The ancients knew stomachache, or epigastric pain, as “heart pain.” It must be distinguished from true heart pain, which originates in the heart.
Etiology and Pathology
Stomachache mostly arises when the patient overindulges in raw, cold foods or excessive spices, or is irregular in hunger and satiation. In such circumstances the spleen and the stomach may be injured and their Qi impeded. Stomachache may also arise when pent-up rage injures the liver, anxiety and brooding injure the spleen, stagnant Qi damages the stomach, or stagnant Qi transforms into Fire and scorches the interior. If spleen-Yang is chronically deficient, so that endogenous Cold is formed, then attack by exogenous pathogenic evil can prevent central Yang action and lead to imbalance in stomach-Qi activity.
Though stomachache is caused by the organ of the stomach, it is intimately related to the liver and the spleen. The liver prefers to function without restriction and governs conduction and facilitation. If liver-Qi moves abnormally, due to obstruction of its normal paths, then the Wood Element becomes too strong and can overwhelm the Earth Element. If Liver-Fire blazes, it can scorch and damage stomach-Yin. If liver-blood becomes static, the stomach loses its nourishment. Thus, illnesses of the stomach are frequently related to dysfunction of the liver. The stomach and the spleen are both the basis of post-natal acquisition and the houses of storage. They complement each other in physiology. The stomach governs the reception and decomposition of foods and drinks, and prefers harmony and normal descending in its functions. The spleen governs the transformation and transportation of the essences derived from foods and drinks, and prefers normal ascending and raising. In pathology too the stomach and the spleen are complementary and affect each other. Where excessive fatigue or exhaustion induces internal injury or cycles of hunger and satiation are irregular, in most cases the spleen and the stomach are similarly affected.
Broadly speaking, the main causes and mechanisms of stomachache include the following.
Pent-Up Rage and Other Passions. Anxiety, brooding, rage and emotional depression all can lead to liver blockage, liver-Qi stagnation and failure of the liver’s functions of conveyance and dispersion. In its attempt to move liver-Qi follows abnormal paths and may attack the stomach. Impedance of movement of Qi and blood also leads to pain. Moreover, because of the interdependence of Qi and blood, if Qi impedance persists for a long time it may lead to blood stasis. Blood stasis in turn causes blockage of meridians. As a result, there is aggravation of the pain and there may be hematemesis, hematochezia and other bleeding. If Qi is stagnant for a long time it may also transform into Fire. Of Fire of the zang viscera, Liver-Fire is the most violent. Liver-Fire blazes upward and scorches liver and stomach Yin, producing long-lasting and unremitting pain.
Dietary Indiscretion. Excessive indulgence in food and drink or irregularities in the cycle of hunger and satiation can easily injure spleen and stomach Qi. Excessive indulgence in raw and cold foods can lead to Cold accumulation in the stomach cavity. This in turn impairs the movement of Qi and blood in the stomach and produces pain. Overindulgence in fats, sweets and spicy foods or in alcoholic drinks can lead to Dampness and Heat blocking the middle-jiao. Heat in the stomach also produces pain. These are all commonly seen in clinical practice.
Innate and Other Deficiency. Innate weakness of the constitution, chronic fatigue, persistent internal injury, prolonged illness and inappropriate medications can all cause spleen and stomach insufficiency. Deficiency-Cold in the spleen and the stomach leading to impaired action of Yang in middle-jiao can produce stomachache. This is frequently precipitated by attack of the exogenous Wind-Cold or dietary indiscretion. Blazing Fire due to Yin deficiency leading to insufficiency of spleen Yin and blood depletion also produce pain. This is frequently precipitated by pent-up passions or over indulgence in dry and hot foods.
In general, the key pathological mechanism of stomachache is stagnation of stomach-Qi. Stagnant stomach-Qi fails to harmonize and descend, and the impaired movement produces pain. The pathological change may be of deficiency or of strength nature. The mechanism of a strength illness causing stomachache is stagnation of Qi in the middle-jiao, stagnant Qi transforming into Fire, or Qi stagnation leading to blood stasis. The mechanism of a deficiency illness is Yang deficiency of spleen and stomach or accumulated Heat injuring Yin. However, deficiency and strength often transform into each other, and are often intermixed.
