03 Hepatogenic “edema” is not “obesity” (One of the common syndromes of “deficiency of blood and weakness of qi “

Preface

Not a few people think themselves “obese”, but they do not know in fact it is hepatic edema.  Because hepatic edema can cause progressive increase of body weight and body figure, so, often times it is erroneously considered as “obesity”.  Actually, many people confuse hepatic edema with “obesity”, and many are misled to adopt incorrect therapeutic measures, for example, abatement of weight can contrarily aggravate edema or even cause “anorexia” which may seriously affect one’s health.

Edema is essentially different from simple obesity.  From the TCM point of view the concept that “nine out of ten obese individuals belong to the category of wetness” is extremely correct.  Edema is also called water puffiness, it is due to excessive fluid retained in the skin and subcutaneous tissues (including spaces in extra-vascular tissues); weighing the body at regular intervals let one know the degree of edema.

Usually, the appearance of edema of face and mild edema of lower limbs indicates that the body weight has already increased 5%.  If edema in these places is marked and pitting edema is present (use the finger to press on the skin over tibial region with persistent mild force, and a pit can be seen when the finger is released) and if the trunk is also edematous, the body weight may have increased about 10%.  What are the causes of edema?  There are many causes, for example, nutritional, endocrine disease, water and electrolyte imbalance, drug allergy or intoxication.  According to the chief causes, one may differentiate, clinically, cardiac edema, hepatic edema, renal edema or nutritional edema.  The following is concerned with hepatic edema, our understanding about which offers to the public for the purpose of reference.

Hepatic edema is very common but, at the same time, easily neglected by patients and physicians.  According to clinical observation, the causes of hepatic edema are many and complicated.  The main reason is that in patients with liver disease, the concentration of retained “antigen-antibody compound” in the body increases as time passes by, leading to the accumulation of inflammatory exudates in tissue spaces and subsequently, formation of hepatic edema.

It is not difficult to justify oneself the existence of hepatic edema or not.   The following questions may be asked :

•  Is there a family history of liver disease?
• Am I confirmed in having liver disease?
• Is there hepatomegaly (including fatly liver) ?
• Are there repeated manifestations of clinical symptoms of TCM chronic hepatitis classification and extra-hepatic disease ?
• Is there acute or slow but significant progressive increase of body weight?
• Is there the presence of enlarged tongue with teeth prints, marked increase of abdominal circumference or pitting mask over pretibial region by pressure?

The answers to the above questions can tell you whether you have hepatic edema or not.

Some people consider themselves “obese” but in fact they are having hepatic edema.  Our research centre received 2883 patients with abnormal margin of hepatic dullness in Hong Kong. Among these cases, 952 had various degrees of hepatic edema, occupying 33% (proportion of male to female is 238 : 75) male 23%, female 38.5%.  From the statistics, it can be seen that in Hong Kong, where the incidence of liver disease is high, hepatic edema is extremely common.  In all of the cases, about ¹/₃ have various degrees of edema clinically, and in females with abnormal margin of hepatic dullness, about 40% have hepatic edema, significantly higher than the male 23.19%.  This is related to the high proportion of deficiency of both qi and blood form in female chronic hepatitis patients and it indicates that hepatic edema is closely related to deficiency of qi and blood and also to anemia.

In the above paragraphs, we have mentioned that hepatophilic virus disease is a disease in which the patient presents abnormality of hepatic dullness, clinical chronic hepatitis conditions showing obstinate, repeated, alternating and multiple systemic symptoms and various diseases induced by acute and chronic damage of liver function.  Therefore, it also includes hepatophilic virus infection induced hepatic edema which is caused by “deficiency of qi and weakness of blood”, dysfunction of nutrition and absorption, malnutrition, anemia, hypo-protinemia, endocrine disorders, vitamin deficiency (such as wet beriberi caused by deficiency of vitamin B1).

In fact, hepatogenic edema, hepatic secondary obesity, and fatty liver all are complications and sequelae of hepatophilic virus disease.  It is when the course of chronic hepatitis has entered a comparatively serious stage that hepatic edema would appear clinically.  If the condition is not treated by systemic TCM therapy, the degree of edema deepens day by day and it may induce cirrhotic ascites, dysfunction of the heart and lungs or even carcinoma of liver; the latter would often be discovered too late.  The former condition is difficult to treat but is still reversible.  So, hepatogenic edema is not “obesity” and one should not go after reducing fat blindly.

From the viewpoint of TCM, “nine out of ten obese individuals suffer from wetness” and this concept is very correct.  There is a basic difference between hepatic edema and simple obesity; one must correctly differentiate what is edema and what is obesity.  One should not think oneself obese on sheer assumption and take fat reducing measures blindly.  If patients with hepatic edema reduce food intake, limit protein ingestion and increase exercise amount which leads to consumption of body energy, or, for the purpose of reducing fat, even take drugs that damage the liver, the hepatic function would be markedly impaired and the liver disease greatly exacerbated.

