Professor Zhu Chenyu Experience in Treating Hepatolienomegaly and Cirrhotic Ascites

The Zhu Chenyu Jinggyan Ji (Collected Experience of Zhu Chenyu) records Professor Zhu Chenyu experience in treating hepatolienomegaly and cirrhotic ascites caused by liver diseases such as chronic hepatitis or cirrhosis; for details see the chapter Chronic Hepatitis and Cirrhosis in that book. Hepatolienomegaly and cirrhotic ascites are also common complications in cancer patients, and Professor Zhu experience can also serve as a reference for oncologists.

Professor Zhu was a disciple and son-in-law of Shi Jinmo, one of the four great physicians of modern Beijing, so academically he inherited Shi style and emphasized pattern differentiation of qi and blood. Professor Zhu held that in chronic liver disease with hepatolienomegaly accompanied by liver pain, one must distinguish whether the condition lies in the qi or the blood. If it is early-stage failure of the liver to freely course and spread, leading to qi stagnation in the Liver channel with distending or dull pain in the liver area, abdominal bloating, and belching, one should use Chaihu Shugan San (Bupleurum Soothing the Liver Powder) plus Jiegeng (Platycodon), Xingren (Apricot Seed), Xiebai (Allium Macrostemon), Chuanlianzi (Melia), and Zelan (Lycopus) to soothe the liver and resolve depression, and regulate qi to stop pain. If the disease has endured and entered the collaterals, with concrete accumulation under the flanks, stabbing pain in both flanks, a dull dark complexion with red thread veins, and a purple-dark tongue—prominent signs of blood stasis—then one should use Gexia Zhuyu Tang (Decoction to Drain Blood Stasis below the Diaphragm), created by Wang Qingren, plus Danshen (Salvia), Qiancao (Rubia), and Sheng Muli (Raw Oyster Shell) to invigorate blood and dissipate concretions, and move qi to stop pain.

This reasoning is very clear. Early liver-disease symptoms match the features of liver depression and qi stagnation, belonging to TCM qi disease, so treatment uses Chaihu Shugan San from the Bupleurum series of liver-soothing, qi-regulating formulas. Some doctors also modify Xiao Chaihu Tang (Minor Bupleurum Decoction) for liver patients at this stage, with effect. When blood stasis is prominent in the middle-to-late stages of liver disease, treatment focuses on activating blood and resolving stasis. Wang Qingren Gexia Zhuyu Tang is composed of Danggui (Angelica), Chishao (Red Peony), Chuanxiong (Ligusticum), Taoren (Peach Kernel), Honghua (Safflower), Xiangfu (Cyperus), Wuyao (Lindera), Zhiqiao (Immature Bitter Orange), Yanhusuo (Corydalis), Mudanpi (Moutan), Wulingzhi (Trogopterus), and Gancao (Licorice). This formula is actually Taohong Siwu Tang (Peach Kernel and Safflower Four-Material Decoction)—which activates blood and resolves stasis—with the cloying Rehmannia removed (as it obstructs the diaphragm), plus qi-regulating, blood-activating herbs; it therefore leans toward regulating qi and activating blood. Blood stasis in liver disease develops from qi stagnation; merely activating blood without regulating qi treats the branch rather than the root. Only by combining qi regulation with blood activation can both root and branch be treated.

Besides this approach, Professor Zhu himself had two commonly used medicinal pairs for hepatolienomegaly.

One is Danshen (Salvia) and Qiancao (Rubia), at usual doses of 30g Danshen and 15g Qiancao. These two cool the blood, invigorate blood, and stop bleeding. Besides blood stasis, liver disease often carries a risk of bleeding, so combining blood-activating and hemostatic herbs can prevent bleeding while resolving stasis.

Some TCM practitioners often do not understand this point, feeling that using blood-activating and hemostatic herbs together seems wrong. In fact, this biphasic action fits very well the way living organisms maintain homeostasis. Modern biology has found that organs and tissues coordinate to keep the organism in a stable state—body temperature, blood pressure, and pH are neither too high nor too low, and coagulation is neither too weak nor too strong; only when functions are moderate can we survive. If we study the human genome, we find many such mutually opposing yet complementary genes, which resonates with the TCM idea of yin and yang interdependently rooting and sustaining each other. So using blood-activating and hemostatic herbs together also fits this feature.

Professor Zhu other medicinal pair is Hehuanpi (Albizia Bark) and Bailili (Tribulus), at usual doses of 10g each. He used this pair to treat hepatolienomegaly or abdominal masses. He believed Bailili soothes the liver and resolves depression, moves qi and breaks blood stasis, while Hehuanpi calms the spirit and resolves depression, brightens the eyes and reduces swelling, harmonizes blood and stops pain. Thus, in treating liver disease, pairing these two has the effect of one dispersing and one supplementing, of simultaneously supplementing and draining, and of activating blood to dissipate concretions.