Clinical Manifestation
The principal symptom is pain in the epigastrium. The pain may be dull, distending, stabbing, vague or acute. Dull or vague pain is particularly common. The pain is often accompanied by epigastric or abdominal distention, foul eructation, acid regurgitation, nausea, vomiting, anorexia, and constipation or watery feces. There may also be lassitude, weakness, a sallow complexion, emaciation or edema.
Key Points of Analysis
Acute versus Gradual Onset. If stomachache begins abruptly it is mostly due to attack by exogenous evils, dietary indiscretion inducing Cold, or gross overindulgence in food and drink. Any of these can lead to Cold injuring Yang in middle-jiao or food retention with indigestion. If stomachache begins gradually it is mostly due to liver blockage and Qi impedance or insufficiency and dysfunction of the spleen and the stomach. In either case, there is disharmony between the liver and the stomach, conducing to Qi stagnation and blood stasis.
Heat or Cold Nature. The nature of Cold is to congeal and astringe. Hence, pain induced by Cold attacking the stomach tends to be accompanied by epigastric distention, with guarding, anorexia, pallid tongue coating and a taut and tight pulse. Pain induced by Cold arising in deficiency of spleen and stomach Yang tends to be vague and accompanied by preference for warmth and pressure, worsening by cold, cold limbs, a pale tongue with thin coating, and a feeble pulse. Pain induced by gelled Heat or Fire, causing the stomach to lose its descending transportation function, tends to be accompanied by irritation, thirst with desire to drink, heat-aversion, cold-preference, scant urine, constipation, dry tongue coating and a taut and rapid pulse.
Deficiency versus Strength. Stomachache with distention and constipation is mainly due to an illness caused by strength pathogenic evils. Stomachache without distention or constipation is mainly due to an illness of deficiency. Preference for cold suggests an illness of strength; preference for warmth suggests one of deficiency. Guarding of the abdomen suggests an illness of strength; amelioration by pressure suggests one of deficiency. Aggravation following eating suggests an illness of strength; aggravation by hunger suggests one of deficiency. A replete pulse and abnormal Qi movement suggest an illness of strength; a depletive pulse and insufficient Qi suggest one of deficiency. Severe and acute pain with fixed location suggests an illness of strength; moderate and slow pain without fixed location suggests one of deficiency. A new illness in a patient with a stout body tends to be of strength; a chronic illness in a patient with weak constitution tends to be of deficiency.
Qi versus Blood. In general, an illness in the initial stage tends to be one of Qi abnormality; a chronic illness tends to be one of blood abnormality. A Qi type of pain is frequently accompanied by distention; distention tends to be the main symptom, whereas pain tends to be intermittent and without fixed location. A blood type of pain is usually persistent and stabbing in quality and fixed in location; the tongue is usually cyanotic. Pain due to retention of food or blockage by Phlegm tends to have fixed location.
Herbal Treatment
The fundamental principle for treating stomachache is to settle the stomach and regulate Qi. For disharmony between the liver and the stomach, unblock the liver and settle the stomach. For disharmony between the spleen and the stomach, strengthen the spleen and settle the stomach. Be careful also to distinguish strength and deficiency, Cold and Heat, and Qi and blood.
Since stomachache often involves Qi impedance, treatment often uses acrid-aromatic herbs that regulate Qi. In general, these should be discontinued as soon as the illness shows significant improvement to avoid depleting Qi and injuring Yin. When using bitter-cold herbs that purge downward, take special care to ensure that the herbs are appropriate for the illness and that the dosage is just right; and avoid prolonged treatment.
Stomach-Cold
Main Symptoms. Sudden acute stomachache; cold-aversion, preference for warmness, amelioration by warmth; and no thirst, preference for warm drinks. The tongue coating is white, and the pulse is taut and tight or taut and slow.
Therapeutic Principle. Warm the stomach, dispel Cold, mobilize Qi and stop pain.
Treatment.Fu Wan (Alpinia-Cyperus Pill). It has the following composition: gaoliangjiang (Alpinia officinarum) 5g, xiangfu (Cyperus) 10 g, ganjiang (Zingiber) 3g, zisu stem (Perilla) 10 g, wuyao (Lindera) 6g, chenpi (Citrus tangerina) 6g, muxiang (Aucklandia) 6g, yanhusuo (Corydalis) 10 g, and gancao (Glycyrrhiza) 5 g.