Hepatic edema is not simple obesity caused by over nutrition; it cannot be cured by reducing fat.  The edema can be eliminated only by treating the liver disease, that is, by the use of effective TCM therapy.  The extended margin of liver dullness can return to normal after several days of treatment and the continuation of therapy can further induce significant regression of edema.  We therefore suggest that before taking fat reduction measures, one must make clear that the edema is not caused by liver disease.  If hepatophilic virus disease can be detected early and is known to have developed hepatic edema and secondary obesity, TCM and WM therapy should be undertaken in time.  In this way, the patient can avoid prolonged suffering from various systemic symptoms of chronic hepatitis and can stop the persistence of edema and secondary obesity and can also keep the body in a healthy condition and prevent progression of the liver disease into cirrhosis or carcinoma.

Cause of hepatic edema

Chromic virus hepatitis produces hepatic edema caused by attack of infections hepatophilic virus which induces a series of immunologic reactions in the body.  Because of disorder of immunologic regulative ability, endotoxemia and microcirculatory dysfunction, the liver cells are damaged liver function is impaired.  Abnormal liver function can lead to regression of function of various systems of the body.  The causes usually are:

(1)           Hepatitis causes symptoms of gastrointestinal disturbance (such as anorexia, nausea, abdominal distention stomache ache, wetness-heat abdominal pain, gastro-intestinal hypersensitivity, constipation, diarrhea). It often affects the patient’s appetite and nutritional absorption.  So, in chronic hepatitis, edema due to malnutrition is frequently encountered.

(2)           Defect in protein synthesis (especially in albumin synthesis): Although the daily protein intake and absorption is normal, but if there is decreased synthetic ability of protein in the liver, the plasma albumin level would be low and also the plasma colloidal permeability is lowered so that mal-nutritional edema is likely to occur.  (Lowering of plasma albumin is of diagnostic value, and 2.5% is considered as marginal level.  In severe edema, the plasma albumin is usually below 2 g %).

(3)           Hepatic coagulopathy: Liver participates with many coagulative functions of the body; besides vitamin K, it can also synthesize fibrinogen and thrombin.  Decrease of hepatic function can affect the coagulation of blood and is likely to cause various kinds of acute or chronic bleeding.  Clinically, the conditions often seen are subcutaneous ecchymosis (皮下瘀斑), hematochezia, epistaxis, hemorrhoidal bleeding, and, especially in female chronic hepatitis patients, irregular menstruation, menorrhagia, prolonged bleeding periods, dark color blood with numerous blood clots and repeated dysmenorrhea.

During delivery, the bleeding is profuse and in operation or trauma, the blood loss is particularly excessive.  Edema caused by repeated and prolonged chronic blood loss is a fact frequently encountered.

(4)           Endocrine disorder: Liver is the target organ of many important hormones and is also the main site of hormone degradation, interchange, transformation, storage and excretion.  Liver can synthesize sodium excretion factor, angiotensinogen (血管緊張素原) and erythropoietinogen (促紅細胞生成素原) and therefore it is also an endocrine organ.  So, in hepatitis, hormonal disturbance is frequently induced, for example, hypothyroidism leads to myxedema (粘液水腫) and also, there may exist a rise of growth hormone and insulin.  Pancreatic glucagonemia causes hepatogenic diabetes or hypoglycemia.  At this time, the patient tends to be hungry easily and eat too much with the result of developing secondary obesity.

Hyperestrogenemia and decrease of male hormone can be frequently seen in hepatic disease.   A small number of male patients have breast development and feminine figure.  If there is decrease of male sexual function in childhood, the patient tends to become fat and the external genital organ would also show significant underdevelopment.

(5)           Abuse of hormones : The patient, because of long term extra-hepatic complications (such as asthma, german measles, eczema, osteal arthritic diseases like gout or erythematosus) used drugs like corticosteroids or sex hormones improperly (such as in treatment of infertility).  In addition, before or after climacteric in male or female, it can also cause, in a short time, retention of water and sodium and subsequently induces edema, obesity and significant increase of body weight.

(6)           Deficiency of B group vitamins: When there is dysfunction of liver, the patient’s thiamine acidifying ability decrease, the usage of vitamins B1 is interfered, the oxidative decarboxylation of pyruvic acid is impaired, so that the oxygenation process of glucose is affected.  Further more, it affects the energy supply of nerve cells, leading to accumulation of pyruvic acid lactic acid in nerve tissues and subsequently, to multiple peripheral neuritis (多發性周圍神經炎) and wet beriberi (濕性腳氣) which produces edema.

In addition, some drugs may damage the liver and electrical therapy or chemotherapy may impair liver function and in such conditions, the patient’s edema may be aggravated.  In clinical practice, it is often observed that long term administration of diuretics does not show marked effect in elimination of edema, but when TCM therapy is used, the edema regresses significantly or even completely disappears.

