TCM Treatment of Tympanites (Ascites)

Cancer and late-stage liver cirrhosis often produce complications such as ascites. This condition, in ancient TCM, belongs to tympanites (gu zhang), one of the four major TCM miscellaneous-disease patterns (wind, consumption, tympanites, and diaphragm). It was listed among the four because the prognosis of tympanites (ascites) is quite poor.

Overview of tympanites (ascites)

Tympanites is named for the abdomen swelling like a drum; from ancient times to the present it has been a critical, poorly-prognosis condition. In TCM, tympanites corresponds to the ascites seen in modern medicine in cancer, late-stage cirrhosis, and advanced schistosomiasis. Ancient TCM already recognized that late-stage tympanites (ascites) shows external signs such as red skin spots, red streaks, and crab-claw markings; the patient's abdomen remains distended, the skin sallow and yellow, blue veins stand out, and the limbs are not swollen or only slightly swollen.

Tympanites (ascites) is very difficult to treat; often it is just brought down in the morning only to rise again at night. Therefore, when treating patients with tympanites (ascites), one must judge the situation and must not abuse fierce, tiger-and-wolf-like purgative herbs. Such patients usually already have cachexia and are extremely weak; once fierce herbs are used, the patient collapses at the first blow, and afterward it is nearly impossible to recover them. In the author's experience, Shizao Tang (Ten-Jujube Decoction), Zilong Wan, and Zhengzheng Wan used for ascites in advanced cancer patients without exception led to rapid death. Rather than using such drastic purgative diuretics, it is better to go to the hospital and draw off part of the ascites to reduce the patient's physical burden.

Ascites is one of the complications extremely hard to avoid when cancer develops to a certain stage. TCM literature divides tympanites into qi tympanites, water tympanites, and gu (parasitic) tympanites; the author personally considers this division of no practical significance. Some so-called qi tympanites do not belong to true tympanites and need not be classified as such.

The pathology of tympanites (ascites) is generally considered closely related to the spleen and stomach. Li Dongyuan held that 'when spleen-stomach qi is weak and cannot transport the refined essence, water and grain accumulate without dispersing, forming fullness.' Liu Hejian held that tympanites arises from internal accumulation of hot qi that does not disperse but gathers. Zhu Danxi held that tympanites is produced when 'damp-heat mutually engenders, the clear and turbid become mixed, and the waterways are obstructed.' The Ming physician Li Ting recognized that tympanites, 'fullness initially arising from qi, over time becomes water'; 'to treat fullness one must supplement the center and drain dampness, together with dispersing accumulation, and further cut out salt and soy sauce.' Zhang Jingyue proposed that treating fullness should consider the patient's deficiency/excess, qi/blood, and cold/heat. The Zabing Yuanliu Xizhu already recognized that tympanites patients may develop mental abnormalities (i.e., hepatic encephalopathy, hepatic coma, etc.) and bleeding and other severe complications.

From the modern-medicine viewpoint, some tympanites (ascites) is treatable and some is not. For ascites patients in reasonably good condition, with certain treatment, after the ascites resolves the patient can live and work normally. But for terminal cancer patients or late-stage schistosomiasis patients, because strength is exhausted, treatment is already hard to make effective. Unless a therapy with definite impact on cancer cells is found, treatment mostly ends in failure. Tympanites (ascites) patients may finally develop hepatic coma, massive hemorrhage, and pulmonary infection, and die from these complications.

Early ascites patients, not yet through much turmoil, will respond to TCM methods of smoothing qi movement, fortifying the spleen and transforming dampness, and dispersing accumulation and fullness; the trauma is small and the effect is certain.

Cause and mechanism of tympanites (ascites)

TCM holds that tympanites (ascites) is mainly caused by intemperate wine and food, emotional injury, or prolonged hepatitis and untreated accumulation. The key lies in damage to the spleen and stomach, disordered transportation, mixing of the clear and turbid, and damp-heat congestion; liver qi rebels horizontally, wood overacts on earth, invading the spleen and stomach; qi movement is obstructed, blood flow is poor, and the channels and collaterals are blocked. In tympanites (ascites) patients, the functions of the liver, spleen, and kidney are all damaged, leading to qi stagnation, blood stasis, and water retention accumulating in the abdomen. The standard Western treatment is diuretics, which modern TCM also uses heavily, but the effect is not very good. The author believes that tympanites (ascites) should be treated with a comprehensive approach and comprehensive means.

The author has personally treated several cases of tympanites (ascites); some responded well, and some were beyond the author's ability. The approach in each case differed, but overall I still emphasized tonifying the kidney and fortifying the spleen while smoothing qi movement and reducing inflammation and bacteria. In my experience, treating ascites of advanced cancer solely with water-draining herbs such as Wuling San or Wuling capsules, although slightly effective, is not markedly effective.