Adding these two pairs on the basis of pattern-based formulas makes a prescription more effective. With the temerity of a dog trailing a sable, I would add that in treating liver disease, including herbs that modern pharmacology confirms are effective against liver disease—and which ancient TCM also believed treat liver disease—such as Biejia (Carapax Trionycis), Shuihonghuazi (Polygonum orientale fruit), Sumu (Sappanwood), and Tubiechong (Eupolyphaga), would yield even better results.

Ascites often appears in late-stage cirrhosis or hepatic tumors; generally speaking, ascites already indicates late-stage disease. By modern medical standards, once ascites appears in a cirrhosis or tumor patient, regardless of distant metastases, the case is advanced or end-stage.

TCM also holds that abdominal distention with ascites is hard to treat. Professor Zhu believed that when the disease reaches the ascites stage, it is because damp-heat has long lingered, damaging the liver and spleen, causing qi flow to be impeded and blood stasis to obstruct the collaterals, leading to spleen-kidney yang deficiency, impaired qi transformation, and internal retention of fluid. So he often treated with Fangji Huangqi Tang (Stephania and Astragalus Decoction) combined with Wuling San (Five-Ingredient Poria Powder). His empirical formula: Sheng Huangqi (Raw Astragalus) 30-50g, Han Fangji (Stephania) 10-15g, Baizhu (Atractylodes) 15g, Guizhi (Cinnamon Twig) 10g, Fuling (Poria) 15-30g, Zhuling (Polyporus) 10g, Zexie (Alisma) 10g, Cheqiancao (Plantago Herb) 30g, Hanliancao (Eclipta) 15g, Danshen (Salvia) 30g, Chishao (Red Peony) 15g, Yimucao (Leonurus) 30g.

In fact, besides combining Fangji Huangqi Tang with Wuling San, his formula also merges another formula named Er Cao Dan (Two-Herb Elixir), composed of Cheqiancao (Plantago) and Hanliancao (Eclipta). This is a TCM prescription for urinary blood, highly recommended in the Chishui Xuanzhu. Merging it is very useful because Cheqiancao and Hanliancao not only promote diuresis but also stop bleeding, helping prevent bleeding in late-stage cirrhosis or liver-cancer patients.

However, I venture to point out that Professor Zhu treatment is not yet complete enough. Late-stage ascites patients, after taking diuretic herbs, often lose much potassium and develop sore, weak legs and general fatigue; the above formula does not address this. Although the patient may indeed get a diuretic effect, the water goes and the person becomes deficient. My own experience is that on top of the above formula, one should also add some supplementing herbs to prevent the patient from becoming utterly weak after diuresis.

My own empirical formula for ascites is somewhat similar to Professor Zhu, also using Fangji Huangqi Tang as the main base, but I mainly combine it with Renshen Banxia Houpo Shengjiang Tang (Ginseng, Pinellia, Magnolia, and Fresh Ginger Decoction). Why combine Renshen Banxia Houpo Shengjiang Tang? Because most late-stage ascites patients also have abdominal bloating and qi stagnation; applying the three-supplement-seven-disperse approach of Renshen Banxia Houpo Shengjiang Tang to address symptoms lets the diuretic formula achieve twice the result with half the effort. I also add the Four Kidney-Tonifying Herbs to support upright qi and prevent diuresis-induced weakness. For details of my empirical formula, see my article An Empirical Formula Relieving Intestinal Adhesion and Obstruction with Ascites in Cancer Patients.

In addition, some patients have dark urine and bound stool, with exuberant damp-heat and a drum-like abdomen. For such patients who are constitutionally replete, Professor Zhu often used Ji Jiao Li Huang Wan (Stephania, Zanthoxylum Seed, Descurainia, and Rhubarb Pill) plus Yinchen (Artemisia Scoparia), Fuling (Poria), Zhuling (Polyporus), Zexie (Alisma), and Cheqianzi (Plantago Seed) to aggressively expel fluid-dampness, promote diuresis and bowel movement, so that water is discharged through both urine and stool.

In treating liver disease, Professor Zhu advocated staged treatment. At the hepatolienomegaly and hepatic-ascites stage, when attacking herbs are needed, one should not hesitate. But once the patient excess pattern is eliminated, one should focus on supporting and tonifying the spleen and kidney, invigorating blood and softening hard masses, proceeding slowly and not rushing, lest upright qi be damaged in vain.