Six Proven Formulas for Stomach Cough (Cough Caused by Gastroesophageal Reflux Disease)

Among the various chronic coughs, one is gastroesophageal reflux cough—a chronic cough caused by reflux of gastric contents. It is easily misdiagnosed as pharyngitis-related cough, cough-variant asthma, postnasal drip syndrome, chronic bronchitis (especially eosinophilic chronic bronchitis), pulmonary tuberculosis, emphysema and other chronic diseases.

This disease has a long course; early patients mostly present with coughing while eating or after meals and a foreign-body sensation in the throat. It lingers and is hard to cure. As the disease progresses, acid regurgitation, heartburn, belching and retrosternal burning pain gradually appear, and the patient may also develop nervous tension. The diagnosis relies mainly on 24-hour pH monitoring, exclusion, and comprehensive diagnosis combined with the patient's symptom description; primary hospitals often lack such diagnostic conditions, so the disease is easily missed or misdiagnosed.

In traditional TCM, gastroesophageal reflux disease has its own disease name—stomach cough or spleen cough; in addition, the TCM disease names heartburn, stomach regurgitation and hiccups are also related to gastroesophageal reflux cough. TCM holds that this cough is caused by upward reversal of stomach qi. The Suwen (Plain Questions), "On Cough," records: "When spleen cough does not cease, the stomach receives it; the pattern of stomach cough is coughing with vomiting, and severe vomiting brings up long worms." Here "long worms coming out" should be understood flexibly; TCM often describes viscous sputum as long worms, and this is a common symptom of severe gastroesophageal reflux cough. In addition, in ancient times this disease often coexisted with ascariasis, so severe cases sometimes appeared together with TCM's "vomiting-worms disease" (ascariasis in vomit).

Early TCM mostly treated this disease with Yigong San (Exceptional Merit Powder), Wumei Wan (Mume Pill) and similar formulas, with varying effects. Later, special formulas for stomach cough were gradually developed. I select six proven formulas from the literature, with brief notes.

Proven Formula 1: Stomach Cough Formula (source: Wu Jutong's Medical Cases, Qing dynasty)

Composition: Banxia 3 qian (9 g), Xiao Zhishi (small immature bitter orange) 1 qian (3 g), Chenpi 1 qian (3 g), Xingren 2 qian (6 g), Sugeng (Perillae Caulis) 2 qian (6 g), Sheng Yiyiren 3 qian (9 g), Shengjiang 2 qian (6 g), Fuling 3 qian (9 g). Decoct in water; one packet divided into two doses, morning and evening.

Modifications: add Ku Tinglizi (Descurainiae Lepidii Semen) 1.5 qian (4.5 g), Banxia 2 qian (6 g), Suzi (Perillae Fructus) 2 qian (6 g); remove Sugeng and take two more packets.

Actions: move qi and harmonize the stomach, expel phlegm and stop cough. Treats stomach cough with phlegm-rheum congestion, panting fullness and shortness of breath.

This is an empirical formula of the Qing-dynasty physician Wu Jutong, derived from Er Chen Tang (Two-Aged Decoction), a famous TCM formula for drying dampness and resolving phlegm. In it, Chenpi and Banxia resolve phlegm and stop cough; Xingren and Sugeng descend qi and stop cough; Fuling and Sheng Yiyiren fortify the spleen and drain dampness to treat the root of phlegm; Xiao Zhishi dissipates glomus and removes stagnation; Shengjiang warms and transforms cold phlegm while harmonizing the stomach and stopping vomiting. Combined, these herbs treat both root and branch of gastroesophageal reflux cough.

Proven Formula 2: Modified Sini San (Four Counterflow Powder; source: TCM Guidance Journal, 2011, 17(10))

Composition: Chaihu 10 g, Gualou (Trichosanthis Fructus) 10 g, Fa Banxia 10 g, Zhishi 10 g, Chenpi 10 g, Baishao (Paeoniae Alba Radix) 15 g, Chuanbeimu 10 g, Gancao 5 g, Pipaye (Eriobotryae Folium) 15 g, Wuweizi 10 g, Sharen 6 g. Decoct in water; one dose daily in two divided doses, morning and evening; seven days per course, four consecutive courses.

Modifications: for post-meal fullness, add Maiya and Shenqu; for belching, add Yujin and Xiangfu; for retrosternal burning pain and acid regurgitation, add Haipiaoxiao (cuttlebone) and Shengdi, and increase Baishao; for yellow purulent sputum, add Huangqin and Yuxingcao (Houttuyniae Herba); for dry throat, add Maidong and Shashen (Glehniae Radix).

Actions: soothe the liver and regulate qi, drain heat and harmonize the stomach. Treats gastroesophageal reflux cough.

This is a modification of Zhang Zhongjing's Sini San, composed of Chaihu, Shaoyao, Zhishi and Gancao. It is one of the Chaihu-series formulas for Shaoyang syndrome; modern formulology textbooks classify it as a harmonizing formula, embodying the "harmonizing method" (he fa) of the eight TCM treatment principles.

