Constipation

//Western Diagnosis// difficult or infrequent bowel movements a symptom not a disease stools too hard, too small, infrequent, difficult to expel, feeling of incomplete evacuation

Signs & Symptoms
1. 3-5 stools per week 2. more than 3 days without stool 3. weight less than 35gm

Etiology
1. obstruction 2. drugs 3. tumors 4. functional disorders a. IBS, hypothyroidism 5. psychological

Complications
1. hemorrhoids 2. diverticulosis 3. colon CA

Treatment
1. hydration, fiber, allergies, exercise 2. psyllium 3. abdominal massage 4. Magnesium, vitamin C

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Constipation (Bìan Bì)
Difficult and/or infrequent defecation. Includes conditions where stool is hard and dry, or where stool quality is normal and there is a desire to defecate but evacuation is difficult and requires significant straining; may also manifest with sluggish or incomplete bowel movements. Constipation primarily involves impairment of the Large Intestines ability to transport and guide turbidity downwards. However, dysfunction of the Spleen, Stomach, Lung, Liver, and Kidney can also lead to constipation.

Relevant Biomedical Diseases
-Habitual constipation -Atonic constipation -Spastic constipation -Intestinal neurosis -Irritable Bowel Syndrome -Bowel obstruction -Intestinal tumor -Perianal perforation and infection (fissure or fistula) -Hemorrhoids -Side-effect of medication -Chronic laxative use

TCM Etiology and Pathology
Essentially comes down to two things: “Lack of water to float the boat” = body fluid, Blood, or Yin vacuity. Wu Ju Tong, in his book Differentiation of Warm Diseases, says: “When fluids are deficient there is not enough water to make the boat move.” [often following a warm pathogen disease] “Lack of force to move the boat” = Qi or Yang Qi vacuity.

Accumulated Heat consuming body fluids in the stomach and intestines (pathology) caused by: 1. Diet: excessive consumption of alcohol, spicy foods 2. Pungent and hot drugs/herbs 3. Constitutional yang excess 4. Febrile diseases -> Heat shifting downward to the intestines 5. Qi stag. -> Heat in ST and LI

Qi stagnation (pathology) caused by: 1. Emotional stress (sorrow, sadness, pensiveness, depression, anger) -> deficiency or stagnation of Qi 2. Physical inactivity -> stagnation of Qi in the intestines 3. Failure of Lung Qi to descend

Deficiency of Qi, Blood, Yin and Essence (pathology) caused by: 1. Childbirth and loss of blood 2, Overwork 3. Aging 4. Chronic illness (constipation with medium stool)

Yang vacuity with Cold stagnation (pathology) caused by: 1. Excessive consumption of raw and cold food 2. Bitter and cold drugs/herbs 3.Constitutional yang vacuity 4.Aging 5.Chronic illness -> impaired flow of body fluids in intestines due to cold stagnation (via qi stagnation) 6.Direct attack of pathogenic Cold

Pathogenesis
-Heat in the Stomach channel of foot Yangming -> intestinal Heat (the Large Intestine channel of hand Yangming is functionally related to the Stomach within the Six channel schema)

-Stagnation of Qi -> Qi is stuck, so cannot move; also causes impairment of body fluids due to depressive Heat or Fire

-Spleen Qi vacuity -> not enough Qi to move

-Blood, Yin, Essence vacuity -> insufficient body fluids to moisten LI -> dryness and difficult passage of stool

-Kidney Yang vacuity -> Cold “congeals” Yang Qi leading to poor fluid distribution and difficulty in LI’s ability to transmit stool

Identification of Types of Constipation
-**Dry, hard stool**, infrequent and difficult defecation, accompanied by a red face, fever, bad breath, mouth sores, dark scanty urine, dry yellow tongue coating, and a forceful slippery pulse = Heat

-**No significant alteration in the quality of stool** (though it can be hard if Qi stagnation has generated Heat), **stool sometimes can be thinner than normal, incomplete or sluggish defecation**, belching, distention in the chest and hypochondrium, distending abdominal pain, a thin greasy, coating and a wiry pulse = Qi stagnation

-Normal desire for defecation, ineffective straining to force bowel movements, great effort and prolonged time required for defecation, **stools generally not dry or hard**, a pale complexion, fatigue, spontaneous sweating and shortness of breath, thin tongue coating, vacuous pulse = Qi vacuity

