Subcostal Pain (Common Internal Medicine Disorders) (Chinese Medicine)

Subcostal pain is the pain mainly below the lower ribs on one or both sides of the waist or upper abdomen.

Etiology and Pathology

The liver is located in the right side of the subcostal region and its main and collateral meridians distribute to both sides. The gallbladder attaches to the liver. Thus, the main pathology of subcostal pain related to the liver and the gallbladder. However, the spleen, the stomach and the kidney are all involved as well.

Subcostal pain may be brought on by exogenous pathogenic evils or by internal injury. The key mechanism is the liver failing to regulate Qi movement and disharmony in its main and collateral meridians. Illnesses that present with subcostal pain may be of strength or deficiency. The main illnesses of strength are Qi stagnation, blood stasis and exogenous Dampness-Heat. The main illness of deficiency is depletion of essence and blood.

Stagnant Liver-Qi. Pent-up passions or rage can injure the liver. When this happens, the flow in the meridians and channels of the liver becomes impeded. Liver-Qi becomes stagnant and leads to subcostal pain.

Blood Stasis Blocking Channels. Qi is the commander of blood. When Qi flows smoothly blood circulates normally, and when Qi movement is impeded blood flow becomes sluggish. If impedance of Qi movement persists for a long time, blood stasis develops and blocks the channels in the subcostal region. Subcostal pain ensues. This can also result from direct traumatic injury to the subcostal region.


Gelling of Dampness-Heat in Liver-Gallbladder. Dampness, whether exogenous or endogenous due to improper diet injuring the spleen, may lodge in the interior, gel and give rise to Heat. Gelled Dampness and Heat can attack the liver and the gallbladder, impairing their ability to regulate Qi movement. This leads to subcostal pain.

Deficiency of Liver-Yin. Protracted illness or chronic overstrain may consume essence and blood, leading to their deficiency and producing subcostal pain. In such circumstances, the Water Element is unable to nourish the Wood Element. Excessive intake of acrid and drying herbs that regulate Qi can also induce deficiency of liver-Yin and failure to nourish the liver meridians and channels. This also induces subcostal pain.

Clinical Manifestation

Subcostal pain, whether one-sided or two-sided, may show several patterns. It may be distending in quality, migrate without fixed location and radiate to the shoulder or upper back. It may be stabbing or prickling in quality, have a fixed location and be accompanied by guarding. It may be vague and lingering in quality. In the initial stages subcostal pain tends to be relatively severe. After a while it tends to become vague and intermittent.

Subcostal pain may be accompanied by epigastric pain, distention or subcostal mass.

Key Points of Analysis

Exogenous versus Internal Injury. Exogenously induced subcostal pain tends to begin suddenly and be accompanied by symptoms of the exterior. These include nausea, vomiting, jaundice, a red tongue with yellow and greasy coating, and a floating and rapid or taut and rapid pulse. It is mainly due to attack on the liver and gallbladder by Dampness and Heat.

Subcostal pain due to internal injury tends to begin gradually and has a longer course. Exterior symptoms are absent. It is mainly due to stagnation of liver-Qi, blood stasis or deficiency of liver-Yin.

Qi versus Blood. Subcostal pain due to Qi stagnation tends to be distending in quality, does not have a fixed location and is aggravated or ameliorated by fluctuations in the emotional state. Subcostal pain due to blood stasis tends to be stabbing or prickling and lingering in quality. It has a fixed location, is accompanied by guarding and tends to be worse at night.

Strength versus Deficiency. Subcostal pain due to a strength illness tends to begin acutely, is relatively severe, and is accompanied by guarding and a full and forceful pulse. It is due mainly to Qi stagnation, blood stasis or Dampness-Heat. Of these Qi stagnation is the most common. Subcostal pain due to a deficiency illness tends to begin and develop gradually, is dull in quality with preference for pressure, and is accompanied by a weak pulse. It is mainly due to insufficiency of essence and blood.

Herbal Treatment

Stagnant Liver-Qi

Main Symptoms. Distending subcostal pain that is migratory, often radiating to the shoulder and upper chest or back. The severity of the pain varies with fluctuations in the emotional state. There may be chest tightness, epigastric distention somewhat relieved by eructation, much sighing and anorexia. The tongue coating is thin and white, and the pulse taut.

Therapeutic Principle. Soothe the liver, relieve stagnation and regulate Qi movement to stop pain.

Treatment. Chaihu Shu Gan San (Bupleurum Liver-Unblocking Powder).

If stagnant Qi has given rise to Fire, with agitation, bitter taste, dark urine, constipation, a red tongue with yellow coating and a taut and rapid pulse, remove acrid-warm chuanxiong and add mudanpi (Paeonia suffruticosa), zhizi (Gardenia), huanglian (Coptis), longdancao (Gentiana) and similar herbs that purge Liver-Fire.

If hyperactive liver-Qi attacks the spleen, with diarrhea and borborygmus, add baizhu (Atractylodes), fuling (Poria) and yiyiren (Coix) to strengthen the spleen and stop diarrhea.

If hyperactive liver-Qi attacks the stomach, with nausea and vomiting, add processed banxia (Pinellia) and shengjiang (Zingiber) to settle the stomach and stop vomiting.

Blood Stasis Blocking Channels

Main Symptoms. Stabbing subcostal pain fixed in location and worse at night; or, dark and lusterless complexion; or, subcostal mass. The tongue is cyanotic and the pulse deep and impeded.

