regurgitant esophagitis, ulceration formation of esophagus and esophageal hiatal hernia. This disease is often caused by abnormal sphincter control of lower portion of esophagus, immense tympanites, cirrhotic ascites and pressure on esophagus by left cardiac hypertrophy. Hepatophilic virus disease patients have marked increase of hepatic volume due to inflammatory edema and cloudy swelling of liver cells. Clinically, it is not rare that the lower margin of liver dullness extends inferiorly as much as 4.5 cm and because the liver is a solid organ, its increase in three dimensions together with its weight can occupy a large space in the abdominal cavity.
Further more, stasis of blood from portal hypertension leads to congestion of gastrointestinal mucosa and lowering down o f peristalsis so that fermentation of intestinal contents is promoted and a high degree of tympanites can be produced. The presence of ascites in cirrhosis of liver, in turn, causes significant rise of intro-abdominal pressure and therefore, gastric contents may easily regurgitate into the esophageal mucosa in which inflammation, erosion and ulceration can be produced. The clinical symptoms are often burning pain or discomfort at the back of sternum, especially marked when lying flat; other symptoms that may occur are unsmooth passing down of food or difficulty or even pain in swallowing. Occasionally, vigorous chest pain may occur (like angina pectoris), and is called “esophagogenic chest pain” (that is obstructive globus hystericus of TCM). But, in hepatophilic virus hepatitis complicated by cranial nerve invalvement, if the glosso-pharyngeal nerve is affected, the patient may show suffocating cough in drinking and unsmoothness or difficulty in swallowing. In the following, we introduce one more typical case of “obstructive globus hystericus”. Before confirmed as chronic virus hepatitis, this case had already shown typical symptoms of Hepatophilic virus disease and repeated episodes of globus hystericus.
| Case 3
Wan (code number 673), female, age 38 years, married. Her first visit was on May, 1991 when she complained of repeated attacks of common cold and also she often had a felling of something obstructing in the chest together with the sensation of a foreign body in the pharynx which could not be coughed out nor swallowed down. There was no sputum in coughing and she often felt abdominal distention and nausea. In physical examination, the liver was found enlarged to costal margin with definite percussion tenderness over hepatic region and so, it was diagnosed as Hepatophilic virus disease, liver stagnation and lung dryness form complicated by globus hystericus. The clinical symptoms disappeared after some period of TCM treatment. In 1993, she had a return visit complaining of insomnia and bleeding form hemorrhoids. She had a blood examination which showed that she was a carrier of hepatitis type B virus. Ultrasonography revealed hepatomegaly of 3 cm and diagnosis was confirmed as type B hepatitis. She was treated intermittently with TCM drugs, but she still had repeated enlargement of liver, globus hystericus, gastrointestinal wetness-heat and symptoms of exopathy. (at that time, the attending physician had not yet established the concept of 4-6 weeks of systemic treatment and the time of TCM treatment was determined at random by the patient herself). A return visit was made in April 1997 when she complained of distensive pain of the stomache together with globus hystericus and chest pain, on account of which gastroscopy was performed with the result of positive pylorus bacteria. A course of antibiotic treatment was given but she still felt abdominal distention and pain, nausea, acid regurgitation and marked sensation of globus hystericus that forced her to make the return visit. Physical examination revealed abnormal margin of liver dullness and hepatomegaly to the costal margin. After systemic TCM treatment for 2 weeks, the liver recovered to normal and clinical symptoms disappeared. Systemic treatment was stopped after 4 weeks of drug administration, at the end of which clinical cure was obtained. She was followed up and there was no relapse up to the present. |
Written by WONG Kwok Hung
published on 26th June 2001
(translated by Professor ZHENG Hua En in December 2002)