Abdominal masses and blockage result from deficiency of genuine Qi and disharmony of zang-fu viscera, so that Qi becomes stagnant and blood static. Qi stagnation and blood stasis in turn lead to accumulation and gelling of turbid Phlegm inside the abdomen, producing masses or blockage.
Masses have defined shape on palpation and tend to be fixed in location. The pain associated with masses also has a fixed location. As an illness, a mass is generally located in the Blood Level.
Blockage generally does not have a defined shape on palpation and is not constant. Its associated pain does not have a fixed location. As an illness, blockage is generally located in the Qi Level.
Etiology and Pathology
The basic pathological factor in the formation of masses or blockage is deficiency of genuine Qi. The most common circumstances are the following.
Emotional Disturbance. When emotional disturbance causes illness it first affects Qi, inducing stagnation of liver-Qi and depression of spleen-Qi. As Qi stagnation reaches the Blood Level it induces blood stasis. Protracted Qi stagnation and blood stasis may lead to the formation of masses or blockage.
Internal Injury by Improper Diet or Alcohol. Overindulgence in alcohol or foods that are fatty, spicy, sweet and pungent or fried may impair spleen and stomach functions, resulting in failure in the transformation and transportation of nutrients. Retained fluid turns into Dampness and may give rise to endogenous Phlegm. Phlegm impedes Qi movement, and impedance of Qi movement leads to blockage. The struggle between Qi and turbid Phlegm may lead to gelling of Phlegm and the formation of masses.
Attack by Exogenous Pathogenic Evils. Exogenous Cold, Dampness or Heat, or Heat toxins, can invade the body and lodge in the abdomen. This causes disharmony between the affected zang-fu organs and impedes the movement of Qi and blood, so that turbid Phlegm forms in the interior. Stagnant Qi and static blood accumulate in the abdomen, and over time develop into masses.
Complications of Other Illnesses. Several other illnesses may lead to masses or blockage. During protracted jaundice or post-jaundice convalescence Dampness may persist and impede Qi and blood movement. The blood fluke impairs the flow of liver and spleen Qi and blood, and this may result in blockage of blood channels. Chronic malaria conduces to the rise and gelling of Dampness and Phlegm, which in turn block the blood vessels and produce masses or blockage.
Though deficiency of genuine Qi is the fundamental pathological change, the location of illness causing mass or blockage is usually the liver and the spleen, with involvement of the stomach and the intestines. The key mechanism is stagnation of Qi, stasis of blood and gelling of Phlegm. In blockage, the principal factor is Qi stagnation. In masses, stagnation of Qi, stasis of blood and gelling of Phlegm are all present, but blood stasis is the main factor.
Clinical Manifestation
Masses and blockage present different clinical pictures.
Blockage tends to develop rapidly and has a shorter course. It is mainly accumulation of stagnant Qi within a hollow organ in the abdomen. The main symptoms include distention and pain that are intermittent, sometimes a sausage-like but vague swelling in the abdomen, a tongue coating that is usually thick and greasy and white or yellow in color, and a pulse that is taut and slippery. During an attack the affected area shows fullness or distention but not palpable mass, and during remission the fullness and distention disappear. If blockage occurs too frequently, there may be lassitude, weakness, anorexia and loose feces.
Masses develop more slowly, have a longer course and are more serious. The abdomen may be distended to various degrees. Masses that are hard tend to progress from small to large and from soft to hard. In the early stages, the affected areas tend to become distended and there may be associated nausea and vomiting, abdominal distention, fatigue and reduced appetite. As the masses increase in size pain tends to become more severe. In time, there may be wan and sallow complexion and progressive weight loss or emaciation. The tongue may develop ecchymosis along the sides. The pulse tends to be taut or threadlike.
Key Points of Analysis
Mass versus Blockage. Masses have specific shapes on palpation, though they may be large or small, and soft or hard. On pressure there may be pain of a distending or stabbing quality. There often are accompanying symptoms such as nausea, vomiting, weakness, anorexia and emaciation. Note also that the formation of masses is often preceded in the same locations by pain.
