TCM Treatments for Hypochondriac Pain
Hypochondriac pain refers to pain in one or both sides of the rib cage, mostly a clinical symptom caused by hepatobiliary disease. In addition, lesions of the pleura, lungs, chest muscles, trauma, ribs, and intercostal nerves can also cause hypochondriac pain. Cancers that have metastasized to the ribs may also cause hypochondriac pain. But clinically the most common cause is still hepatobiliary disease: hepatitis, cholecystitis, gallstones, cirrhosis, liver cancer, gallbladder cancer, and cholangiocarcinoma can all cause it.
According to the principles of TCM syndrome differentiation, hypochondriac pain is divided into the following types, each treated differently.
Damp-heat accumulation pattern: This type of hypochondriac pain is often accompanied by nausea and vomiting, aversion to greasy food, bitter mouth, dry mouth, yellow greasy or thick greasy tongue coating, fever, dark urine, jaundice of the eyes, sallow complexion, grayish stools, poor appetite, poor sleep, and irritability. These are typical symptoms of hepatobiliary disease; the patient should be advised to undergo hepatobiliary-pancreatic color Doppler ultrasound and liver-kidney function tests to identify the cause. Major diseases such as liver cancer, gallbladder cancer, and cholangiocarcinoma should especially be ruled out; if imaging reveals a space-occupying lesion in the hepatobiliary region, further needle biopsy and pathological analysis should be performed.
Regardless of which hepatobiliary disease the patient has, the TCM treatment for damp-heat-accumulation-type hypochondriac pain is uniform: clearing and draining damp-heat is the general principle. Representative formulas include Yinchenhao Tang (Artemisia Decoction), Yinchen Wuling San (Artemisia Five-Ingredient Powder), Qingre Lishi Tang (Heat-Clearing and Damp-Draining Decoction), and Gegen Qinlian Tang (Pueraria-Scutellaria-Coptis Decoction). Patent medicines include Longdan Xiegan Wan (Gentiana Liver-Draining Pill) and Yinzhihuang granules. For marked hypochondriac pain, combine with Yuanhu Zhitong Pian (Corydalis Pain-Relieving Tablets).
Gallstone patients who take Yinzhihuang granules together with Shugan Hewei Wan (Liver-Soothing Stomach-Harmonizing Pill) and ursodeoxycholic acid tablets not only relieve pain but may also shrink or even eliminate stones. However, if the stones are too large, or if they are sand-like and fill the entire gallbladder, the gallbladder should be surgically removed.
In addition, patients with solitary gallbladder polyps larger than one centimeter, or with large long-standing gallstones, all have premalignant gallbladder cancer lesions. Such patients should not take it lightly; surgery is best to prevent malignant transformation.
Liver-qi stagnation pattern: This type generally presents as distending pain in both rib spaces, more pronounced on the right, with chest tightness, reduced appetite, irritability and easy anger, frequent belching that brings some relief, white tongue coating, intermittent pain that comes and goes, and a wandering pain location. Such patients are often difficult to diagnose precisely with modern medical equipment: some have chronic digestive tract diseases, some have emotional disorders such as anxiety or depression, and some have no such problems yet develop the above symptoms for no clear reason—especially after excessive stress and staying up late.
The TCM treatment principle for this type of hypochondriac pain is to soothe the liver and move qi; the main patent medicines are Xiaoyao Wan (Free-and-Easy Pill), Jiawei Xiaoyao Wan (Augmented Free-and-Easy Pill), Shugan Hewei Wan, and Chaihu Shugan Wan (Bupleurum Liver-Soothing Pill). These formulas often contain Chaihu (Bupleurum), because it soothes the liver, moves qi, and relieves constraint. Note here that Xiaoyao Wan may cause constipation; patients with a prior tendency toward constipation may do better with Jiawei Xiaoyao Wan.
Qi stagnation and blood stasis pattern: The hallmark feature of this type is a fixed pain location, mainly stabbing pain, with a purple-dark tongue or even petechiae; some patients can feel a palpable mass below the rib. Unless caused by trauma, such patients are mostly those with hepatosplenomegaly, cirrhosis, or hepatobiliary tumors. In TCM this is called jiju (accumulation), feiqi, or nüemu—mostly space-occupying lesions. Before treatment, a hepatobiliary-pancreatic color Doppler ultrasound should be performed to confirm the cause.
Relieving this type of hypochondriac pain is quite difficult; internal and external treatment should be combined. Internal options include Chaihu Shugan Wan, Yuanhu Zhitong Pian, Xihuang Wan, Biejia Ruangan Pian (Turtle Shell Liver-Softening Tablet), and Biejia Jian Wan (Turtle Shell Decoction Pill); external options include Anyang Jingzhi Gao and Chanwu Babu Gao.
Liver-yin insufficiency pattern: This type of hypochondriac pain is dull, accompanied by irritability, dry mouth, dizziness, impatience, a red tongue with little coating, and a fine rapid pulse. For this type I often use Shaoyao Gancao tea: 1-3 g each of Baishao (White Peony) and Gancao (Licorice), steeped in boiling water like tea and drunk as a beverage; the effect is excellent. If the patient is emotionally depressed, rose buds or China rose flowers may be added. The patent formula Xiao Zhong Tang (Small Center-Focusing Decoction) also works well for such patients.