In this context, the abdomen refers to the anterior trunk from the epigastrium to the pelvic bone. The abdomen is subdivided into regions that are not precisely demarcated. The epigastrium principally relates to the stomach. The large central region principally relates to the spleen and the intestines. The middle lower abdomen principally relates to the kidney, the urinary bladder, the large intestine and the domains of the Chong and Ren Meridians. The two sides of the lower abdomen principally relates to the Liver Meridian and the large intestine.
Etiology and Pathology
Abdominal pain relates mainly to exogenous evils, intemperate diet, the passions or deficiency of visceral Yang.
Exogenous Evils. When exogenous Cold and Wind attack the middle-jiao, or Cold gels in the interior and blocks the stomach and the intestines, or excessive raw and cold foods injure middle-jiao-Yang, Qi movement is impaired, so that its ascent and descent become abnormal, and Yin-Cold becomes strong in the interior. In all these cases Qi movement is blocked, and such blockage leads to pain. Excessive exposure to summer heat as well as Dampness invading and lodging in the middle-jiao can also disturb stomach and intestine functions and lead to pain.
Yang Deficiency. Several circumstances can result in chronic deficiency of YangQi. Depression of spleen-Yang results in the loss of motive force for transportation and transformation. Such loss of nourishment makes the visceral organs insufficient and at risk for the production of endogenous Cold. Depletion of middle-jiao-Yang enables Cold and Dampness to lodge in the middle-jiao and cause blockage. Insufficiency of Qi and blood means the visceral organs lose their nourishment. Similarly, insufficiency of genuine Fire permits endogenous Cold to form and to cause Qi and blood to fail to nourish the visceral organs. In these circumstances abdominal pain can also result.
Intemperate Diet. Overeating injures the middle-jiao and can lead to food retention and the formation of endogenous Heat. These in turn cause blockage of stomach and intestine Qi. Excessive fats or spices facilitate the interaction between Dampness-Heat and retained food and induce impedance of Qi movement. Rotten or unclean foods also injure the spleen and the stomach. All these can lead to abdominal pain.
Passions. Passions, rage and depression all can injure the liver and cause blockage of the normal paths for liver-Qi movement. Pent-up liver-Qi then moves abnormally. This may lead to impairment of the functions of other visceral organs. The resultant Qi stagnation and blood stasis can also produce abdominal pain.
Less common causes of abdominal pain include malnutrition due to parasitic infestation, kidney insufficiency with anuria and abdominal masses.
The illnesses that present with abdominal pain also fall in the two categories of strength and deficiency. Strength illnesses are those caused by exogenous Cold, Dampness or Heat, or food retention, all leading to impedance to Qi movement and blood flow. Deficiency illnesses are those due to deficiency of visceral Qi, with endogenous Cold and inability to Qi and blood to warm and nourish.
Clinical Manifestation and Key Points of Analysis
Abdominal pain may be acute and short lasting or chronic and long lasting. It may be distending, vague, stabbing, twisting (colicky) or burning in quality.
Acute versus Chronic
Acute abdominal pain tends to begin abruptly and be severe. There often are prominent accompanying symptoms. Acute abdominal pain is usually due to attack by exogenous pathogenic evil, intemperate diet or parasitic infestation. Chronic pain begins slowly, has a prolonged course and is not very severe. It is usually due to internal injury, gelling of formless pathogenic evils such as Cold or Heat, chronic illness, or deficiency of Yang with Cold in the visceral organs.
Quality of Pain
Cold. Cold-induced abdominal pain tends to have an urgent quality, is severe and is associated with borborygmus. If the pain is due to strong exogenous Cold, it may be accompanied by Qi stagnation and vomiting and tends to be acute and have a distending and firm quality. If the pain is due to deficiency Cold, it tends to be continual and to persist.
Heat. Heat-induced abdominal pain is mainly peri-umbilical and often has a feverish quality. It may be accompanied by constipation and preference for cold drinks.
Qi Stagnation. Abdominal pain in Qi stagnation tends to fluctuate in severity and migratory in location. There are chest and subcostal discomfort, eructation and abdominal distention. Passing of gas usually brings temporary relief.
Blood Stasis. Abdominal pain due to blood stasis tends to have a fixed location and is stabbing in character. There is guarding. It usually worsens at night. It is usually accompanied by a dusky complexion and cyanotic lips.
Overindulgence or indigestion produces abdominal pain with eructation. The pain is alleviated by defecation.
Abdominal pain due to deficiency is chronic and often persistent. There is no guarding; sometimes there is preference for pressure.
Abdominal pain due to the pathogenic evil strength is acute and abrupt, and is often accompanied by abdominal distention, vomiting and guarding.