For blockage the characteristic feature is Qi collecting inside the abdomen causing distention and pain in a hollow organ. It is usually intermittent. During an attack the affected area shows distention and fullness, but there is no specific shape on palpation. Blockage tends to arise rapidly, and its occurrence often is intimately related to changes in the emotional state.
Clinical Course. Blockage generally results from stagnation of liver-Qi or improper diet preventing Qi from its normal dispersal. Blockage is generally located in the Qi Level, so that the principal factor is strong pathogenic evil. Because of its relatively rapid development and short duration its course does not show stages.
Masses generally result from deficiency of Qi and blood so that blood becomes static and Phlegm arises and gels. Masses are generally located in the Blood Level. In the early stage, genuine Qi has not been damaged; evil Qi is strong, but not extremely so. During this phase the mass is relatively small and is relatively soft, and the patient’s general condition is fair. In the middle stage, genuine Qi is declining and evil Qi gaining strength. The mass is now larger and firmer on palpation. Pain is now continual, and is accompanied by worsening appetite, weakness and wasting. In the late stage, genuine Qi is depleted and evil Qi very strong. The mass has increased further in size and is now very hard. Pain is severe, and is accompanied by marked anorexia, dusky or sallow complexion, and severe emaciation.
Location of Mass. The specific visceral organ affected determines the location of the mass. A mass in the right subcostal abdomen, accompanied by subcostal stabbing pain, jaundice and abdominal distention is located in the liver. A mass in the epigastrium, accompanied by vomiting or hematemesis, is located in the stomach. A mass in the right abdomen, accompanied by diarrhea or constipation, emaciation and weakness, is located in the intestines. A mass in the left abdomen, accompanied by increased frequency of defecation and feces that contain pus and blood, is also located in the intestines.
Herbal Treatment
Blockage
Stagnation of Liver-Qi
Main Symptoms. Distention and pain in a hollow organ; intermittent and not fixed in location; and subcostal distention and discomfort. The tongue coating is thin, and the pulse taut.
Therapeutic Principle. Unblock the liver, release stagnation and mobilize Qi to relieve blockage.
Treatment. Muxiang Shun Qi San (Aucklandia Qi-Regulating Powder). It has the following basic composition: muxiang (Aucklandia lappa) 10 g, xiangfu (Cyperus rotundus) 10 g, Qingpi (Citrus tangerina) 6g, sharen (Amomum vil-losum) 3g, cangzhu (Atractylodes lancea) 10 g, chenpi (Citrus tangerina) 6g, houpo (Magnolia officinalis) 10 g, gancao (Glycyrrhiza uralensis) 6g, zhiqiao (Poncirus trifoliata) 10 g, wuyao (Lindera strychnifolia) 10 g, shengjiang (Zingiber officinale) 6 g, chuanxiong (Ligusticum chuanxiong) 10 g, and rougui (Cinnamomum cassia) 6 g.
If there are symptoms of Heat as well, such as bitter taste and red tongue, remove wuyao, cangzhu and rougui and add huanglian (Coptis), wuzhuyu (Evodia) to purge Liver-Heat.
If there are lassitude, weakness and loose feces, add dangshen (Codonopsis) and baizhu (Atractylodes) to augment Qi and strengthen the spleen.
Food Retention and Phlegm Blockage
Main Symptoms. Abdominal distention or pain, with periodic sausage-like masses on palpation; pain aggravated by pressure; and constipation and anorexia. The tongue coating is greasy, and the pulse taut and slippery.
Therapeutic Principle. Regulate Qi, dissipate Phlegm, unblock intestines and release retention.
Treatment. Liu Mo Tang (Decoction of Six Ground Substances).
For marked food retention, add shanzha (Crataegus), laifuzi (Raphanus) and shenqu (medicated leaven) to strengthen the spleen and promote digestion.