If Cold is severe, add wuzhuyu (Evodia).
If there are cold-aversion, fever, body aches and symptoms of the exterior, add zisu leaf (Perilla) and shengjiang (Zingiber) to dispel Wind and Cold.
If the Cold evil lodges for a long time and gels, there are alternating chills and fever, chest tightness and distention, anorexia, nausea, vomiting, epigastric pain with a burning quality, a bitter taste and dry mouth, a red tongue with yellow tongue coating and a soft and rapid pulse. In this case, use acrid-bitter Banxia Xie Xin Tang to treat both Cold and Heat.
Stomach-Heat
Main Symptoms. Intermittent but urgent stomachache, epigastric discomfort; acid regurgitation; irritability, irascibility; and a dry mouth with a bitter taste. The tongue is red with yellow coating, and the pulse is taut and rapid.
Therapeutic Principle. Clear the stomach, purge Heat and stop pain.
Treatment. Hua Gan Jian (Liver-Comforting Decoction) combined with Zuo Jin Wan. The combined composition is as follows: huanglian (Coptis) 5g, mu-danpi (Paeonia suffruticosa) 10 g, zhizi (Gardenia) 10 g, baishaoyao (Paeonia) 10 g, wuzhuyu (Evodia) 5 g, chuanlianzi (Melia) 10 g, Qingpi (Citrus tangerina) 10 g, zhuru (Phyllostachys nigra) 10 g, lugen (Phragmites) 10 g, and gancao (Glycyrrhiza) 5 g.
For abnormal movement of stomach-Qi with frequent eructation, add daizheshi (hematite) and chenxiang (Aquilaria).
For food retention, with fetid eructation and a dirty tongue coating, add shenqu (medicated leaven), maiya (Hordeum) and shanzha (Crataegus).
For Dryness and stagnation of visceral Qi due to stomach-Heat, with constipation and thick yellow and dry tongue coating, add raw dahuang (Rheum palmatum) and mangxiao (sodium sulfate).
For Dampness and Heat gelling in the stomach, with nausea, vomiting and a yellow greasy tongue coating, add huangqin (Scutellaria), houpo (Scutellaria) and pugongying (Taraxacum).
For intermixed Cold and Heat in the stomach, see Stomach-Cold, above.
Food Retention
Main Symptoms. Epigastric distension and pain, with guarding, fetid eructation, and acid regurgitation; or, vomiting of undigested food followed by easing of symptoms, anorexia and constipation. The tongue coating is thick and greasy, and the pulse slippery.
Therapeutic Principle. Promote digestion, remove food retention, settle the stomach and stop pain.
Treatment. Bao He Wan.
If epigastric distention does not abate, add xiangfu (Cyperus) and zhiqiao (Poncirus trifoliata).
If retained food has given rise to Fire, with yellow tongue coating and constipation, add mangxiao (sodium sulfate) and dahuang (Rheum palmatum) to relieve blockage.
Qi Stagnation
Main Symptoms. Attacks of epigastric pain with distention, extending to the flanks; chest tightness; eructation; and frequent sighing. Pain is often precipitated by emotional distress or pent-up rage. The tongue coating is thin and white, and the pulse taut. In severe cases, pain is severe and acute; there are accompanying agitation and irascibility, acid regurgitation, a dry mouth with bitter taste, a red tongue with yellow coating, and a taut and rapid pulse.
Therapeutic Principle. Unblock the liver, regulate Qi, settle the stomach and stop pain.
Treatment. Chaihu Shu Gan Yin (Bupleurum Liver-Unblocking Drink). Its composition is as follows: chaihu (Bupleurum) 6g, xiangfu (Cyperus) 10 g, zhiqiao (Poncirus trifoliata) 10 g, chuanxiong (Ligusticum) 6g, chenpi (Citrus tangerina) 6 g, baishaoyao (Paeonia) 10 g, foshou (Citrus medica L. v. sacrodactylis) 10 g, danshen (Salvia) 10 g, and gancao (Glycyrrhiza) 5 g.
If pain is severe, add yanhusuo (Corydalis) and chuanlianzi (Melia) to enhance Qi regulation and pain stopping.
For belching, add baidoukou (Amomum cardamomum), chenxiang (Aquilaria) and xuanfuhua (Inula britannica) to normalize Qi movement and suppress the abnormally rising Qi.
