English Chinese (Simplified) Japanese Korean Spanish

"Case Study" By Carmela (Lina) Yerkes

By Carmela (Lina) Yerkes

HISTORY

Chief Complaint (CC’s)
The patient is a 16yr old male with a chief complaint of hypochondriac pain on the right side.  The patient also suffers from frontal and bilateral headaches.

History of Present Illness (HPI)

The symptoms for the chief complaint began in May of 2005 and the pain was described as continuous, sharp, stabbing, pulsating and exhausting.  The specific location was on the right upper abdominal quadrant. The pain wakes the patient up at night and rates an 8 out of 10 on the scale, with 1 signaling the least pain and 10 the most. In addition, the patient suffers from intermittent frontal and bilateral headaches with tenderness in the joints of the knees and elbows. The pain seems to be aggravated by stress or consumption of fatty foods and even slight odors may aggravate the headaches.  The pain is alleviated with hot packs applied to the area, massage, relaxing music or cool rags applied to the head.
The patient has sought medical help for this condition and was hospitalized at different times in the past. Xavier is currently under medical supervision at Rady Children’s Hospital in San Diego and he is receiving acupuncture treatments twice a week in the department of Integrative Medicine.

Past Medical History (PMH)

At age 11, the patient suffered lacerations to the liver and head following a bicycle accident. The head injury required 75 sutures, there was not a neurological sequela but there was a bone fracture of the right radial bone. After the accident, the patient began to feel dizzy, had a pale complexion and displayed both an elevated heart and blood rate.
In addition the patient has a history of bleeding, and he was hospitalized in November of 2008 with rectal bleeding.  He has had been hospitalized eight times over the last year for bleeding issues.
Patient underwent a surgical biopsy of the liver in June of 2006 for NASH. Although the pathogenesis of this condition is still poorly understood, it seems to be linked to an insulin resistance, obesity or a dyslipidemia. Patients with these conditions seem to be more at risk for NASH.  (Merck Manual, online medical library)

Medication (MEDS):
  Prescription medication includes: Methadone, Prevacid 30 mg, Rifampin, Lactulose and
Carafate 10 ml.  Non-prescription includes: Multivitamins, Vitamin B2 riboflavin 400mg. Vitamin K 5mg

Allergy Reactions (All/RXNs):
  Ciprofloxacin

Social History:
  Xavier lives with his mother and sister in Solana Beach and they have two dogs. He is in 10th grade and he is home schooled. He likes video games, likes to play with his dogs and has a few good friends who often come to spend time with him.

Work History:  N/A

Family History

The patient’s sister is presently 20 years old. At the age of 13 years she suffered from liver pain accompanied with nausea and low appetite.  The issue has since resolved itself and she is no longer displaying symptoms, however, she now uses bifocals and her eyesight seems to have greatly deteriorated.

Obstetrical History (where appropriate):  N/A

Current Health Status:
Due to the difficulties in digesting fats, the patient has changed his diet to include only lean meats. There has been a marked decrease in his intake of animal protein and he is consuming more fruits, vegetables and fiber. Stress seems to make the pain worse while dark rooms, music or distractions of television and video games relax the patient and ease the discomfort.  The patient is often woken up during the night by the pain and, as a result, he usually feels fatigued and irritable during the day. He falls asleep between the hours of 12 and 1 am and wakes up between the hours of 11am and 12pm.

Review of Systems:
Temperature: 96.9 Pulse 73 bpm.  Blood pressure 125/57
Sweat:  N/A
Appetite/Taste: Difficulty digesting fatty foods
Urination: N/Ap
Bowel Movement: 1 or 2 bm per day. Consistency: loose
Pain: Neck pain - occipital pain

Sleep: He wakes up at night due to pain. Goes to bed at 12pm and sleeps till 11:30 am

Physical Exam: 
The attending physician recorded that abdominal bio-sounds are normal and active. The right upper quadrant is tender to palpation. No masses are felt but the tip of the spleen is palpable.
Patient has a pale and sallow complexion, and is obese and displays a malodorous foot fungus on the right foot. The tongue is red on the tip and sides with a moderate white coat. The pulse is thin, wiry, choppy and about 90 beats per minute.  