Sini San vents constrained heat and soothes the liver and regulates the spleen; it treats yang-depression counterflow patterns with cold hands and feet, abdominal pain, or diarrhea with tenesmus and a wiry pulse; it also treats liver-spleen qi stagnation with hypochondriac fullness, epigastric and abdominal pain and a wiry pulse. Clinically it is used for chronic hepatitis, cholecystitis, cholelithiasis, biliary ascariasis, intercostal neuralgia, gastric ulcer, gastritis and esophagitis of the liver-gallbladder qi stagnation, liver-stomach disharmony type.

Using Sini San as the base formula is essentially treating the root of reflux gastroesophageal disease. Adding Gualou, Banxia and Chenpi resolves phlegm and stops cough; Chuanbeimu moistens the lung and stops cough; Pipaye clears the lung, descens rebellion and stops cough; Wuweizi astringes yin and stops cough; Sharen aids digestion. Combined, these follow the principle of treating both root and branch, so this prescribing approach is also excellent.

Proven Formula 3: Modified Xuanfu Daizhe Tang (Inula and Haematite Decoction; source: China Foreign Medical Treatment, 2008, 27(36))

Xuanfuhua (Inulae Flos) 9 g (wrapped), Dangshen 10 g, Daizheshi (Haematitum) 15 g (wrapped in cloth, decocted first), Zhi Gancao (processed licorice) 6 g, Jiang Banxia (ginger-prepared pinellia) 9 g, Shengjiang 2 slices, Dazao (Jujubae Fructus) 8 pieces, Mahuang (Ephedrae Herba) 9 g.

Modifications: for cold asthma presenting with clear, white, foamy sputum, cold body and limbs, and thin white or white slippery coating, add Xixin (Asari Herba), Ziwan (Asteris Radix) and Kuandonghua (Farfarae Flos) as appropriate; for hot asthma presenting with thick yellow sputum, difficult expectoration, red tongue and yellow greasy coating, add Huangqin and Sangbaipi (Mori Cortex) as appropriate. One dose daily, decocted in water, morning and evening.

Actions: expel phlegm and downbear qi, dissipate glomus and stop belching. Treats gastroesophageal reflux-associated asthma.

Xuanfu Daizhe Tang comes from Zhang Zhongjing's Shanghan Lun, composed of Xuanfuhua, Daizheshi, Renshen (Dangshen), Gancao, Banxia, Shengjiang and Dazao. It treats stomach deficiency with phlegm obstruction and upward-rebellion qi failing to descend; modern practitioners use it for acute and chronic gastritis, reflux esophagitis, nervous vomiting and pyloric obstruction. This formula cleverly adds Mahuang—herb that stops cough and calms wheezing—so that while treating digestive disease it also relieves cough and wheezing. This elegant composition is worth learning.

Proven Formula 4: Jiangni Hewei Zhike Tang (Rebellion-Downbearing, Stomach-Harmonizing Cough-Stopping Decoction; source: Hubei Journal of TCM, 2001, 23(9))

Fa Banxia 12 g, Zhiqiao (Aurantii Fructus) 12 g, Houpo 12 g, Binglang 12 g, Baibu (Stemonae Radix) 12 g, Chenpi 9 g, Huanglian 6 g, Wuzhuyu (Evodiae Fructus) 6 g, Laifuzi (Raphani Semen) 15 g, Duan Walengzi (calcined Arcae Concha) 45 g, Baiji (Bletillae Rhizoma) 60 g, Aidicha (Ardisiae Japonicae Herba) 24 g.

Modifications: for cold sensitivity in the epigastrium, remove Huanglian and add Gaoliangjiang (Alpiniae officinari Rhizoma); for qi deficiency, remove Huanglian and add Huangqi and Baizhu; for blood stasis, add Danshen and Yuanhu; for heat vexation, increase Huanglian, remove Wuzhuyu, and add Yuanhu and Chuanlianzi (Toosendan Fructus).

Soak the herbs in cold water for 2 hours before decocting. After boiling, simmer over low heat for 20 minutes; decoct three times and collect 750 ml. Take in three divided doses half an hour before meals.

Actions: downbear rebellion and harmonize the stomach, move qi and conduct stagnation. Treats gastroesophageal reflux cough.

This is a modification of the combined Zuojin Wan (Left Gold Pill) and Banxia Houpo Tang (Pinellia and Magnolia Bark Decoction). Zuojin Wan, composed of Huanglian and Wuzhuyu, drains fire, soothes the liver, harmonizes the stomach and stops pain; it treats liver fire invading the stomach with epigastric and hypochondriac pain, bitter mouth and gnawing hunger, vomiting sour fluid, and aversion to hot drinks. Banxia Houpo Tang, composed of Banxia, Houpo, Fuling, Zisu Ye and Shengjiang, moves qi and dissipates masses, downbears rebellion and transforms phlegm; it treats plum-pit qi (mei he qi) and throat foreign-body sensation—most of which are actually reflux diseases.

