Concepts in treating Hepatitis B and C for Practitioners
What I did at the Beijing City TCM Hospital was sit for a very intense week of 2002 in the office of Dr. Shu, a student of Dr. Guan, one of the foremost TCM hepatitis specialists in China. In the next month I also had numerous talks with another of his students, Dr. Qi Jing, who gave me some of her papers that she had co-written with Dr. Guan. Helping with the translation was Wang Ruping, a PhD doctor, who worked until a few years ago in that department and now works upstairs in the internal medicine ward.
Hepatitis has 3 stages. The acute has jaundice and vomiting and where the patient definitely knows that they are ill. This happens in Hepatitis A, and to lesser extent in B and an even lessor extent by C. The middle stage does not occur with A because you get better, it's over. B and C however go "chronic" and this stage can last for decades. That is what we are now finding middle aged patients who were infected decades ago and are now just getting symptoms. As the Kidney declines, the person has gotten weaker with age and the body then feels the effects of the build-up of the external attack. The liver may show signs of fibrosis or hardening. People may get extreme fatigue and muscle aching. The third stage occurs in about 5 percent of those who have Hepatitis B or C, which has turned to extreme Liver cirrhosis or liver cancer. Let's look at the first stage and the treatment we have for it. In Stage One for TCM we see this as Damp heat in the Gall Bladder System. The Damp permeates the gallbladder making the bile spill over into the body, causing jaundice. The symptoms are a yellow face and body, yellow eyes (fresh strong yellow color), thirst, sweating on the head, frequent and difficult urination. The Tongue, which we use extensively for diagnosis, is yellow with a "greasy" coat The pulse is deep and forceful, or slippery and rapid
The representative formula for this situation is Yin Chen Hao Tang, which consists of only 3 herbs: Yin Chen Hao, Da Huang and Zhi Zi. Yin Chen Hao clears damp-heat from Liver and Gallbladder channels and has the special function for removing jaundice. It also helps increase urination to drain the heat from the bile. Zhi Zi (or gardenia) is very effective for draining heat from the body. Da huang (rhubarb) is usually used as purgative for constipation but when cooked for 15 minutes it stops being a purgative and is very effective for clearing damp heat and heat in the blood. Da Huang Pharmacological Action 1.Sennoside A is the component for purgation. 2.Promoting biliary secretion and enhancing the amount of bilirubin and bile acid. 3.Rhein and Emodin exert bacteriostatic effect by inhibiting the synthesis of DNA, RNA and protein in bacteria. 4.Emodin is a component for hypotensive. 5.Oral use of its extract reduces the ratio of serum cholesterol and total phospholipid in rabbits with hypercholesterolemia. 6.Chrysophanol, an other active component, exerts a hemostatic effect.
So although a doctor here may not have a chance to treat an acute case of hepatitis, in Beijing I saw the formula being used many times in combination with other herbs when the patient back-slid into signs of jaundice.
Our real challenge is in the second stage. If you were a purist Luddite Chinese doctor then you would never look at blood tests. However, these tests do give us an opportunity to preventatively treat future problems. I will say the following for the Chinese practitioners. It is easy to get confused while trying to treat a "Western" disease with Chinese Medicine. What I mean by that, the best approach when faced with a patient in the office is to treat what you see and know from Chinese Medicine. Look at the tongue, take the pulse and ask all the questions that are relevant to Chinese Medicine. Then, that accomplished, if you have the blood and viral tests, use those. I feel hepatitis is one of the half dozen diseases that blood tests become relevant for the Chinese practitioner, but I am a bit of a Luddite.
We can look at chronic hepatitis theory in 3 ways. They are somewhat subtle differences between them. Again what we are looking at is the middle stage of hepatitis where there may not be any symptoms other than a general constitutional pattern. None of these are wrong, and they are all so closely aligned that all of them have been used to successfully treat hepatitis. I offer them without judgement although I am stressing what I learned in Beijing because it誷 less well-known here. If there are symptoms they generally fall into gastro-intestinal problems including nausea and lack of appetite. We would see this as liver overacting on Spleen and/or a Spleen/Stomach disharmony. Fatigue or Qi and blood deficiency is another common complaint. As well there is often a confused or "fuzzy" mental state conforming to a Chinese diagnosis of damp.