Therapeutic Principle. Mobilize blood, remove stasis and unblock channels to stop pain.

Treatment. Xue Fu Zhu Yu Tang (Decoction for Releasing Blood Stasis).

If there is a subcostal mass but genuine Qi is not deficient, add sanleng (Sparganium), ezhu (Curcuma) and tubiechong (Eupolyphaga sinensis) to remove stasis and dissipate masses.

If blood stasis is especially severe, or there is severe traumatic injury, use Fu Yuan Huo Xue Tang (Decoction for Revival and Blood-Mobilization) instead. It has the following composition: dahuang (Rheum palmatum) 6g, taoren (Prunus persica) 10 g, honghua (Carthamus) 10 g, chuanshanjia (Manis pentadactyla) 10 g, tianhuafen (Trichosanthes) 10 g, chaihu (Bupleurum) 10 g, danggui (Angelica) 10g, and gancao (Glycyrrhiza) 10 g.

Gelling of Dampness-Heat in Liver-Gallbladder

Main Symptoms. Distending or suffocating subcostal pain, exquisitely tender to touch; anorexia, nausea; aversion to fatty or oily foods; bitter taste; dry mouth; or, jaundice; or, chills and fever. The tongue coating is yellow and greasy, and the pulse taut and slippery.

Therapeutic Principle. Cool Heat, eliminate Dampness, regulate Qi and unblock channels.

Treatment. Longdan Xie Gan Tang (Liver-Clearing Gentiana Decoction).

If subcostal pain, nausea and vomiting are especially severe, remove danggui and shengdihuang and add chuanlianzi (Melia), yujin (Curcuma), processed banxia (Pinellia) and chenpi (Citrus tangerina) to enhance the actions of soothing the liver, regulating Qi, settling the stomach and suppressing the abnormally risen.

If gelled Dampness-Heat forms stones, which block the bile duct and produce subcostal pain that radiates to the shoulder and upper back, add jinqian-cao (Glechoma), haijinsha (Lygodium), yujin (Curcuma), jineijin (Gallus gallus domesticus) to remove gallstones.

If the subcostal pain is excruciating and the patient vomits ascarid worms, prescribe Wumei Wan first to subdue the worms followed by a vermicide.

If Heat is very strong and damages the body fluids, with abdominal distention and constipation, add dahuang (Rheum palmatum) and mangxiao (Mirabilite) to relax the bowels and purge Heat.

Deficiency of Liver-Yin

Main Symptoms. Continual vague subcostal pain aggravated by fatigue; dry mouth and throat; restless agitation; dry eyes; and dizziness with blurred vision. The tongue is red, with slight coating. The pulse is taut, threadlike and rapid.

Therapeutic Principle. Nourish Yin, soften the liver, generate blood and unblock channels.

Treatment. Yi Guan Jian (Yin-Generating Liver-Opening Prescription).

For prominent restless agitation and dry mouth, add mudanpi (Paeonia suffruticosa), zhizi (Gardenia) and suanzaoren (Ziziphus) to cool Heat and calm the mind.

For dry eyes with photophobia or blurred vision, add nuzhenzi (Ligustrum) and juemingzi (Cassia obtusifolia) to nourish the liver and restore vision.

Acupuncture Treatment

Stagnant Liver-Qi. Select the acupoints Qimen (LR-14), Yanglingquan (GB-34) and Taichong (LR-3). Use filiform needles and apply the reducing method.

Blood Stasis Blocking Channels. Select the acupoints Qimen (LR-14), Yan-glingquan (GB-34) and Sanyinjiao (SP-6). Use filiform needles and apply the reducing method.

Gelling of Dampness-Heat in Liver-Gallbladder. Select the acupoints Qimen (LR-14), Yanglingquan (GB-34) and Zhigou (SJ-6). Use filiform needles and apply the reducing method.

Deficiency of Liver-Yin. Select the acupoints Ganshu (BL-18), Shenshu (BL-23), Qimen (LR-14) and Sanyinjiao (SP-6). Use filiform needles and apply the reinforcing method.

Case Study

The patient was a 36-year old male who had right-sided subcostal pain for half a year. For 1 day prior to admission, the pain suddenly became severe. It was stabbing in quality and radiated to the right shoulder and upper back. He had mild fever. His urine was dark yellow and his feces were watery. His tongue coating was yellow and greasy, and his pulse taut. Ultrasound study showed sand-like stones in the bile tract.

Diagnosis. Gelled Dampness-Heat in the liver and the gallbladder impeding drainage.

Therapeutic Principle. Unblock the liver and the gallbladder.

Treatment and Course. Chaihu Pai Shi Tang (Bupleurum Stone-Eliminating Decoction). It has the following composition: chaihu (Bupleurum) 18 g, huangqin (Scutellaria) 10 g, jinqiancao (Glechoma) 30 g, huzhang (Polygonum) 16 g, haijinsha (Lygodium) 10 g, yanhusuo (Corydalis) 10 g, jineijin (Gallus gallus domesticus) 10 g, chuanlianzi (Melia) 10 g, yuxingcao (Houttuynia) 15 g, yinchenhao (Artemisia) 15 g, baishaoyao (Paeonia) 16 g, and liujinu (Artemisia anomala) 10 g.

After seven doses all symptoms significantly improved. The prescription was continued. One and a half months later, ultrasound study showed that the sand-like stones were gone.

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