Chengqi Tang for Resolving Incomplete Intestinal Obstruction in Cancer Patients

When the contents of the intestine cannot move or pass normally, the condition is called intestinal obstruction. By severity, intestinal obstruction is divided into complete and incomplete obstruction.

A milder obstruction is called incomplete intestinal obstruction, a common abdominal-surgical condition. Patients with incomplete obstruction generally have difficult defecation, thinned stool, abdominal pain, abdominal distention, and intestinal bloating. Complete obstruction usually develops from incomplete obstruction: the intestinal tube is fully blocked, contents cannot pass at all, and symptoms are more severe—intense abdominal pain, vomiting, distention, and cessation of flatus and defecation at the anus.

Advanced cancer patients often develop intestinal obstruction. If the tumor is large enough to cause complete obstruction, there is no good option apart from palliative surgery and ostomy. But if it is incomplete obstruction, the TCM "purging method" can still play a role.

Whether the obstruction is complete or incomplete, the patient should no longer take hard-to-digest pill medicines; they should take decoctions and powders instead. If pills accumulate undigested in the digestive tract, they worsen the obstruction and, in severe cases, can be fatal.

For advanced cancer patients with complete obstruction, TCM decoctions do not help much either; the patient should promptly undergo palliative surgery and ostomy to relieve gastrointestinal burden, and only afterward consider oral medicines to control rapid tumor progression.

Chengqi Tang is the formula most used in TCM for intestinal obstruction, but Chengqi Tang is a series of formulas, not a single one. The ones I commonly use include Zengye Chengqi Tang, Huanglong Tang, Da Chengqi Tang, Xiao Chengqi Tang, Tiaowei Chengqi Tang, Fufang Chengqi Tang, Chengqi Yangying Tang, and Dahuang Gancao Tang.

I also often combine Chengqi Tang with Xia Yu Xue Tang, Dahuang Mudanpi Tang, and Siwu Tang to resolve the patient's obstruction.

Out of personal habit, I use Zengye Chengqi Tang most, because among the Chengqi Tang formulas it is the safest.

Zengye Chengqi Tang: xuanshen (scrophularia) 30 g, sheng dihuang (raw rehmannia) 24 g, maimendong (ophiopogon) 24 g, mangxiao (mirabilite) 30 g (taken in two divided doses), raw dahuang (rhubarb) 3–30 g (the rhubarb dose can be adjusted to the patient's constitution).

But when I use Zengye Chengqi Tang for weak advanced cancer patients, I usually do not use it as-is; I use my own modified version: xuanshen 30 g, sheng dihuang 24 g, maimendong 24 g, danggui (angelica) 12 g, baishao (white peony) 12 g, roucongrong (cistanche) 30–90 g, huomaren (hemp seed) 30 g, yuli ren (bush cherry seed) 30 g, huangjing (polygonatum) 15 g, yuzhu (Solomon's seal) 15 g.

Why remove the harsh mangxiao and dahuang and replace them with mild laxatives like danggui, baishao, roucongrong, huomaren, and yuli ren, and add tonics like huangjing and yuzhu? Because most modern advanced cancer patients are already extremely weak, and their families are usually laypeople who cannot give careful care; a careless slip while taking rhubarb and mirabilite could cause a medical accident.

Of course, for young, robust advanced cancer patients, the original Zengye Chengqi Tang may be used. But when doing so, the doctor must stay in twenty-four-hour contact with the patient. Once the bowels move, the patient must be told at once to stop Zengye Chengqi Tang and switch to a gentler lubricating laxative. A moment's carelessness with such critically ill patients can bring disaster.

In earlier years I was often called to emergency consultations and treated many obstruction patients; the results won praise even from experienced Western physicians. What I used most were Zengye Chengqi Tang and its various modifications tailored to each patient—effective and safe.

Whether complete or incomplete, intestinal obstruction is a critical acute abdominal condition. To avoid unnecessary doctor-patient disputes, when the family demands too much yet trusts too little, I firmly decline to treat. Treating such acute abdomen carries very high risk; if the family does not understand, a doctor who rushes in is simply laying his neck on the blade.

Huanglong Tang is another formula I commonly use for obstruction. It comes from the Shanghan Liushu; the Ming physician Tao Jiean modified Da Chengqi Tang to treat weak patients, so strictly speaking it is also part of the Chengqi Tang series.

My usual Huanglong Tang dose: dahuang 3–30 g, mangxiao 10–30 g, danggui 10 g, zhishi (immature bitter orange) 10 g, renshen (ginseng) 6 g, houpo 6–30 g, gancao 3 g, jiegeng (platycodon) 3 g, fresh ginger 3 slices, jujube 2–5 pieces.

