Clinical Experience: Treating Post-Infectious Ileus in an Elderly Patient
Cheng, male, 84 years old, was admitted to Fuyang District First People's Hospital in Hangzhou on January 31, 2024 (admission no. 02434411) for severe constipation following COVID-19 infection and community-acquired pneumonia. The patient had a history of type 2 diabetes, hypertension, and coronary atherosclerotic heart disease, with prior cardiac stent placement. After five days in hospital, despite treatments such as enemas and laxatives, the constipation worsened daily, and the hospital diagnosed intestinal obstruction. Because of limited local medical resources, the patient was transferred to Zhejiang Provincial First Hospital for continued treatment; conventional Western laxative therapy produced very poor results.
On February 7, 2024, the patient's family remotely sought my help, hoping I could offer suggestions from a TCM perspective. By then the patient had not had normal bowel movements for nine days; his abdomen was distended like a drum, though he could occasionally pass gas, so this was likely partial intestinal obstruction that could still be treated with oral medication. But given the patient's advanced age and multiple underlying diseases, medication had to be especially cautious—excess or deficiency could both cause adverse consequences. I therefore advised the family to first try the safer Zengye Tang augmented.
The formula was as follows: 30g of scrophularia root (Xuanshen), 24g of unprocessed rehmannia root (Shengdi), 24g of Ophiopogon tuber (Maidong), 12g of Chinese angelica (Danggui), 12g of white peony root (Baishao), 60g of cistanche (Roucongrong), 30g of hemp seed (Huomaren), 20g of mirabilite (Mangxiao, dissolved in two divided doses), 15g of magnolia bark (Houpo), and 10g of costus root (Muxiang). Three doses. I also instructed the family to separately buy 50g of unprocessed rhubarb (Sheng Dahuang); if the above was ineffective, 10–20g of rhubarb could be added when decocting the second packet.
First decoct one dose in water and take it in two divided portions. After the first portion, observe for eight hours; if no stool passes, take the remaining medicine. The patient began taking the medicine at 10:30 on February 7. Around 11:30, the family reported that the patient began to feel uncomfortable. I told them that such laxative herbs cause a period of discomfort after taking effect, and to keep observing.
Around 13:30, the patient passed stool—not much in volume and loose—but flatus increased markedly. The abdomen remained distended like a drum, containing both retained stool and intestinal gas. The family wanted stronger treatment to speed things up. I therefore told them to add 10g of unprocessed rhubarb and 10g of immature bitter orange (Zhishi) when decocting the second packet. After taking one more dose with these two added, the patient passed a large amount of stool, flatus also increased, and abdominal distension markedly decreased. Because constipation had lasted so long, the stool was black; examination revealed gastrointestinal bleeding, for which he was given hemostatic treatment.
After finishing the second dose, the family asked me for a further plan. I advised stopping the decoction and switching to Muxiang Shunqi Pills for recovery. If the patient still had difficulty passing stool later, they could use some probiotics to regulate the gut, with no need for further laxatives. The family followed this plan; the elderly patient's intestinal gas further improved and basically returned to normal.
Why should strong purgatives not be used on such elderly patients? Because the elderly are frail; if the medication is too strong, it easily overshoots and causes relentless diarrhea, further weakening the patient. The modified Zengye Chengqi Tang is exactly suited to such elderly people. Elderly patients have poor intestinal motility together with qi and blood deficiency; Zengye Chengqi Tang plus white peony, Chinese angelica, and cistanche both improves constipation and provides tonification. To treat such elderly patients safely and effectively, one must simultaneously attack and tonify, and closely observe the patient's response after dosing.