For the most part TCM practitioners in the West see hepatitis as a Shao Yang Disease. I've been looking at an article about the late Yi Tian Ni who proposed that many chronic modern diseases are Shao Yang. In many ways the way we treat or at least how I used to treat hepatitis is as a shao yang pattern. The guiding formula for this pattern Xiao Chai Hu tang. No matter what we approach we take to hepatitis we have to look at Xiao Chai Hu tang. One of the principals of Shao Yang is that there is both an excess and a deficiency. A pathogen is lodged in the Shao Yang or Gall Bladder channel. Because of deficiency of Qi it cannot be expelled by the immune system.
Chai Hu (Radix Bupleuri) Huang Qin (Radix Scutellariae Baicalensis) Ban Xia (Rhizoma Pinelliae Ternatae) Ren Shen (Radix Ginseng) Zhi Gan Cao (Radix Glycyrrhizae Praeparatae) Sheng Jiang (Rhizoma Zingiberis Officinalis Recens) Da Zao (Fructus Zizyphi Jujubae) Explanation o Chai Hu (Radix Bupleuri), which is light in weight and has ascending and dispersing effects, promotes the dispersion of pathogens, clears heat in shaoyang and relieves stagnation of qi. Huang Qin (Radix Scutellariae Baicalensis), assists Chai Hu in clearing heat from shaoyang and can avoid the possible impairment of yin fluids due to Chai Hu ascending and dispersing properties. Ban Xia (Rhizoma Pinelliae Ternatae) and Sheng Jiang (Rhizoma Zingiberis Officinalis Recens): help the Stomach when the Stomach qi rebels upwards to cause poor appetite and nausea. Ren Shen (Radix Ginseng), Zhi Gan Cao (Radix Glycyrrhizae Praeparatae) and Da Zao (Fructus Zizyphi Jujubae) all function to support the vital qi and supplement Qi to expel pathogens by strengthening vital qi therefore preventing the further inward transmission of pathogens.
Many practitioners use this formula over a broad-range of patterns. It is very flexible and you can go either way to emphasize either heat clearing or building qi. But as I am finding out more and more, the concept of deficiency and excess pathogen together is not just a Shao Yang concept. For example, in the case of the Chinese concept of wind it is said that wind cannot penetrate unless there is a deficiency. So we have Xiao Feng San where the key ingredient is Huang Qi to raise the protective Qi. And in the case of internal Wind there must be a kidney or liver deficiency that creates the wind. Just because there is a combination of excess and deficiency does not always put the syndrome in the Shao Yang category.
I'm going to look at two students of Dr. Guan You Bo who I worked with in Beijing. From what I have learned they have different views of the hepatitis. Dr. Guan You Bo is known throughout China for his hepatitis treatments. I worked with Dr. Shu for a few weeks. This consisted of sitting in a room and patients would come in the morning and often times in the afternoon. We would see about 30-40 patients a day. We would take the patient誷 pulse, look at the tongue, talk and then Dr. Shu would write down an herbal formula. Translating was Dr. Wang Ruping who himself worked in the hepatology department for a number of years.
And finally, Dr. Qi Jing in the same department gave me several papers she had written with Dr. Guan and with whom I had a number personal conversations in Beijing. She is also a student of Dr. Guan. I offer what I learned without judgement as to which is a more correct view and then we can back and look at the strengths and weaknesses of each approach. So let's look at the 3 approaches: 1. Shao Yang 2. Dr. Shu/ blood heat 3. Dr. Qi/ damp Dr. Shu's theory has three features. 1. Liver Yin Xu 2. Pi/Wei disharmony or Stomach Spleen disharmony 3. Heat in the Blood The treatment of Chronic Hepatitis is then to: 1. Strengthen liver Yin 2. Strengthen spleen 3. Cool blood So let's look at one patient from Dr. Shu, a rather advanced case, age 60 who was diagnosed with Hepatitis B 10 years ago and now has cirrhosis with an ultrasound showing splenomegaly of 1 cm below the ribs. His pulse was wiry and tight. He had a dry mouth, night sweats and a bitter taste in his mouth. His tongue was red with no coat. The formula is Huang Qi (100grams), Yin Chen Hao (20) Huo Xiang, Xing Ren, Ju Hong, Bai Zhu, Huang Lian, Bai Shao, Chi Shao, Dang Gui, Chai Hu, Zi Lan (30), Che Qian Zi, Cao He Che, Sha Ren, Bai Mai Hua, Mao Gen, Gan Cao. 2 or 3 things we want to look at here.
