Epigastirc+Pain

Epigastric Pain (Wèi Tòng)
Pain located between the inferior border of the sternum and the umbilicus, and bordered by the infracostal margins. May be accompanied by belching, acid regurgitation, anorexia, and hypochondriac and abdominal distention. Chronic epigastric pain that is accompanied by hematemesis, melena, vomiting, and dysphagia generally has a poor prognosis.

Relevant Biomedical Diseases
Acute or chronic gastritis Peptic ulcer Upper GI bleeding Pancreatitis Gastroptosis Prolapse of gastric mucosa Gastric neurosis Duodenitis Gastric cancer

Etiology and Pathology
Attack of the Stomach by Cold -> Qi stagnation Injury of the Stomach by irregular food intake stagnation of food -> blockage of Qi in the Stomach -> failure of the Stomach Qi to descend Persistent emotional stress -> Liver and Stomach Qi stagnation -> failure of the Stomach Qi to descend Chronic disease, congenital vacuity or taxation -> fatigue -> Yang vacuity and Cold in Middle Jiao, Yin vacuity in the Stomach -> malnourishment of the Stomach

Differential Dx of Epigastric Pain
-Patient often has hx of heart disease -S/S: L-sided chest pain with chest congestion, SOB, profuse sweating, cold limbs, cyanotic lips and nails, intermittent or knotted pulse -Distinguishing Vacuity Patterns from Repletion Patterns || -Pain is usually felt lower (between/around umbilicus and pubic bone) ||
 * Cardiac Pain (Zhēn Xīn Tòng) || Abdominal Pain (Fù Tòng) ||
 * -More common among middle-aged or elderly

Colicky pain Triggered or aggravated by cold/raw foods or exterior cold invasion Alleviated by warm compress or drinking warm beverages || Thirst present May have bitter taste in the mouth, bad breath, and constipation Burning pain Alleviated by cold compress or drinking cold beverages ||
 * Distinguishing Cold Patterns from Heat Patterns**
 * Cold || Heat ||
 * Absence of thirst

Pain: distending, migratory May be accompanied by belching || More chronic Pain: fixed, sharp/stabbing May be accompanied by hematemesis or melena ||
 * Distinguishing Qi Stagnation from Blood Stasis Patterns**
 * Qi Stagnation || Blood Stasis ||
 * More recent onset

Identification of Organ Involvement
Liver: pain is recurrent, migrating, distending, elicited by emotional stress, and radiates to the hypochondriac regions. Spleen:pain is dull, has a prolonged course, is aggravated by hunger and relieved by eating. Usually accompanied by sallow complexion, fatigue, loose stool, and a moderate pulse. Stomach: pain often has an acute onset caused by invasion of exterior pathogens or improper diet. Pain is constant, with fullness and distention, belching, irregular or incomplete bowel movements and a slippery pulse.

Attack of the Stomach by Exogenous Cold
[Gao liang jiang (10g), Xiang fu (10g)] Other considerations: Ginger tea; Huo Xiang Zhen Qi San
 * Main Symptoms :** sudden onset of severe, colicky epigastric pain that is relieved by warmth or drinking warm beverages and aggravated by cold and pressure
 * Secondary Symptoms:** no thirst or possibly thirst with a desire for warm beverages, possible aversion to cold/ preference for warmth, loose stools, copious, clear urine
 * Tongue:** thin white tongue coating
 * Pulse:** wiry, tight
 * Treatment Principle:** Warm up the Middle Jiao and scatter Cold to relieve pain
 * Herbal Treatment:** Liang Fu Wan (Lesser Galangal and Cyperus Pill)

Food Stagnation in the Stomach
[Ban Xia (10g), Fu Ling (10g), Chen Pi (10g), Shan Zha (10g), Shen Qu (10g), Lai Fu Zi (10g), Lian Qiao (10g), Zhi Gan Cao (10g)]
 * Main Symptoms:** distending, epigastric pain which is worse with pressure; belching, acid regurgitation, halitosis
 * Secondary Symptoms:** nausea, vomiting of undigested food, epigastric pain relieved after belching or vomiting, anorexia, incomplete evacuation of stool or loose, foul-smelling stool or constipation with dry stool
 * Tongue:** thick, greasy coating
 * Pulse:** slippery
 * Treatment Principle:** Disperse food, eliminate stagnation and relieve pain
 * Herbal Treatment:** Bao He Wan (Harmony Preserving Pill)

Attack of the Stomach by Liver Qi
[Chai hu (10g), Xiang fu (10g), Zhi ke (10g), Chen pi (10g), Bai shao (10g), Chuan xiong (10g), Zhi gan cao (3g)
 * Main Symptoms:** wandering and distending pain in the epigastric and hypochondriac regions which often fluctuates with emotional state
 * Secondary Symptoms:** belching, frequent sighing, irritability, incomplete evacuation of stool
 * Tongue:** thin white coating
 * Pulse:** wiry
 * Treatment Principle:** Course the Liver, regulate Qi, harmonize the Stomach, relieve pain
 * Herbal Treatment:** Chai Hu Shu Gan San (Bupleurum Course the Liver Decoction)