Location of Pain
Abdominal pain between the lower ribs and the umbilicus relates mostly to the spleen, the stomach and the intestines.
Peri-umbilical pain that fluctuates and sometimes becomes prostrating is often due to heavy parasitic infestation. Often there is vomiting of yellow-green fluids or of parasites. When the pain subsides, the appetite returns to normal. Pain due to parasitic infestation is most commonly seen in children.
Abdominal pain below the umbilicus, on one or the other side or on both sides, relates mostly to illness in the Liver Meridian.
Abdominal pain below the umbilicus that comes in recurrent attacks, often accompanied by spasm or firm masses, relates mostly to disease in the kidney or urinary bladder.
Herbal Treatment
When treating abdominal pain, be careful to identify the affected meridian, ascertain whether it is due to Qi or blood or to Cold or Heat, and differentiate between strength and deficiency. For abdominal pain of strength emphasize expulsion of disease evil and relief of blockage. For abdominal pain of deficiency-Cold emphasize warm-augmentation of Yang-Qi.
Blockage by Cold
Main Symptoms. Severe acute abdominal pain worsened by cold and lessened by warmth; cold-aversion; lying in curled position; absence of thirst; either diarrhea or constipation; and clear urine. The tongue coating is thin and white, and the pulse taut and tight.
Therapeutic Principle. Warm the interior, dispel Cold and stop pain.
Treatment. Zheng Qi Tian Xiang San (Qi-Supporting Cyperus Powder). It has the following composition: xiangfu (Cyperus) 10 g, wuyao (Lindera) 10 g, zisu leaf (Penila) 10 g, muxiang (Aucklandia) 10 g, yanhusuo (Corydalis) 10 g, ganjiang (Zingiber) 3g, gaoliangjiang (Alpinia officinarum) 6 g, and fried gancao (Glycyrrhiza) 6 g.
If Cold is especially severe and the pain violent, add processed fuzi (Aconitum) and rougui (Cinnamomum).
If there is constipation, add processed fuzi (Aconitum) and dahuang (Rheum palmatum) to warm and unblock visceral Qi.
If the pain is due to ascarid roundworms, and there is vomiting of worms or passing of worms in the feces, add Wumei Wan (Wumei Pill).
If there is lower abdominal spasm or cold pain, add wuzhuyu (Evodia) and xiao-huixiang (Foeniculum vulgare).
Deficiency-Cold
Main Symptoms. Intermittent or continual abdominal pain, preference for warm pressure which alleviates the pain; lusterless complexion; lassitude; cold-intolerance; and shortness of breath. The tongue is pale and the coating white. The pulse is threadlike and without force.
Therapeutic Principle. Warm the middle-jiao, augment Qi and strengthen the spleen to stop pain.
Treatment. Xiao Jian Zhong Tang (Minor Middle-Jiao-Strengthening Decoction).
If there is blood loss causing deficiency, so that abdominal pain is unrelenting or spasm in the lower abdomen radiates to the waist and back, add danggui (Angelica).
If there is Qi deficiency, with spontaneous sweating, shortness of breath and fatigue, add huangqi (Astragalus).
In some patients, Yin-Cold is especially severe and causes excruciating epigastric pain. There is usually vomiting with inability to eat, or borborygmus. On palpation there may be a mass that seemingly has head and feet and that is exquisitely tender to touch. In such patients, add wuzhuyu (Evodia), wuyao (Lindera) and huajiao (Zanthoxylum bungeanum).
If Cold is in the Taiyin Meridian, abdominal pain is accompanied by borboryg-mus. There is no guarding, but the patient prefers warmth and pressure. There is either constipation or watery diarrhea. The urine is clear and increased in volume. The hands and feet are cold and difficult to warm. The tongue is pale, with white and smooth coating. The pulse is deep and threadlike, or slow. Treat with Li Zhong Wan.
If Cold is in the Yueyin Meridian, the limbs are cold and the pulse is threadlike and on the verge of collapse. Treat with Danggui Si Ni Tang.
If the large intestine is the site of deficiency-Cold, there is cold constipation and abdominal pain. Treat with Wen Pi Tang.
Dampness-Heat
Main Symptoms. Sudden abdominal pain and abdominal distention with guarding; constipation, foul feces; fetid eructation; nausea and vomiting. The tongue coating is yellow and greasy, and the pulse taut and rapid.
Therapeutic Principle. Cool Heat, dry Dampness, relieve stagnation and stop pain.
Treatment. Modified Da Cheng Qi Tang (Potent Purgation Decoction), with the following composition: raw dahuang (Rheum palmatum) 10 g, houpo (Magnolia) 10 g, zhishi (Citrus aurantium) 10 g, binglang (Areca) 5g, zhizi (Gardenia jasmi-noides) 10 g, muxiang (Aucklandia) 6g, and gancao (Glycyrrhiza) 6g.