Huang Qi is thought to have anti-cirrhosis properties when given in the large doses such as 100 grams. In 90 percent of the cases I saw in the clinic, Huang Qi was the first herb given in amounts of 50-100 grams. The one thing that makes this formula different is that Chai Hu was given. Dr. Shu explained to me that in this hospital there is more emphasis on Dang Gui and Bai Shao to strengthen Liver Yin Xu and softening of the liver when there are no other obvious symptoms. When Chai Hu was given it was most often with vinegar. Treating Chai Hu this way will diminish the spreading effect of Chai Hu and the sourness aids in directing the formula towards the liver.
Two herbs that we don't use that much here are Cao He Che and Xiao Ji, which cools blood and relieves toxins. The other thing to look at is the rather large dose of Ze Lan in order to circulate the blood. Bai Mao Gen is used to cool the blood in accordance with the concept of heat in the blood. Chi Shao and were often used together, simply called Er Shao or the two Shaos. Bai Shao to tonify and Chi Shao, of course, is more for cooling the blood.
Let's look at another case of a thin woman with Hepatitis B. She came in with her husband and would like to have a baby. She is always tired and has a pain in the liver region. Her tongue was pale and I noticed she had cold hands. Her pulse was thready/wiry. Dr. Shu made a diagnosis of Spleen Qi and Yang Xu, Liver stagnation. The formula focused on warming. Huang Qi, Bai Zhu, Dang Gui and Bai Shao, Niu Zhen Zi, Xu duan (tonify Yin and Yang), Xiang Fu, Xiao Ji (to cool blood), Cao He Che, He gen, Sheng Di and Shu Di huang, Yi Mu Cao, Bai Ji lian (resist viruses and cancers) and Zhi Zi.
One of the more important cases was a young woman of 18. Her tongue to me seemed pale and the pulse slightly slippery. However Dr. Shu said the woman had "no special symptoms". Of course we don't have many cases of "normality" in Chinese Medicine and one can always find or should be able to find some direction off of center in our patients. But the important thing is that Dr. Shu saw no special symptoms here. When I pointed this out to him we agreed that her formula could be seen as the "base formula" for Hepatitis B. It consisted of Ku Shen, Ban Zi Lian (anti-viral), Huang Qi, Tai Zi Shen, Dang Gui, Bai Shao, Chi Shao, Shen Dou Gen, Wu Wei Zi, Dan Shen, Bai Zhu, Niu Zhen Zi, Xu Duan, Cao He Che, Xiao Ji, Yi Mu Cao, Bai Hua She She Cao. Let's go back to Dr. Shu's principles of Hepatitis pathology: Liver Yin Xu, heat in the blood, Spleen Xu with Sp/St. disharmony.
As we look at the herbs remember that Dr. Shu would stress that the particular herbs were not that important as long as the basic ideas were there in the formula. If we were to break this formula down into three parts we see the Huang Qi, Tai Zi Shen and Bai Zhu as tonifying Spleen Qi. Dang Gui, Bai Shao, Yi Mu Cao and Nu Zhen Zi are tonifying liver blood and yin. Chi Shao, Bai Hua She She Cao, Dan Shen, Ku Shen, Xiao Ji and Cao He Che are clearing heat concentrating on the blood. Wu Wei Zi and Xu Duan are added to tonify the Yang within the Yin. We know now that wu wei zi is a very good anti-viral. Note that Ku Shen is used here to clear heat and promote urination and not as an anti-viral. Cao He Che has the same properties.
Dr. Qi Jing誷 papers reflect more of Dr. Guan誷 theories. It differs in what Dr. Shu talked about in that in addition to his three principals, as the hepatitis progresses then there is also dampness. Hepatitis C if it should progress into cirrhosis also has the feature of blood stagnation in the liver. The section of chronic hepatitis in Blue Poppy Press's The Treatment of Modern Western Diseases with Chinese Medicine has obviously been influenced by papers by Dr. Guan. In it they write," ...the perverse qi associated with chronic active hepatitis should be described as a hidden or deep-lying warm evil that is damp and hot in nature and lodges in the blood division... If damp heat transforms into fire and brews toxins, it may harass the constructive (ying) and the blood." Qi Jing, a student of Dr. Guan's, has co-written several articles about Hepatitis C. She writes that the progression starts with a deficiency of Zheng Qi which allows the virus to enter into the blood. Phlegm stagnation toxins block the luo collaterals of the liver meridian.
Let's review the term Zheng Qi.