Pattern-based treatment of early tympanites (ascites)

Treatment of ascites patients should fully consider their constitution. If the constitution is still good, using an approach focused on smoothing qi movement, appropriately combined with some water-draining herbs, with both physician and patient patient, the ascites can usually be safely and effectively absorbed within about a month, without aftereffects, after which the patient can live and work normally.

There was once an advanced liver-cancer patient with ascites who, after two famous old Beijing TCM physicians failed with water-draining treatment, came to the author. The author, using as the main approach Professor Zhao Shaoqin's commonly used cancer-treatment combination of Shengjiang San (Ascending-Descending Powder) plus Shengmai Yin (Pulse-Generating Drink), supplemented with qi-smoothing and phlegm-transforming, nodule-dispersing herbs, the author treated the patient for over a month; not only did the ascites completely disappear, but the cancer markers also fell to normal. The four prescriptions were as follows:

December 1, 2013

The patient, after half a month of prior treatment with raw Huangqi 30 g, Baizhu 30 g, Zhuling 30 g, Dongguapi (Benincasae Exocarpium) 30 g, Tinglizi (Descurainiae Semen) 30 g, Cheqianzi (Plantaginis Semen) 20 g, Xuanfuhua (Inulae Flos) 10 g, raw Zheshi (Hematitum) 10 g, Houpo 10 g, Dafupi (Arecae Pericarpium) 20 g, Chenpi 15 g, Danggui 10 g, Caohuoche (Polygoni Bistortae Rhizoma) 30 g, Shancigu (Cremastrae/Appendiculatae Pseudobulbus) 10 g, Lufengfang (Vespae Nidus) 5 g, Lulu (Rhapontici Radix) 30 g, still had ascites and sought treatment. The initial diagnosis differentiated liver depression together with lung cold and phlegm; treatment focused on transforming phlegm and dispersing nodules, smoothing qi movement, and clearing and draining damp-heat. Prescription:

Shashen 10 g, Maidong 10 g, Wuweizi 10 g, Pianjianghuang (Curcumae Longae Rhizoma) 6 g, Chantui 6 g, fried Jiangcan (Bombyx Batryticatus) 10 g, Yujin (Curcumae Radix) 6 g, Chaihu 6 g, Xiangfu 10 g, Xuanfuhua 10 g, Xingren 10 g, Pipaye (Eriobotryae Folium) 10 g, Maozhaocao (Ranunculi Ternati Radix) 30 g, Xuchangqing (Cynanchi Paniculati Radix) 15 g, Yinchen (Artemisiae Scopariae Herba) 10 g, fried Zhizi 6 g, Banzhilian 10 g, Baishao 10 g, Chishao (Paeoniae Rubra Radix) 10 g, Qiancao 10 g, raw Huangqi 20 g, Qianliguang (Senecionis Scandentis Herba) 15 g, Qinpi 10 g.

On December 8, the follow-up visit reported dull periumbilical pain after taking the above, loose stool, indigestion after meals, and a dragging, stagnant, distended feeling around the ribs. Prescription:

Dangshen 15 g, Fabanxia (processed Pinelliae Rhizoma) 10 g, Chenpi 10 g, Zisu (Perillae Folium) 10 g, Chaihu 10 g, Huangqin 10 g, Huanglian 6 g, Pianjianghuang 6 g, Chantui 6 g, fried Jiangcan 10 g, Maozhaocao 30 g, Baihua Sheshecao 30 g, Zhizi 10 g, fried Baizhu 10 g, Cangzhu 10 g, fried Zhiqiao 10 g, Jineijin (Galli Gigerii Endothelium Corneum) 30 g, Jiaoshanzha 15 g, Shuihonghuazi (Polygonorientis Semen) 10 g, Ezhu 6 g, Zhigancao (honey-fried Glycyrrhizae Radix) 6 g, Muxiang 10 g, Fuling 15 g, Zhuling 15 g, Baishao 15 g.

On December 14, the third visit reported deep gastric erosion after prior interventional therapy; long-standing gastric discomfort, occasional twinging abdominal-muscle pain, and wiry pulse. Prescription:

Chenpi 6 g, Chaihu 6 g, Chuanxiong (Ligustici Chuanxiong Rhizoma) 4 g, fried Zhiqiao 4 g, Chishao 6 g, Zhigancao 2 g, Xiangfu 6 g, Maozhaocao 30 g, Gualoupi (Trichosanthis Pericarpium) 30 g, Baihai shi ... 30 g, raw Shigao (Gypsum Fibrosum) 30 g, Yinchen 10 g, Baiji 6 g, Duanwaleng (calcined Arcae Concha) 15 g.