Case 1

Run (code number 2027) female, age 32 years.  First visit: December 1999.  She complained of suffering from acute nephritis when she was 10 years old and it was finally cured.  In the recent 5 years, she had edema which was more masked in the lower limbs.  She received repeated TCM and WH treatment with no effectiveness.  She had many times of physical examination and laboratory examination which ruled out cardiac and renal edema.  Some physicians diagnosed it as endocrine disorder, but still the cause of edema was not clarified.  At the onset of edema, she felt distensive pain in the lower limbs and afterwards, for a long period, she experienced tiredness, dreamfulness, poor sleeping, headache, abdominal distention, constipation and her body weight increased from 110 lbs to 130 lbs.  She had irregular menstruation the amount of which was large with many blood clots and she occasionally had dysmenorrhea.

Physical examination: fissured tongue with red tip, medial furrow and white coating, face flushing, abdomen depressed without ascites, shrinkage of area of percussion dullness, liver lower margin 4.5 cm. above costal margin (3 finger breath above coastal margin), lower limbs with (+++) pitting edema more marked over dorsal surface of both feet, the latter showing extremely thin dorsal skin with transparency.  (She brought her 1997 blood and urine examination reports, liver and spleen computer scan, chest and reprography x-ray film, but these did not reveal any abnormality ).

After taking 3 parcels of TCM drugs, shrinkage of liver dullness disappeared and through percussion the liver was actually enlarged to 1.5 cm with percussion tenderness.  Another 4 parcels were taken and the liver was normal.  She was treated afterwards by systemic TCM therapy and the edema gradually subsided, the clinical symptoms disappeared.  She received TCM therapy for about 3 months and the edema of the lower limbs disappeared completely.  Treatment was stopped after clinical cure and the patient was followed up.

Chan (code number 2832) female, age 67 years.  Her first visit was on March 26, 2002 with the complaint of repeated abnormal sensation of lower limbs which included numbness, soreness, formication (蟻走感), burning heat sensation and paroxysmal pain of right gastronomies muscle.  The latter condition caused persistent pain for two months with functional disability two years ago.  Now the pain persisted for two more weeks and severe calf pain and fatigue attacked her for several days.  Physical examination: haggard, puffy, flushing of face, tongue enlarged, lower limbs edema (+++), gastrocnemius muscle no significant tenderness, abdomen soft and distended, hepatomegaly of 1.5 cm.

After taking two parcels of TCM drugs, she had diarrhea, bowel movements 3 times in one hour amount large and stinking.  When 3 parcels had been taken, edema of the lower limbs nearly disappeared and pitting edema was (+).  The tongue was still enlarged but the liver was normal.  Another week of TCM treatment gave her no pain in walking.  In the course of treatment, she had occasional insomnia, fatigue, headache, acid regurgitation, stomache distention after meal and drawing pain of the diseased leg in walking.  When going upstairs, pain was felt over the right gastroenemius muscle and in the third week of treatment, the right angle of lips showed vesicular eruptions.  The symptoms disappeared when TCM treatment was going on.  After 6 weeks of systemic TCM therapy, clinical cure was obtained and treatment was stopped for observation.

Yang  (code number 2769) male, age 45 years.  First visit: January, 2002.

He complained of being a carrier of type B hepatitis virus for ten more years and he had a history of asthma in childhood.  Twenty years ago, he had gastric hemorrhage and now he still felt upper abdominal distention and belching whether hungry or full.  Gastroscopy revealed no abnormality.  In recent years, he often experienced photophobia, dermal pruritus, fatigue, edema of lower limbs and early whiteness of hair which was dyed.

Physical examination: skin color dark, puffy, lips edematous with fissuring,  After taking 3 parcels of TCM drugs, gastric discomfort was relieved; belching and flatulence stopped and the liver was normal.  During the administration of TCM drugs, he experienced dryness of eyes, fatigue, sleepiness, dreamfulness, yellowish urine with foam, repeated belching, occasional diarrhea and pain of hypochondria (脅痛); edema of lower limbs disappeared.  A total of 42 parcels of TCM drugs were taken, at the end of which clinical cure was attained.  After that, he was followed up.

Lin (code number 2341) female, age 63 years.  She first visited the clinic in January 2001 with the complaint of having fatigue, discomfort of heart, shortness of breath, itching of throat, coughing, shoulder and loin pain and insomnia for ten more years.  Repeated drug treatment was not effective.  She received hysterectomy (子宮切除) because of uterine myoma (宮肌瘤) ten more years ago.

Physical examination: puffy, skin palish yellow, tongue enlarged with medial fissure, tympanitic frog like abdomen, hepatomegaly of 1.5 cm, percussion tenderness over hepatic region, edema of lower extremities, pretibial pitting edema (+).

After taking 3 parcels of TCM drugs, the liver returned to normal.  Her sleeping could last for five hours, but she still had mild vertigo and shortness of breath.  One week later, the edema improved and fatigue disappeared.  She had some itching of throat, occasional cough with abundant sputum and her sleeping was good.  Mild vertigo occurred after waking up in the morning.  She had bowel movement once in several days; the stools were hard.  Blood pressure: ¹¹⁰/₇₀ mmHg.  The tongue was enlarged and liver normal.  Edema of lower extremities disappeared.  For the treatment of shoulder and loin pain caused by hepatic osteal malnutrition, she was given TCM therapy for nearly three months.

Published on 20th June 2002

Translated by Professor Zheng in December 2004