For chronically stagnant Qi transforming into Fire and Heat accumulating in the liver and the stomach, with burning epigastic pain and distress and acid regurgitation, add mudanpi (Paeonia suffruticosa), zhizi (Gardenia jasminoides), huanglian (Coptis) and wuzhuyu (Evodia) to clear Heat and purge Fire in the stomach.
For vomiting and nausea, add banxia (Pinellia) and zisu stem (Perilla).
For acid regurgitation, add wuzeigu (Sepia esculenta) and walengzi (Arca inflate).
Blood Stasis
Main Symptoms. Stabbing or cutting epigastric pain, with fixed location and guarding; or, hematemesis and melena. The tongue is cyanotic or speckled with petechiae. The pulse is impeded.
Therapeutic Principle. Mobilize blood and relieve stasis. (Note that since Qi is the commander of blood, when Qi moves normally so does blood circulate normally; hence when mobilizing blood use a formula that also contains herbs to mobilize Qi).
Treatment. Shi Xiao San (Stasis-Relieving Powder). It has the following composition: puhuang (Typha angustifolia) 10 g, wulingzhi (Pleropus pselaphon) 6g, yanhusuo (Corydalis) 10 g, Qingpi (Citrus tangerina) 10 g, danggui (Angelica) 10 g, danshen (Salvia) 10 g, zhiqiao (Poncirus trifoliata) 10 g, sharen (Amomum) 6g, and tanxiang (Santalum album) 5 g.
If there is Qi deficiency as well, add dangshen (Codonopsis), baizhu (Atracty-lodes), huangqi (Astragalus) and huangjing (Polygonatum) to augment Qi. The ancients regarded dangshen and wulingzhi as incompatible, but the concern is unnecessary in some cases. These two herbs enhance each other to augment Qi and mobilize blood.
If the pain is especially severe, add taoren (Prunus persica), honghua (Carthamus), yujin (Curcuma) and chishaoyao (Paeonia).
Deficiency Cold
Main Symptoms. Vague but constant epigastric pain, preference for warmth and pressure, alleviation by food; occasional regurgitation of clear fluid from stomach; reduced appetite; weakness, lassitude; cold hands and feet; and loose feces. The tongue is pale, and the pulse threadlike and feeble.
Therapeutic Principle. Warm Yang of the middle-jiao, augment Qi, settle the stomach and strengthen the middle-jiao.
Treatment. Huangqi Jian Zhong Tang (Astragalus Middle-Strengthening Decoction). It has the following composition: dangshen (Codonopsis) 12 g, huangqi (Astragalus) 12 g, guizhi (Cinnamomum) 6g, baishaoyao (Paeonia) 12 g, baizhu (Atractylodes) 10 g, shengjiang (Zingiber) three slices, dazao (Ziziphus) five pieces, and fried gancao (Glycyrrhiza) 6 g.
If there is vomiting of much clear fluid, add chenpi (Citrus tangerina), processed banxia (Pinellia) and fuling (Poria) to suppress the abnormally risen and settle the stomach.
If there is vomiting of much acid fluid, add calcined walengzi (Arca inflate) huan-glian (Coptis) and wuzhuyu (Evodia).
If cold-pain in the stomach is severe, add gaoliangjiang (Alpinia officinarum) and xiangfu (Cyperus) to enhance the action of warming the middle-jiao, dispelling Cold, mobilizing Qi and stopping pain.
For melena, add charred ganjiang (Zingiber), fulonggan (baked yellow earth), baiji (Bletilla), and charred diyu (Sanguisorba).
Yin Deficiency
Main Symptoms. Vague burning epigastric pain; dry mouth and throat, strong thirst with desire to drink; reduced appetite; and dry feces. The tongue is red and has little coating. The pulse is either threadlike and rapid or threadlike and taut.
Therapeutic Principle. Replenish Yin and nourish the stomach.
Treatment. Yi Wei Tang (Stomach-Nourishing Decoction). It has the following composition: nanshashen (Adenophora tetraphylla) 10 g, maimendong (Ophiopogon) 10 g, yuzhu (Polygonatum) 10 g, shengdihuang (Rehmannia) 10 g, processed banxia (Pinellia) 10 g, foshou (Citrus medica L. v. sacrodactylis) 6g, dazao (Ziziphus) five pieces, and gancao (Glycyrrhiza) 5 g.