Laboratory Results:
Low platelet count of 46 to 54, (above baseline and at high risk for bleeding). Tests reveal Hyper-ammonia (high ammonia in the blood) of 34, insulin resistance and high WBC count.
                                                                     

ASSESSMENT

TCM disease category: 
This is hypochondriac pain (xie tong), marked by aching pain or discomfort beneath the coastal margin area. The liver and gallbladder and their channels primarily influence this area.  Xie Tong with blood and qi stagnation can be considered a serious and chronic pathology, usually due to either a prolonged liver disease such as liver qi stagnation or damp heat that can secondarily lead to blood stasis. Stagnant blood is a common complicating feature of other prolonged liver pathologies like,  cirrhosis or cancer of the liver. The Handbook of Internal Medicine, Maclean W. Lyttleton J. (1998) p.564

TCM Working Diagnosis:
Qi and Blood Stagnation with underlying SP Deficiency, dysfunction of both the Liver and Spleen.

TCM Differential Diagnosis:
Ashites (Gu Zhang), is fluid in the interstitial tissue with “drum like” distention of the abdomen and pain of the upper quadrant with fluid that accumulates in the abdominal cavity.  This condition effects the whole body particularly the limbs due to the liver no longer performing its function of coursing qi throughout the body, filtering toxins, producing bile and other important substance such as coagulants and antibodies. As a result of these impaired functions, there is a disruption of fluid metabolism and movement, with fluid accumulating in the abdomen and a hard  “drum like” distention.  Normally in this pattern there is a mixture of excess and deficiency, with deficiency generally being more significant as the patient becomes weakened due to the pain and the prolonged qi and blood stagnation. Consequently there is significant damage to the Spleen, which is no longer able to properly transform and transport fluids, blood and qi throughout the body. Clinical Handbook of Internal Medicine, Maclean W. et all. (1998) p.730-740

Etiology and Pathomechanisms:
This is hypochondriac pain (xie tong) of the Qi and Blood Stagnation type with Spleen Qi Deficiency and Dampness.  This pattern slows blood circulation, which causes stagnation and fixed stabbing pain in the hypochondriac region where the liver organ resides.  In Traditional Chinese Medicine the time of the liver organ is from 1 to 3 am.  This could explain why the patient wakes up during the night with pain.  Blood stagnation is usually a result of prolonged qi stagnation, dampness or damp heat.  This presentation indicates a severe degree of damage to the Liver and or the Spleen with possible development of abdominal masses, enlarged spleen and liver (hepatosplenomegaly).  This condition could also lead to Ascitis, (gu zhang). This pattern displays more severe symptoms due to the disruption of fluid metabolism and fluid accumulating in the middle or lower jiao.  If the patient’s condition should progresses to this stage it is quite serious.  Maclean, W. et all. (1998) p.576-579

Biomedical differential diagnosis:
Portal hypertension is a condition also known as a Fatty liver (hepatic steatosis) and is the most common response to an injury to the liver marked by excessive accumulation of lipids in the hepatocytes.  Fatty liver is also seen in pregnancy or alcoholic liver disease. However NASH (non-alcoholic steatohepatitis) develops in patients who are not alcoholic but is identical to that of alcoholic hepatitis.) This liver disease (Nash) has emerged as the leading cause of chronic liver disease in children and adolescents in the United States.  In the US over the last two decades, there has been a two to three-fold rise in the rate of obese nonalcoholic children.   This statistic presents itself a primary reason for the NAFLD epidemic. Emerging data suggests that children with nonalcoholic steatohepatitis (NASH) progress to cirrhosis, which may ultimately increase liver-related mortality. More worrisome is the recognition that cardiovascular risk and morbidity in children and adolescents is associated with fatty liver. Pediatric fatty liver disease often displays a histological pattern distinct from that found in adults. Liver biopsy remains the gold standard for diagnosis of NASH. Hepatology (Baltimore, Md.). 2009 Oct; 50(4):1282-93 (Advances in pediatric nonalcoholic fatty liver disease. Loomba R, Sirlin CB, Schwimmer JB, Lavine JE) http://www.ncbi.nlm.nih.gov/pubmed/19637286

Treatment Principle:
Invigorate blood and eliminate blood stagnation. Move Qi and Tonify Spleen

Acupuncture Treatment:
Would consist of 11 points bilaterally with a total of 22 needles inserted during one treatment session.