Zheng Qi is translated as Upright Qi and is defined in Giovanni Maciocia as "a General term to indicate the various Qi having the function of protecting the body from invasion by exterior pathogenic factors. It is a term that is usually only used in relation and contrast to Pathogenic Factors (Xie Qi) and indicates the body's resistance to exterior diseases."
Again Qi Jing writes: "When Zheng (Vital) Qi is present in the Interior, the Evils cannot penetrate in." "For Evil to encroach, the Qi must be deficient." There are hundreds of diseases that take advantage of deficiencies and enter the body. The root cause of this disease is Zheng (Vital) Qi Deficiency. Zheng Qi Deficiency causes Qi and Blood insufficiency, which would result in the loss of nourishment for the Liver. As the Evil stagnates in the Liver organ, the Qi is blocked and stagnated, causing hypochondriac pain. As Damp-Evil hinders the Spleen, and the Liver overacts on the Spleen, the Spleen becomes deficient and loses the transportation function. And the Stomach would fail to harmonize and lose its descending function, causing epigastric and abdominal distention and loss of appetite. With the appearance of the common symptoms of jaundice, hypochondriac pain, fatigue, epigastric and abdominal distention, and loss of appetite, the disease has manifested.
Dr. Qi then puts more emphasis on dampness than Dr. Shu does. Her treatment principles then are to Benefit Qi and support Zheng Qi, activate blood, detoxify and transform phlegm and dispel pathogenic qi. In a study she writes about the base formula consists of Huang Qi, Bai Shao, Dan Shen, Ju Hong, Cao He Che, Xiao Ji and Ze Lan. The formulas were then modified for each patient.
For example to severe Spleen Deficiency Dang Shen, Bai Zhu and similar herbs are added. For blood stagnation, Xia Ku Cao, Xiang Fu. One of her clinical research studies was with 50 patients using Chinese Herbs and 11 patients using interferon mono-therapy for 9 months. The results were that both had HCV-RNA status of HCV-RNA turning negative had the interferon group being higher. 6 months after treatment the results were basically the same. However remember that herbal therapy can be continued even at the end of the study while interferon treatment would just end. Figure 5: Status of HCV-RNA Turning Negative before and after Treatment Group n Turning Negative after Treatment (%) Turning Negative Half-Year after Treatment (%) Treatment 50 16 (32) 13 (26) Control 11 6 (54.5) 3 (27.2)
Furthermore, studies have shown that herbal treatment with interferon treatment has better success than interferon alone. The herbal compound Bing Gan Tang combined with interferon-alpha showed significantly better effects on clearance of serum HCV RNA (relative risk 2.54; 95% confidence interval 1.43 to 4.49) and on normalisation of serum alanine aminotransferase activity (relative risk 2.54; 95% confidence interval 1.43 to 4.49) than interferon-alpha monotherapy. The herbal compound Yi Zhu decoction showed a significant effect on clearance of serum HCV RNA and normalisation of ALT levels compared to glycyrrhizin plus ribavirin. Yi Er Gan Tang showed a significant effect on normalising serum alanine aminotransferase compared to silymarin plus glucurolactone.
If we look at the 3 views of hepatitis lets look at some of the criticisms each have gotten.
Dr. Shu said that Hepatitis is not a Shao Yang disease particularly because it doesn't have the feature of Alternating Chills and Fever. Yi Tian Ni's definition of Shao Yang is "modern" and she expanded the definitions of Shao Yang.
In addition we know that Chai Hu raises interferon levels to toxic levels when used with interferon. It would make sense that without interferon Chai Hu should be used to raise those natural interferon levels. Some have criticized the aspect of heat in the blood, which is a major part of Dr. Shu's diagnosis. The tongue is rarely red, there are few red skin spots which we usually define as heat in the blood.
Dr. Tong and Peng write about the B virus this way, "therefore if the latent pathogen lives within the shao yin, and based on the theory that the liver and kidney share a common source, and if the kidney is vacuous (deficient) then the liver becomes vacuous also.. it is easier to understand that the hepatitis B virus lies latent/hidden within liver blood." Yet we know that the final result of hepatitis is a liver blood stagnation and deficiency which comes from blood heat. And of course in the final stages of cirrhosis there are red spots, bleeding gums and spider aginomas reflecting blood heat.
For those who aren't conversant with Chinese Medicine all of this may seem rather esoteric and technical.For those practitioners treating hepatitis the distinctions made here may help to fine-tune treatments.