If Heat is stronger than Dampness, add huanglian (Coptis), huangqin (Scutellaria), pugongying (Taraxacum) and baijiangcao (Bombyx).
If Dampness is stronger than Heat, with white and greasy tongue coating, add cangzhu (Atractylodes), yiyiren (Coix) and sharen (Amomum).
If there is food retention as well, add laifuzi (Raphanus), jineijin (Gallus gallus domesticus) and shanzha (Crataegus).
Qi Stagnation
Main Symptoms. Intermittent and migratory abdominal distention and pain, the pain followed by spasm; eructation, which brings some relief; and pain aggravated by irascibility. The pulse is taut.
Therapeutic Principle. Unblock the liver, relieve stagnation, regulate Qi and stop pain.
Treatment. Chaihu Shu Gan San (Bupleurum Liver-Unblocking Powder). It has the following composition: chaihu (Bupleurum) 10 g, baishoyao (Paeonia) 10 g, zhiqiao (Poncirus trifoliata) 10 g, Qingpi (Citrus tangerina) 6g, xiangfu (Cyperus) 10 g, chuanxiong (Ligusticum) 6g, and gancao (Glycyrrhiza) 6g.
If there is severe chest and subcostal pain as well, add chuanlianzi (Melia) and yanhusuo (Corydalis).
Blood Stasis
Main Symptoms. Persistent stabbing abdominal pain that has no fixed location and that worsens at night; and in some patients abdominal masses. The tongue is cyanotic. The pulse is impeded.
Therapeutic Principle. Mobilize blood and remove stasis.
Treatment. Shao Fu Zhu Yu Tang.
If static blood accumulates in the abdomen, producing stabbing pain between the ribs in addition to abdominal pain, add chaihu (Bupleurum), jianghuang (Curcuma), taoren (Prunus persica) and dahuang (Rheum palmatum).
If there is Cold in addition, add rougui (Cinnamomum) and ganjiang (Zingiber).
Acupuncture Treatment
The causes of abdominal pain are many, and each produces a different clinical picture. Acupuncture treatment uses the basic approach of harmonizing the intestines and the stomach and regulating Qi to suppress pain. The most commonly selected acupoints are Zhongwan (CV-12), Qihai (CV-6) and Zusanli (ST-36).
Treat abdominal pain due to Cold strength by warming the middle-jiao and dispelling Cold. Add the acupoints Liangmen (ST-21) and Shenque (CV-8). Apply the reducing method and moxibustion. For Shenque apply moxibustion with salt.
Treat abdominal pain due to deficiency-Cold by warming the middle-jiao and augmenting Qi. Add the acupoints Zhangmen (LR-13), Tianshu (ST-25) and Guanyuan (CV-4). Apply the reinforcing method and moxibustion.
Treat abdominal pain due to Qi stagnation by unblocking the liver and regulating Qi. Add the acupoints Neiguan (PC-6), Qimen (LR-14) and Yanglingquan (GB-34). Apply the reducing method.
Treat abdominal pain due to blood stasis by promoting blood circulation and activating the channels. Add the acupoints Shuidao (ST-28) and Qimen (LR-14). Apply the reducing method.
Treat abdominal pain due to accumulation of Dampness-Heat by cooling Heat and relieving accumulation. Add the acupoints Tianshu (ST-25), Shangjuxu (ST-37), Sanyinjiao (SP-6) and Yinlingquan (SP-9). Apply the reducing method.
Case Study
The patient was a sexagenarian who came to the clinic because of severe acute periumbilical pain. The pain was aggravated by food. Defecation and urination were normal. The tongue coating was thin and greasy, and the pulse deep and taut. Stool examination did not show any parasitic ova.
He was treated for stagnation of liver-Qi with vinegar-treated chaihu (Bupleu-rum), zhiqiao (Poncirus trifoliata), Qingpi (Citrus tangerina), danggui (Angelica), baishaoyao (Paeonia), xiangfu (Cyperus), wuyao (Lindera), chuanlianzi (Melia), muxiang (Aucklandia) and foshou (Citrus medica L. v. sacrodactylis). After three doses, abdominal pain worsened and the patient groaned incessantly. He also vomited half a bowl of blood.
Because the pain had a fixed location and was aggravated by food and there was hematemesis, a new diagnosis of evil Qi entering blood, with stasis in the blood vessels and overflow of blood, was made. Wulingzhi (Pleropus pselaphon) 10 g was added to the previous formula. After three doses of the augmented formula, pain lessened, the patient was able to eat, and the illness was eight-tenths improved. The formula without wulingzhi was continued until the patient was completely cured.
