02 Hepatogenic Anemia One of the common symptoms of “Deficiency of blood and weakness of qi”

“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 re-examined 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.

Elder 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.
Younger 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.

General knowledge about liver disease

 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.