This formula modifies the two and adds Baiji to repair the digestive mucosa. But in my experience, when Baiji is used at 60 g it very easily triggers thrombotic disease; patients with a history of heart disease, cerebrovascular disease or arterial thrombosis must be especially careful. This formula actually also embodies the logic of Wu Ji San (Bletilla and Cuttlebone Powder), except that Wu Ji San uses Wuzeigu (cuttlebone) and Baiji, whereas here Duan Walengzi is paired with Baiji. Both Duan Walengzi and Wuzeigu are mainly calcium carbonate and neutralize gastric acid; Baiji repairs the gastric mucosa, giving this formula a root-treating effect on acid-related gastroesophageal disease.

The Binglang, Zhiqiao and Laifuzi in this formula regulate qi and downbear rebellion, serving as auxiliary symptomatic herbs; the Baibu and Aidicha and other herbs have specific cough-stopping and wheezing-calming effects.

Judging from its composition, this formula also adopts the approach of combining category-formulas and category-herbs into a compound that treats both root and branch.

Proven Formula 5: Zhiju Liujunzi Tang (Immature Bitter Orange-Red Tangerine Six-Gentleman Decoction; source: Shanxi Journal of TCM, 2009, 30(12))

Composition: Chao Maiya (fried barley sprout) 30 g, Dangshen 15 g, Zhe Beimu 15 g, Wuzeigu (cuttlebone) 15 g, Zhiqiao 10 g, Chenpi 10 g, Baizhu 10 g, Fuling 10 g, Banxia 9 g, Sheng Gancao 6 g. Decoct in water; one dose daily, morning and evening; seven days per course. During treatment, advise a reasonable diet: more vegetables, grains as the staple, less wheat products.

Modifications: for dry throat, add Tianhuafen and Shihu (Dendrobii Caulis); for vomiting, add Lugen (Phragmitis Rhizoma), ginger juice and Zhi Pipaye.

Actions: fortify the spleen and regulate qi, also diffusing the lung. Treats gastroesophageal reflux cough.

Liujunzi Tang (Six-Gentleman Decoction), composed of Dangshen, Baizhu, Fuling, Gancao, Chenpi and Banxia, boosts qi, fortifies the spleen, dries dampness and resolves phlegm; it treats phlegm-dampness due to spleen deficiency. This formula adds acid-neutralizing, pain-relieving Wuzeigu, adds Zhe Beimu to stop cough and wheeze, and adds Zhiqiao to regulate qi and downbear rebellion, treating both root and branch of gastroesophageal reflux cough.

Proven Formula 6: Baohe Wan Combined with Sanzi Yangqin Tang (Source: Journal of Guiyang College of TCM, 2010, 32(4))

Composition: Jiao Shanzha (scorched hawthorn) 30 g, Chao Shenqu (fried medicated leaven) 10 g, Zhi Banxia (processed pinellia) 10 g, Fuling 10 g, Chenpi 5 g, Lianqiao (Forsythiae Fructus) 5 g, Chao Maiya 5 g, Zisuzi (Perillae Fructus) 12 g, Baijiezi (Sinapis Semen) 10 g, Laifuzi 9 g. One dose daily, decocted in 500 ml water to 300 ml, divided into three doses.

Modifications: for marked belching and vomiting, add Xuanfuhua and Daizheshi; for lung yin deficiency, add Shashen and Tianhuafen; for lung-spleen qi deficiency, add Huangqi, Fuling and Baizhu; for qi deficiency with phlegm-stasis, add Taoren and Wushaoshe (Zaocys); for spleen-kidney yang deficiency, add Shanzhuyu (Corni Fructus) and Yinyanghuo (Epimedii Herba).

Actions: harmonize the stomach and downbear rebellion, diffuse the lung and stop cough. Treats gastroesophageal reflux cough.

Baohe Wan (Harmonizing Powder) is a famous formula of Zhu Danxi, one of the four great masters of the Jin-Yuan dynasty; composed of Shanzha, Shenqu, Banxia, Fuling, Chenpi, Lianqiao, Chenpi and Laifuzi, it digests food, conducts stagnation and harmonizes the stomach, treating food accumulation with epigastric fullness, foul belching and acid regurgitation, and poor appetite. Sanzi Yangqin Tang (Three-Seed Elder-Nourishing Decoction), composed of Zisuzi, Baijiezi and Laifuzi, warms the lung, resolves phlegm, downbears rebellion and stops cough. Combining these two formulas treats both the gastrointestinal and cough symptoms of gastroesophageal reflux cough.

All the above compositions embody the spirit of TCM pattern differentiation and treatment, with some formulas also incorporating disease differentiation. Different composing approaches lead by different roads to the same destination, all treating gastroesophageal reflux cough.