Taken together with compound berberine tablets and Xiangsha Liujun Wan.

On December 22, the pulse was basically steady and all symptoms improved. Prescription:

Chaihu 12 g, Huangqin 12 g, Fabanxia 10 g, Dangshen 15 g, Baishao 12 g, Chishao 12 g, Zhigancao 6 g, Yinchen 6 g, Maozhaocao 30 g, Shandougen (Sophorae Tonkinensis Radix) 6 g, Baihua Sheshecao 30 g, Xiangfu 10 g, Xingren 10 g, Jiangcan 10 g, Chantui 6 g, Pianjianghuang 6 g, ginger 5 slices, jujube 5 pieces.

Examination one week later showed the ascites gone and cancer markers down to normal. The patient was then adjusted with this approach for over a year and in good condition. Later, out of admiration for fame, the patient went to another well-known anticancer professor, changed the treatment approach, and died.

Another patient with peritoneal mesothelioma also came to the author for ascites. The author gave modified Yanghe Tang, using almost none of the common water-draining herbs; the ascites also disappeared after about a month of medication, cancer markers returned to normal, and the patient still follows up and works and lives normally. The author organized the treatment record in the article 'A Two-plus-Year Pure-TCM Case Record of a Shandong Mesothelioma Patient' and will not repeat it here.

For such patients in reasonably good condition, during treatment the author almost disregarded the ascites itself and directly sought the root cause triggering the ascites; as a result, the ascites was dealt with very safely.

These two patients had both previously sought treatment from well-known TCM professors, whose approaches all centered on draining water. I personally do not believe that a cancer patient's ascites can be treated by draining water alone; one should treat the disease for its root, with only appropriate attention to draining water. Otherwise, if the root cause is not removed, although water-draining herbs may temporarily increase urine output, ascites will continuously reaccumulate, and such treatment is of little meaning.

Early ascites patients, although ascites can already be detected, have only a slightly protruding abdomen, no exposed blue veins on the abdominal skin, and no marked resistance on palpation—some abdomens are even fairly soft. Such patients are not yet fated to die; their strength is generally good and they can still eat and live normally. Early ascites may also be treated with acupuncture or moxibustion, mainly garlic-separated warm moxibustion around the navel.

Treatment of middle-stage tympanites (ascites)

When ascites enters the middle stage, it has usually persisted for a long time or been improperly treated, so that the ascites worsens day by day and interferes with normal living and eating; treatment is already quite difficult. The author lacks experience treating such patients, so below I introduce several approaches compiled by Professor Zhao Shaoqin for middle-stage ascites, for readers' reference. Professor Zhao mainly differentiated middle-stage ascites into three types: qi tympanites, blood tympanites, and water tympanites, each with different treatment principles. Even so, there is one overarching principle: TCM emphasizes that when treating a major illness one should 'stop once more than half is reduced'; ascites should not be pursued over-aggressively, and treatment should reach only the point of relieving the patient's suffering, after which the body is conditioned by nourishing qi and blood and fortifying the spleen and kidney. Under no circumstances should treatment be too fierce, or it will cause the patient to die too quickly.

Qi-tympanites type ascites

Such patients have a distended, bloated abdomen that sounds like a drum when tapped; chest and rib-side fullness and pain; poor appetite, marked postprandial abdominal distension; belching and scant urine; white greasy tongue coating; wiry slippery pulse.

Method: soothe the liver and move qi, eliminate dampness and fullness.

Formula, modified Zhongman Xiaofen Wan: Houpo 10 g, Zhishi (Aurantii Fructus Immaturus) 6 g, Huanglian 3 g, Huangqin 10 g, Zhimu (Anemarrhenae Rhizoma) 6 g, Banxia 10 g, Chenpi 6 g, Fuling 10 g, Zhuling 10 g, Zexie 10 g, Sharen 3 g, Ganjiang 3 g, Jianghuang 6 g, Renshen 3 g (ground, taken separately), Baizhu 10 g, Gancao 10 g.

Modifications: for scant urine, add Suye (Perillae Folium), Xingren, Cheqianzi, Qumai, etc.; for severe abdominal distension, add Muxiang, Dafupi, Dafuzi (Arecae Semen), etc.; for single abdominal distension with dark complexion and yellow scant urine—qi stagnation with heat—use Paichai Yin plus Baimaogen (Imperatae Rhizoma), Cheqiancao (Plantaginis Herba), etc.