For turbid Phlegm blocking the middle-jiao, with nausea, vomiting and greasy tongue coating, add cangzhu (Atractylodes), banxia (Pinellia), chenpi (Citrus tan-gerina) and shengjiang (Zingiber) to dissipate Phlegm and suppress the abnormally risen.
If blockage is due to the accumulation of ascarid worms, treat with Wumei Wan (Wumei Pill) in addition to Liu Mo Tang.
Mass
Early Stage (Qi Stagnation and Blood Stasis)
Main Symptoms. Soft abdominal mass; with distension and pain. The tongue coating is thin and white or speckled with ecchymosis. The pulse is taut.
Therapeutic Principle. Regulate Qi, mobilize blood, unblock channels and dissipate mass.
Treatment. Use Jinlingzi San (Melia Powder) and Shi Xiao San together. The combined composition is as follows: chuanlianzi (Melia toosendan) 12 g, yanhusuo (Corydalis yanhusuo) 10 g, wulingzhi (Pleropus pselaphon) 6g, and puhuang (Typha angustifolia) 6g.
If abdominal pain is severe, add taoren (Prunus persica), honghua (Carthamus), chishaoyao (Paeonia) and danshen (Salvia) to dissolve stasis and stop pain.
For more severe Qi stagnation and blood stasis with additional symptoms of Cold, use Da Qi Qi Tang (Major Seven-Qi Decoction). Among its ingredient herbs, Qingpi (Citrus tangerina, fresh peel), chenpi (Citrus tangerina, aged peel), jiegeng (Platycodon grandiflorum), xiangfu (Cyperus rotundus) and huoxiang (Agastache rugosa) mobilize Qi and dissipate masses, and rougui (Cinnamomum cassia), san-leng (Sparganium stoloniferum) and ezhu (Curcuma aeruginosa) warm and unblock blood vessels and soften the hard.
Middle Stage (Static Blood Gelling in Interior)
Main Symptoms. Mass becoming larger and harder; mass and pain in fixed location; anorexia, weakness; recurring chills and fever; dusky complexion; and emaciation. Females may develop amenorrhea. The tongue is cyanotic or speckled with purpuric spots. The pulse is taut and slippery or threadlike and impeded.
Therapeutic Principle. Remove blood stasis, soften hard masses and regulate the spleen and the stomach.
Treatment. Ge Xia Zhu Yu Tang (Decoction for Relieving Stasis Below the Diaphragm).
Liu Jun Zi Tang (Six-Nobles Decoction) may be alternated with Ge Xia Zhu Yu Tang as clinically indicated to nourish and strengthen the spleen and the stomach.
If the mass is marked, add shuizhi (Hirudo nipponica), mengchong (Tabanus bivittatus), shanjia (Manis pentadactyla), and biejia (Amyda) and other herbs that mobilize blood and dissipate masses.
Late Stage (Genuine-Qi Depletion)
Main Symptoms. Hard mass; progressively worsening pain; anorexia; sallow or dusky complexion; and extreme emaciation. The tongue is pale purple and without coating. The pulse is threadlike and rapid or taut and threadlike.
Therapeutic Principle. Augment Qi, nourish blood, release blood stasis and dissipate masses.
Treatment. Combined Ba Zhen Tang (Eight Treasures Decoction) and Hua Ji Wan (Mass-Dissipating Pill).
Hua Ji Wan has the following composition: sanleng (Sparganium stoloniferum) 6 g, ezhu (Curcuma aeruginosa) 6 g, sumu (Caesalpinia sappan) 6 g, awei (Ferula sinkiangensis), wulingzhi (Pleropus pselaphon) 10 g, xiangfu (Cyperus rotundus) 10 g, binglang (Areca catechu) 6 g, haifushi (pumice) 6 g, walengzi (Arca inflate) 6 g, and xionghuang (realgar) 3 g.
For marked Qi deficiency, add huangqi (Astragalus), shanyao (Dioscorea) and yiyiren (Coix) to augment Qi and strengthen the spleen.
If Yin is damaged, add shengdihuang (Rehmannia), xuanshen (Scrophularia), maimendong (Ophiopogon) and shihu (Dendrobium) to nourish Yin and generate fluid.