    LV 14 - located on the mamillary line in the six intercostals space, 4-cun lateral to the midline of the chest. It’s indicated for blood stasis with cutting stabbing pain in the chest, lateral costal region and abdomen. Treats liver stomach disharmony, spreads and regulates liver qi, invigorates blood and disperses masses. Deadman P. Al Khafaji M. Baker K. (1998) p. 490
    SP 21 -  located on the mid axillary line, in the seventh intercostals space. This point is the Luo connecting point of the Spleen channel, which is said to embrace the blood of all the luo connecting channels. This point is for pain in the whole body and problems of limbs and joints. Regulated qi and blood and firms the sinews and joints, unbinds the chest and benefits the lateral coastal region.
Deadman P. et all. (1998) p. 204
    A combination of SJ 6 and GB 34 that benefits the abdomen and relieves pain of the hypochondria. GB 34 is the He Sea and Earth point of the Gall Bladder channel and it activates the channels alleviates pain, spreads Liver Qi and also benefits the lateral costal region, clears damp heat in the LV and GB and harmonizes Shao Yang. While SJ 6 located on the arm 3 cun from the wrist between the radius and ulna bones regulates and clears heat in the three Jiao’s and relieves pain of the lateral costal region. Deadman P. et all. (1998) p.450-452
    UB 17 - the meeting point of blood, is located on the back 1.5 cun lateral to the spinous process of the seventh thoracic vertebra.  This point is indicated for blood stasis and bleeding anywhere in the body, for stabbing pain anywhere and epigastric pain fullness of the abdomen and lateral costal region and difficult digestion. Deadman P. et all. (1998). p. 273
    UB 18 - the Back Shu point of the Liver, is located also on the back right beneath UB 17 but level with the lower border of the ninth spinous process of the thoracic vertebra.  This point is indicated for all liver pathologies whether deficient or excess, affecting the chest Lung, lateral costal region and abdomen. Has the action of spreading Liver Qi, regulating and nourishing liver blood, it clears damp heat and pacifies Liver wind. Deadman P. et all. (1998) p. 275
    LI 4 - the Source point of the Large Intestine channel. I chose this point because it’s indicated for pain and especially headaches; it relieves pain and spasms and promotes smooth flow of qi. It’s located on the dorsum of the hand between the fist and second metacarpal bones at the midpoint of the second metacarpal bone and close to its radial border. Deadman P. et all. (1998) p. 103
    The Three Yellows - Master Tong’s acupuncture points: These points are indicated for Cirrhosis of the Liver, hepatitis inadequacy of liver function leading to exhaustion and taxation, liver pain and indigestion. These points will make the patient feel stronger and can be used often with longer needle retention time. They also treat the ill effects of too many antibiotics and other medications. These points are located with the patient in supine position.  The first point is found by locating the midpoint of the interior medial thigh (On the Liver Meridian line). The other two are respectively 3 cun above the midline and the 3 cun below the midline. The three yellows are needled bilaterally so it is a total of six points.  Depth of needle should be between 1.5 to 2.5 cun. Lee, M. (1992) p.108-110

Adjunctive Therapies:  
Relaxing and stretching once a week.

Herbs:
The herbal formula best suited for this diagnosis is Xue Fu Zhu Yu Tang (Drive out stasis from the mansion of blood decoction). This formula invigorated the blood and dispels blood stasis especially in the upper part of the body. Persica semen (tao ren) catharmi flos (hong hua) and chuan xiong rhizoma (chuan xiong) are the chief herbs for this function. Angelica sinensis (dang gui) and paeoniae radix rubra (chi shao) also invigorate blood but concentrate more on lower body while nourishing blood and moistening. Other herb like Rehmanniae radix (sheng di huang) has the function of cooling the blood, clearing heat and improving circulation without injuring the yin. 
Blupleuri radix (chai hu) smoothes the flow of liver qi and relieves constraint facilitating the raising of clear yang.  Other minor herbs in this formula are Platycodi radix (jie geng) Auranti fructus (zhi ke) and glycyrrhizae radix (gan cao) and all three move qi while regulating its function.
In addition the herb salvia miltorrhizae radix (dan shen) curcuma radix (yu jin) and tabanus (meng chong) and aspongopus (jiu xiang chong) were added to the original formula to address the pain of the hypochondria resulting from an enlarged liver. 
Scheid, V. Bensky, D. Ellis, A. Barolet, R. (1990) p.564-567