Blood-tympanites type ascites

Long-standing tympanites has entered from the qi phase into the blood phase: the abdomen is large and hard, the abdominal skin is faintly purplish-red, there is a palpable mass under the rib-side, the face is stasis-dark, spider angiomata on the head and neck, lips purple-brown, hematemesis and epistaxis, black stool; deep rough or fine pulse, thin red dry tongue with petechiae.

Method: invigorate blood and dispel stasis.

Formula, modified Huayu Tang: Danshen 10 g, Mudanpi (Moutan Cortex) 10 g, Danggui 10 g, Chishao 10 g, Qiancao 10 g, Jianghuang 6 g, Dahuang 3 g, Chuanxiong 10 g, Xiangfu 10 g, Chuanlianzi 6 g, Wulingzhi (Trogopterori Faeces) 10 g, Taoren (Persicae Semen) 6 g, Muli 20 g (decocted first), Zhenzhumu (Margaritiferae Concha) 15 g (decocted first).

This pattern arises when blood stasis obstructs the liver-spleen collaterals and the waterways are blocked. The formula is composed of blood-nourishing and blood-activating, blood-cooling and stasis-resolving, and hardness-softening and nodule-dispersing herbs, jointly activating blood and resolving stasis, moving qi and dispersing hardness and water.

Water-tympanites type ascites

These patients mainly present with thin abdominal skin, a large abdomen with shifting dullness, sallow complexion, exposed blue veins, protruding navel, scant urine, white greasy tongue coating, and moderate soft slippery pulse. This type is mainly ascites and is usually treated in three subtypes:

1. Cold-damp type: white, moist, slippery tongue; deep soggy weak pulse; aversion to cold; loose stool. Treatment warms yang, disperses cold, transforms dampness, and disinhibits water.

Formula, modified Shiyi Yin (True-Solid Beverage): Fuzi 6 g, Ganjiang 3 g, Baizhu 10 g, Gancao 10 g, Houpo 10 g, Muxiang 6 g, Caoguo (Tsaoko Fructus) 4 g, Dafuzi 10 g, Fuling 10 g, Mugua (Chaenomelis Fructus) 10 g, fresh ginger 3 slices, Dazao 5 pieces.

This formula mainly addresses cold-damp retention blocking the middle yang, with water stored and not moving, hence the large, full abdomen; treatment should disperse cold, warm yang, and transform dampness. In the formula, Fuzi, Ganjiang, and Caoguo warm yang, disperse cold, and eliminate dampness; Baizhu and Gancao fortify the spleen and transport dampness; Houpo, Muxiang, Dafuzi, and Mugua broaden the middle, move qi, and transform dampness; Fuling seeps dampness and disinhibits water. Together they restore spleen yang and transform water-dampness.

Zhiyuan's note: Such patients may also respond to formulas from the Shenqi Wan series; Jisheng Shenqi Wan has a good diuretic effect on them. The Jingui Shenqi Wan now produced by Tongrentang is actually the formula of Jisheng Shenqi Wan, containing Cheqianzi and Niuxi—note this when purchasing.

2. Damp-heat type ascites

In addition to ascites, damp-heat-type patients show irritability, bitter mouth, many dreams, dark urine and dry stool, red tongue edges and tip, yellow greasy coating, wiry rapid pulse. Treatment clears heat and transforms dampness.

Formula, modified Yinchenhao Tang plus Daochi San: Yinchen 10 g, Zhizi 6 g, Dahuang 6 g, Mutong (Akebiae Caulis) 2 g, Gancaoshao (Glycyrrhizae Radix tip) 10 g, Zhuye (Lophatheri Herba) 10 g, Shengdi 10 g.

Modifications: for severe water-dampness obstruction, temporarily use Zhouche Wan, 2–3 g each time, 1–2 times daily. For sudden massive bleeding due to heat forcing blood to overflow, try Xijiao Dihuang Tang. For damp-heat obscuring the pericardium with coma, use Angong Niuhuang Wan or Zhibao Dan, but the dose must be small.

3. Dual yin-yang deficiency type ascites

Long-standing ascites patients, with emotional tension and severe yin depletion, show dry mouth and crimson tongue; the pulse is often wiry fine and slightly rapid.

Method: primarily nourish kidney yin, using modified Liuwei Dihuang Wan. If yin deficiency with yang hyperactivity causes nose or mouth bleeding, consider Xijiao Dihuang Tang. If the tongue is pale, enlarged, tender at the edges with teeth marks, and the pulse is deep fine, or wiry large and weak on heavy pressure, fortify the spleen, warm the kidney, transform qi, and move water, using Fuzi Lizhong Wan or Guifu Dihuang Wan. Generally by this point the patient's life is near its end; treatment aims only at maintaining quality of life and can hardly be complete.