-**Dry pebble-like stool** that is difficult to evacuate, pale complexion, palpitations, dizziness, a pale tongue, and a thin or choppy pulse = Blood vacuity

-**Dry pebble-like stool** that is difficult to evacuate, malar flush, dizziness, vertigo, thirst with desire for sips of water, night sweats, palpitations, soreness and weakness of the lower back and knees, emaciation, red tongue with little or no coat, fine and rapid pulse = Yin vacuity

-**Stools generally neither dry or hard**, difficult and sluggish defecation requiring great effort, cold limbs and/or general cold intolerance, copious clear urine, a moist white tongue coating, and a deep, slow pulse = Yang vacuity

Heat Accumulating in the Large Intestine and Stomach
Ma Zi Ren (20g), Da Huang (10g.), Xing Ren (10g.), Bai Shao Yao (10g.), Zhi Shi (10g.), Hou Po (10g.)]
 * Signs:** dry stool with difficult, infrequent defecation, dark scanty urine, [urinary frequency w/ ST heat]
 * Symptoms:** abdominal distention or pain that increases with pressure, red complexion, sensation of heat, dry mouth, halitosis, or even ulcerations in the mouth
 * Tongue:** red with a dry yellow coating
 * Pulse:** slippery, rapid
 * Treatment Principle:** Clear Heat, moisten the intestines, and promote bowel movement
 * Acupuncture Treatment:** [ST-25, BL-25, SP-15, TB-6, KI-6] + LI-11, LI-4, ST-44
 * Herbal Treatment:** Ma Zi Ren Wan

Qi Stagnation
Liu Mo Tang: Mu Xiang (10g.), Wu Yao (10g.), Chen Xiang (3g.), Da Huang (10g.), Bing Lang (10g.), Zhi Shi (10g.)]
 * Signs:** constipation with a desire for defecation, well-formed stool (not necessarily dry) which is hesitant and difficult to push out
 * Symptoms:** frequent sighting, fullness and distention in the chest and hypochondrium, distention and pain in the abdomen, irritability
 * Tongue:** thin, greasy coating
 * Pulse:** wiry
 * Treatment Principle:** Course the Liver, regulate Qi,eliminate stagnation
 * Acupuncture Treatment:** [ST-25, BL-25, SP-15, TB-6, KI-6] + CV-12, LV-3, CV-6
 * Herbal Treatment:** Liu Mo Tang (Six Ground-Herbs Decoction) OR Xiao Chai Hu Tang/Da Chai Hu Tang

Qi Vacuity
Huang Qi (20g.), Huo Ma Ren (15g.), Feng Mi (12g.), Chen Pi (12g.)] Hypertension w/ concerns of Huang Qi's ascendant quality: + Huang Qin, Xia Ku Cao, Zhi Shi, Zhi Ke, Niu Xi
 * Signs:** difficult defecation despite the need to move the bowels, stools are neither particularly hard nor dry, possible feeling of fatigue after bowel movement
 * Symptoms:** bright-white or pale complexion, spirit fatigue/listlessness, disinclination to speak, shortness of breath, spontaneous perspiration
 * Tongue:** pale and tender with a thin white coating
 * Pulse:** weak pulse
 * Treatment Principle:** Boost Qi, promote bowel movement
 * Acupuncture Treatment:** [ST-25, BL-25, SP-15, TB-6, KI-6] + ST-36, SP-6, CV-4, BL-20
 * Herbal Treatment:** Huang Qi Tang (Astragalus Decoction)
 * Modifications:**

Blood Vacuity
Sheng Di Huang (20g.), Dang Gui (15g.), Tao Ren (10g.), Huo Ma Ren (10g.), Zhi Ke (6g.)]
 * Signs:** constipation with small, dry and round stools
 * Symptoms:** pale and sallow complexion, palpitations, amnesia, dizziness, vertigo, blurred vision, tingling of the limbs, pale lips, possibly following labor/surgery
 * Tongue:** pale
 * Pulse:** fine
 * Treatment Principle:** Nourish Blood, moisten the intestines, promote bowel movement
 * Acupuncture Treatment:** [ST-25, BL-25, SP-15, TB-6, KI-6] + SP-6, ST-36, BL-17, BL-20, CV-4
 * Herbal Treatment:** Run Chang Wan (Moisten the Intestines Pill) OR Ba Zhen Tang