The Wenbing Tiaobian adds Xinjia Huanglong Tang, which removes the zhishi, houpo, jiegeng, ginger, and jujube of Huanglong Tang and adds sheng dihuang, maimendong, and xuanshen, each 15 g, plus two sea cucumbers. It is essentially a modified combination of Zengye Tang and Da Chengqi Tang.

Both Huanglong Tang and Xinjia Huanglong Tang suit very weak incomplete-obstruction patients who pass clear watery stool of a bluish-green color, or have bound stool, abdominal pain that resists pressure, fever and thirst, fatigue and shortness of breath, even clutching at clothes and gazing into space, clouded spirit and cold limbs, a dry yellow or dry black burnt coating, and a weak, forceless pulse. This is seen mostly in end-stage cancer patients. Treating them requires both purging heat and supporting upright qi, hence formulas like Huanglong Tang and Xinjia Huanglong Tang that do both.

Da Chengqi Tang gives quick results for obstruction patients with a large amount of dry stool in the colon. It consists of four herbs—dahuang, mangxiao, houpo, and zhishi—whose doses are adjusted to the patient's condition. Abdominal palpation is required: press around the navel. If the area around the navel is hard, the pain resists pressure, and there is sweating or even fever, Da Chengqi Tang may be used.

When Zhang Zhongjing used Da Chengqi Tang he often first tried Xiao Chengqi Tang to test the response. Xiao Chengqi Tang is Da Chengqi Tang minus mangxiao, with reduced doses. Only after the patient "passes flatus" (breaks wind) after Xiao Chengqi Tang would he use Da Chengqi Tang. This shows Zhang Zhongjing was cautious in clinical use and did not abuse Da Chengqi Tang.

Tiaowei Chengqi Tang is Da Chengqi Tang minus zhishi and houpo, plus honey-fried licorice. It suits obstruction patients with milder disease and insufficient original qi.

Chengqi Yangying Tang is Da Chengqi Tang minus mangxiao, plus sheng dihuang, baishao, danggui, and zhimu (anemarrhena). It not only softens the purgative action but also adds yin-nourishing, blood-enriching sheng dihuang, baishao, danggui, and zhimu—again accounting for the patient's weakness.

Fufang Chengqi Tang is Da Chengqi Tang with zhishi changed to zhike (immature bitter orange, shell), plus stir-fried laifuzi (radish seed) 15–60 g, chishao (red peony) 10–15 g, and taoren (peach kernel) 6–9 g. It is used for incomplete obstruction with especially severe intestinal bloating.

When using the Chengqi Tang series, you must first communicate fully with the patient and family, explaining the principle of this TCM purging method for obstruction, and warn them in advance of the side effects: diarrhea and abdominal pain.

Modern patients generally welcome tonics but fear purgatives. If the patient and family are not reasonable, do not fully understand medical risk, or cannot accept the side effects, Chengqi Tang must not be used.

Chengqi Tang must follow the ancient principle of "stop once the disease is reached." After relieving the obstruction, switch to lubricating laxatives such as Maren Wan and do not continue Chengqi Tang. When prescribing Chengqi Tang, give only one day's dose at a time. Tell the patient to observe patiently for eight hours after the first dose; if the bowels move within those eight hours, stop. If not, another dose may be taken after eight hours, with the purgative strength adjusted as appropriate.

I once treated an end-stage cervical-cancer patient with Zengye Chengqi Tang. Before taking it, this patient was in agonizing pain from obstruction, and the Western physicians at her Sichuan Cancer Hospital wanted to operate. But the patient refused surgery and insisted I treat her with Chinese medicine.

I prescribed Zengye Chengqi Tang. After taking it the pain grew even more excruciating; after ten hours of distress the bowels finally moved. With just one dose, the severe pain that had tormented her for nearly a month was resolved. But during those ten hours I myself was on tenterhooks, truly feeling that life was not worth living, fearing an accident.

So when using these formulas, be cautious again and again. Unless there is especially strong mutual trust, do not lightly prescribe them. TCM physicians lacking clinical experience must be extra careful. TCM enthusiasts, patients, and families with modest skill must be doubly cautious in choosing Chengqi Tang. If you misjudge the strength, the result backfires: too weak a dose not only fails to help but worsens the patient's suffering, while too strong a dose is very unsafe. So use this series only under the guidance of an experienced TCM physician.

Here I also want to remind patients and families: in treating severe disease, doctors risk their own lives and livelihoods to win a slim chance for the patient. Doctors are not gods; if the patient and family are not rational, no doctor dares to take the risk of truly meaningful treatment. Many patients who had a slim chance were given up on for exactly this reason.