For severe stomach Heat, add huanglian (Coptis) and zhuye (Phyllostachys nigra) to enhance Fire-purging and Heat-cooling.
For poor appetite, add chenpi (Citrus tangerina), shenqu (medicated leaven) and maiya (Hordeum) to smooth the path of stomach-Qi and enhance its actions.
For acid regurgitation, add calcined walengzi (Arca inflate).
If pain is severe, add baishaoyao (Paeonia) and gancao (Glycyrrhiza) to calm the liver and relieve spasm and pain.
For severe distending pain, add the blossom of Sichuan houpo (Magnolia), fos-hou (Citrus medica L. v. sacrodactylis), meigui (rose) and similar herbs.
If accompanied by blood stasis, add danshen (Salvia) and taoren (Prunuspersica) to mobilize blood and remove stasis.
Acupuncture Treatment
Zhongwan (CV-12), Neiguan (PC-6) and Zusanli (ST-36) are among the most commonly selected acupoints for treating stomachache.
If there is Qi stagnation, add Qimen (LR-14), Zhigou (SJ-6) and Yanglingquan (GB-34).
For food retention, add Liangmen (ST-21), Jianli (CV-11) and Tianshu (ST-25). For Stomach-Fire, add Neiting (ST-44) and Lidui (ST-45).
For stomach-Cold, add Pishu (BL-20), Weishu (BL-21) and Gongsun (SP-4). For blood stasis, add Geshu (BL-17) and Qimen (LR-14).
For pain due to parasites, add Siba (ST-2) needled through Yingxiang (LI-20), Tianshu (ST-25), Xuehai (SP-10) and Shangjuxu (ST-37).
For gastric distress and acid regurgitation, add Yanglingquan (GB-34) and Qiuxu (GB-40).
In general, for illnesses of strength or Heat, apply the reducing method. For illnesses of Cold or deficiency, apply the reinforcing method and moxibustion.
Case Study 1
The patient was an adult male who had suffered from stomachache for several years. The pain was worse on an empty stomach and lessened with food. He also had much eructation. His tongue coating was greasy in the middle. The tongue itself was somewhat pale. His pulse was small and taut.
Diagnosis. Stomachache due to deficiency and stagnation of middle-jiao-Qi and failure of the stomach’s functions of harmonizing and descending.
Therapeutic Principle. Strengthen the middle-jiao and warm the stomach.
Treatment and Course. The formula prescribed had the following composition: roasted guizhi (Cinnamomum) 3g, baishaoyao (Paeonia) 12 g, fried gancao (Glycyrrhiza) 5g, parched dangshen (Codonopsis) 12 g, parched baizhu (Atracty-lodes) 10 g, ganjiang (Zingiber) 3g, processed xiangfu (Cyperus) 10 g, gao-liangjiang (Alpinia officinarum) 3 g, and dazao (Ziziphus) four pieces.
After 5 days treatment the stomachache essentially abated. The formula was continued for a while to consolidate the therapeutic efficacy.
Case Study 2
The patient was a 71-year old male who had had stomach problems for 20 years. The current problem began 2 weeks ago, with periodic pain worst in the afternoon and the night. The pain was burning, and was accompanied by an epigastric mass, eructation, anorexia, and a dry mouth. The tongue was red with a coating that was yellow and greasy in the middle. The pulse was taut and threadlike.
Diagnosis. Stomachache caused by Dampness-Heat blocking the middle-jiao and failure of stomach-Qi to harmonize and descend.
Therapeutic Principle. Regulate Qi and settle the stomach by means of bitter to induce descending and acrid to unblock.
Treatment and Course. The formula prescribed had the following composition: parched huangqin (Scutellaria) 10 g, processed banxia (Pinellia) 10 g, zhuru (Phyllostachys nigra) 10 g, binglang (Areca) 10 g, wuyao (Lindera) 10 g, Shi Xiao San (Stasis-Relieving Powder) 10 g, chenpi (Citrus tangerina) 10 g, wuzhuyu (Evodia) 3 g, zisu stalk (Perilla) 3 g, baidoukou (Amomum cardamomum) 1.5 g, and jiangxiang (Dalbergia odorifera) 3 g.
After 2 days treatment the pain diminished. After five doses, it subsided and appetite improved.