Acupuncture Treatment
Blockage
Stagnation of Liver-Qi. Select the acupoints Ganshu (BL-18), Zhangmen (LR-13), Shangwan (CV-13), Qihai (CV-6) andDadun (LR-1).
Food Retention and Phlegm Blockage. Select the acupoints Zhongwan (CV-12), Qihai (CV-6), Tianshu (ST-25), Dachangshu (BL-25), Fenglong (ST-40) and Zusanli (ST-36).
Masses
Early Stage (Qi Stagnation and Blood Stasis). Select the acupoints Ganshu (BL-18), Zhangen (LR-13), Geshu (BL-17) and Xingjian (LR-2).
Middle Stage (Static Blood Gelling in Interior). Select the acupoints Pishu (BL-20), Weishu (BL-21), Ganshu (BL-18) and Taichong (LR-3).
Late Stage (Genuine-Qi Depletion). Select the acupoints Zhongwan (CV-12), Zusanli (ST-36), Qihai (CV-6), Geshu (BL-17), Pishu (BL-20) and Sanyinjiao (SP-6).
Case Study
The patient was a 63-year old male. He had an upper right abdominal mass for over half a year, accompanied by abdominal fullness and distention, lassitude, weakness, mild fever and palpitation of the heart. His complexion was dusky. His tongue was dark with a thick yellow coating. His pulse was deep, threadlike, rapid and forceless.
Diagnosis. Mass due to Qi stagnation and blood stasis, with deficiency of both Qi and blood.
Therapeutic Principle. Regulate Qi, mobilize blood, unblock channels and dissipate mass.
Treatment and Course. The prescribed formula had the following composition: dried toad venom (Bufo bufo gargarizans) 10 g, biejia (Amyda sinensis) 10 g, chuanshanjia (Manis pentadactyla) 6g, danshen (Salvia miltiorrhiza) 10 g, chaihu (Bupleurum chinense) 10 g, baishaoyao (Paeonia lactiflora) 10 g, muxiang (Aucklandia lappa) 6g, Qingpi (Citrus tangerina, fresh) 6g, chenpi (Citrus tangerina, aged) 6g, danggui (Angelica sinensis) 6g, meihua (Armeniaca mume) 10 g, and taizishen (Pseudostellaria heterophylla) 10 g.
The patient took this formula daily. Over half a year his mass gradually shrank, his spirit improved and all symptoms resolved. He was instructed to continue the prescription intermittently.
Comment. In this patient, the mass resulted from disharmony between the liver and the spleen, leading to Qi stagnation and blood stasis. These in turn block the channels. Over time, the stagnant Qi and static blood gelled together and gradually enlarged. The prolonged presence of gelled Qi and blood and the patient’s senescence together injured both Qi and blood, resulting in lassitude and weakness. The blood insufficiency led to the mild fever and palpitation of the heart. The dusky complexion, thick yellow tongue coating and the deep, threadlike, rapid and forceless pulse reflected Qi stagnation, blood stasis and deficiency of both Qi and blood. They indicated that the illness was moving into the middle stage of mass disease, with relative weakness of genuine Qi. For this reason, the therapeutic principle required simultaneous attack and restoration. In the prescribed herbs, the toad skin (chanpi) requires elaborate preparation. It has an acrid flavor and a cool nature and is slightly poisonous. It has the ability to soften the hard, reduce the swollen and dissipate the gelled Qi and mass. Biejia and chuanshanjia assist chanpi to dissipate masses. Chaihu, Qingpi, chenpi, muxiang and lu-e-mei regulate and mobilize Qi. Danshen, baishaoyao and danggui generate and mobilize blood. Taizishen augments Qi and nourishes Yin. Hence, this formula attacks masses but is not harsh and restores but does not impede. In constructing this formula, the goal is gentle action, as this type of illness develops over a long time so that treatment must not be harsh or rushed. Doing so can only further injure genuine Qi.