Accumulation of Heat in the Liver and Stomach
[Mu dan pi (10g), Zhi Zi (10g), Bai shao (15g), Qing pi (6g), Chen pi (6g), Ze Xie (6g), Chuan bei mu (6g)] + [Wu Zhu Yu (3g.), Huang Lian (18g.)]
 * Main Symptoms:** acute, burning epigastric pain accompanied by acid regurgitation
 * Secondary Symptoms:** irritability, dry mouth, bitter taste in the mouth, gnawing hunger
 * Tongue:** red tongue yellow coating
 * Pulse:** wiry and rapid
 * Treatment Principle:** Soothe the Liver, clear Heat, harmonize the Stomach, relieve pain
 * Herbal Treatment:** Hua Gan Jian (Liver Transforming Brew) + Zuo Jin Wan (Left Metal Pill)

Obstruction of the Collaterals of the Stomach by Blood Stasis
[Wu ling zhi (12g), Pu huang (10g)]
 * Signs:** fixed, stabbing epigastric pain that is aggravated by pressure and often increases at night
 * Symptoms:** pain may increase after eating, possibly hematemesis or melena (tarry stool)
 * Tongue:** dark purple with ecchymoses
 * Pulse:** choppy
 * Treatment Principle:** Quicken the Blood and transform stasis, open the collaterals and relieve pain
 * Herbal Treatment:** Shi Xiao San (Sudden Smile Powder)

Stomach Yin Vacuity
[Mai men dong (10g), Sha shen (10g), Sheng di huang (10g), Gou qi zi (10g), DangGui (10g), Chuan lian zi (10g)]
 * Signs:** vague, dull, burning epigastric pain
 * Symptoms:** dry mouth and throat, or thirst with a desire for drinking small amounts, hunger with inability to eat much, constipation with dry stool
 * Tongue:** red and dry with little or no coating
 * Pulse:** thready, rapid
 * Treatment Principle:** Nourish Stomach Yin to relive pain
 * Herbal Treatment:** Yi Guan Jian (All-the-Way Through Brew)

Vacuity Cold in the Stomach and the Spleen
[Huang Qi (10g), Yi Tang (30g), Gui Zhi (6g), Bai Shao Yao (10g), Zhi Gan Cao (3g), Da Zao (10 pc.), Sheng jiang (10 slices)]
 * Signs:** persistent, dull epigastric pain that is relieved by warmth, pressure and after eating, and aggravated by cold and hunger
 * Symptoms:** occasional regurgitation or vomiting of watery/thin fluids, poor appetite, general lassitude, spirit fatigue, cold limbs, loose stool,
 * Tongue:** pale with white coating
 * Pulse:** deep, weak, and slow
 * Treatment Principle:** Warm and supplement the Stomach and Spleen to relieve pain
 * Herbal Treatment:** Huang Qi Jian Zhong Tang (Astragalus Center-Fortifying Decoction)

Herbal Additions for Specific Sx’s
Pain: Liver Blood vacuity + Shao Yao Gan Cao Tang: shao yao 12g, zhi gan cao 12g Liver constraint with Heat + Jing Ling Zi San: jin ling zi (chuan lian zi) 30g, yan hu suo 30g

Acid regurgitation: + Zuo Jin Wan: Huang Lian, Wu Zhu Yu (ratio 6:1) + Wa Leng Zi, Hai Piao Xiao

Ulcer: + Hai Piao Xiao, Bai Ji, Zhen Zhu Fei (pearl powder)

Bleeding: + Xian He Cao, E Jiao, Zi Zhu Cao, San Qi, Ou Jie, Wu Zei Gu/Hai Piao Xiao

Hypochlorhydria (decreased production of stomach acid): + Shan Zha, Wu Mei

Helicobacter Pylori (HP) positive: + Pu Gong Ying, Da Huang, Huang Lian

Prevent progression of chronic disease to cancer +Bai Hua She She Cao, Ban Zhi Lian, Yi Yi Ren

Dr. Jiao Shude’s Empirical Formulas San He Tang = Dan Shen Yin (dan shen, tan xiang, sha ren) + Bai He Tang (bai he, wu yao) + Liang Fu Wan (gao liang jiang, xiang fu) Si He Tang = San He Tang + Shi Xiao San (pu huang, wu ling zhi)

Acupuncture for Epigastric Pain
Primary Points: CV 12, ST 36, SP4, PC 6 Supplementary Points: Repletion Cold: CV 6, CV 8, CV 10, ST 34 Food Stagnation: Inner Neiting, CV 10, CV 11, ST 21 Attack of ST by LV Qi: LV 14, LV 3, GB 34 Accumulation of Heat in LV and ST: LV2, ST 44 Blood Stasis: BL 17, SP 10 ST Yin Vacuity: BL 20, BL 21 Vacuity Cold: BL 20, BL 21, CV6, CV 8

Clinical Tips for Treating Epigastric Pain
Always rule out gastric bleeding and cancer. Epigastric pain of recent onset, particularly if it is increasing in severity, requires medical referral for evaluation. Be alert to changes in the timing, frequency, or associated symptoms of chronic epigastric pain. For example, chronic epigastric pain accompanied by recent complaints of distention, nausea, and dizziness requires immediate medical referral to rule out gastric bleeding even in the absence of hematemesis. Clinical Tips for Treating Epigastric Pain Middle-aged patients with recurrent epigastric pain who respond poorly to herbal tx and exhibit emaciation, low-grade fever and melena should be evaluated for gastric cancer.