Lifestyle Recommendations:  Patient has already made some good changes in his diet by reducing animal protein and eating only a very small amount of lean meats, more vegetables and fruit. 
I also recommend that the patient keep his exposure to toxins to a minimum by avoiding certain fumes chemicals and drastically reduce the intake of medications such as pain killers, whenever possible.  Regular exercise, for at least 30 minutes daily, for the reduction of stress and to aid blood circulation.  The patient should also avoid processed sugars and drink plenty of water.

Prognosis:
The patient’s condition is chronic and serious and the prognosis is poor. The treatment will be palliative, mainly to help with the pain and to strengthen the patient. This will serve to help arrest any further deterioration until such time as a liver transplant is available. If the patient is compliant and adheres to the lifestyle changes recommended, it is estimated that the number of acupuncture treatments to make a change in this case is, at least, 6 months once or twice a week. Progress will be evaluated every 21 days. Improvement in the patient’s condition will be evaluated by measuring the duration and the quality of the pain, coupled with positive changes in the overall energy and emotional disposition.

Summary Conclusion:
This patient’s case is complicated and there are a variety of factors implicated in this diagnosis. The patient’s chief complaint is a right-sided abdominal pain that is sharp and continuous. Furthermore, the patient also suffers from pain in the joints and there is a history of bleeding. This condition is further aggravated by multiple factors including, physical trauma from a bicycle accident, obesity, lifestyle and a possible genetic predisposition to liver disease. The traditional Chinese medical diagnosis for this patient’s chief complaint is hypochondriac pain of the qi and blood stagnation type (xie tong).  The bleeding, the sharp quality of the pain and the fatigue all indicate a chronic blood and qi stagnation. 
In traditional Chinese medicine it is said that the blood travels with qi and if the circulation of qi is impaired for long periods of time, eventually it results in injuring the blood and qi mechanism.  The biomedical diagnosis for this condition is NASH (non alcoholic steatohepatitis) also known as fatty liver. This is considered a serious disorder that often progresses to cirrhosis of liver, heart related problems and eventually death. This condition will require extended treatments of acupuncture, medicinal herbs and lifestyle changes. The treatments will only improve and manage the pain by keeping the patient from further deteriorating until the time that the patient can acquire a liver transplant, for which the patient is currently on the donor’s list. 
The TCM treatment principle is to invigorate the blood and to eliminate blood stagnation while tonifying the Spleen qi. The primary acupuncture points chosen for the patient’s chief complaint, hypochondriac pain, are a combination of SJ6 and GB34. The point SP21 was chosen to address pain of the joints or anywhere in the body. The acupoints UB17 address the blood stagnation while UB21 tonifies the spleen qi.  In addition to the above point prescription, a combination of three alternative points were added from Master Tong’s Acupuncture treatment that are indicated for liver issues with hepatic conditions.
The herbal medicinal formula chosen for Xavier is “Xue Fu Zhu Yu Tang” (Drive out stasis from the mansion of blood decoction) and it is modified with the addition of a four more herbs to address the long term chronic blood stagnation and the pain of the hypochondria. 
The patient’s prescription also includes lifestyle changes of regular exercise, elimination of animal fat from the diet, and improved sleeping habits. 
The treatments are long term and the progress is expected to be slow but effective in treating pain and improving overall quality of life.

REFERENCE LIST:

Scheid, V. Bensky, D. Ellis, A. Barolet, R. (1990), Chinese herbal medicine, 2nd edition formulas and strategies. Seattle, Washington.  Eastland Press Inc.

Maclean, W.  Lyttleton, J. (1998), Clinical handbook of internal medicine. 
Sidney, Australia. Pangolin Press.

Deadman, P. Al-Khafaji, M. Baker, K. (1998), A manual of acupuncture.  
East Sussex, England.  Eastland Press. 

Lee, M. (1992) Master Tong’s Acupuncture, An Ancient Alternative Style in Modern Clinical Practice. Colorado, USA. Blue Poppy Press.