Yin Vacuity
Xuan Shen (30g.), Sheng Di Huang (24g.), Mai Men Dong (24g.)]
 * Signs:** constipation with dry, hard stool
 * Symptoms:** malar flush, dizziness, vertigo, thirst with desire for sips of water, night sweats, palpitations, soreness and weakness of the lower back and knees, emaciation
 * Tongue:** red with little or no coat
 * Pulse:** fine and rapid
 * Treatment Principle:** Nourish yin, supplement the Kidney, moisten the intestines, promote bowel movement
 * Acupuncture Treatment:** [ST-25, BL-25, SP-15, TB-6, KI-6] + SP-6, KI-3
 * Herbal Treatment:** Zeng Ye Tang (Increasing Fluids Decoction)

Kidney Yang Vacuity
Rou Cong Rong (12g.), Dang Gui (10g.), Huai Niu Xi (10g.), Ze Xie (5g.), Zhi Ke (3g.), Sheng Ma (5g.)] + Tu Si Zi
 * Signs:** difficult defecation, dry or moist (well-formed) stools, profuse clear urine
 * Symptoms:** abdominal coldness & pain, preference for warmth & aversion to cold, cold limbs, soreness and coldness of the lower back, bright-white or bluish complexion
 * Tongue:** pale with a white coat
 * Pulse:** deep, slow
 * Treatment Principle:** Warm the yang, supplement the Kidney, and promote bowel movement
 * Acupuncture Treatment:** [ST-25, BL-25, SP-15, TB-6, KI-6] + CV-8, CV-6 + moxa
 * Herbal Treatment:** Ji Chuan Jian (Float the Boat Decoction) OR Zhen Wu Tang (True Warrior Decoction)

Acupuncture for Constipation
Primary Points: ST-25, BL-25, SP-15, TB-6, KI-6

Supplementary Points: Heat in LI and ST: LI-11, LI-4, ST-44, ST-36 Qi Stagnation: CV-12, LV-3, CV-6, PC-6, CV-10 Qi vacuity: ST-36, SP-6, CV-4, BL-20 Blood vacuity: SP-6, ST-36, BL 17, BL-20, CV-4 Yin vacuity: SP-6, KI-3, LU-7 Yang vacuity: CV-8, GV-4, BL-23, CV-6 + moxa

Auricular: ST, LI

Abdominlal Massage

Herbal Teas: Ban Xie Ye, He Shou Wu, Feng Mi, Jue Ming Zi (10-15g.)

Clinical Tips for Treating Constipation
Constipation itself is not a critical disorder; its clinical significance is closely related to its complications. Constipation can be a cost of auto-intoxication via resorption of toxins that remain in the intestines. Symptoms of auto intoxication include dizziness, headache, loss of appetite, irritability, insomnia, acne, and dry, cracking or peeling skin. Chronic constipation can also lead to stubborn perianal disorders that do not respond well to treatment, including hemorrhoids, perianal fissures and fistulas, and perianal abscesses. Finally, it is possible for constipation to provoke a medical crisis; for example cerebrovascular accident due to hemorrhage and myocardial infarction may be induced by forcing and straining during defecation.

Discontinue bitter and cold herbs that drain downwards once the therapeutic effect has been achieved. The most common method for treating constipation is draining Heat and unblocking intestinal obstruction. This strategy incorporates herbs that are extremely bitter and Cold and thus has a tendency to injure the Spleen/Stomach. Hence the need to discontinue this strategy once a therapeutic effect has been achieved.

Support Upright Qi to restore normal bowel movements. In the late stages of a Warm-febrile disease, constipation is a common symptom, caused by decreased food and water intake during the acute stage. Treatment to promote bowel movements might not be necessary in such a case. Instead, nourish Stomach yin and strengthen Stomach Qi. Once the Upright Qi recovers and normal food and fluid intake resumes, bowel movements will be restored.

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============================================================ =Potential Contributing Factors= -Variations in blood calcium levels -Arginine Deficiency

=Treatment= -Enema = =

Dietary Recommendations
Drink 2 liters of water/day. Eat vegetable fibers which are necessary for a healthy intestinal tract: green vegetables and fruit, bran (cholesterol must be lowered), muscilages. Avoid spicy food. Eat whole wheat organic bread (bran), cooked prunes, prune juice, green vegetables, fresh figs. No pulses or bananas.

Orthomolecular Treatment
-Glucomannan - Fructo-oligosaccharides

Prescription
Morning, upon waking: Vaccinum Vitis Idaea, 75 drops