Diarrhea

General Introduction 1. Definition: Diarrhea is referred to increase of defecation times, with clear and dilute stool, even watery stool, or indigested stool.

2. Scope in western medicine: all diarrhea induced by functional or organic pathological changes of the stomach, intestine, liver, gallbladder, pancreas and other digestive organs; such as diarrhea caused by acute, chronic colitis(enteritis); Nonspecific ulcerative colitis irritable colon; intestinal tuberculosis

Pathogenesis Key organs: spleen, related to stomach, large and small intestine. Key causes: dampness Key pathology: deficiency of spleen and excessive dampness

Details in pathogenesis Exopathic factors astrict the spleen (esp. dampness) dysfunction of Improper diet impair the spleen spleen in Emotional disorder stagnation of liver-qi transporting & attacking the spleen transforming Overstrain or Weakness of the prolonged illness spleen and stomach failure in lucid Deficiency of the failure in warming yang ascending kidney-Yang the spleen & turbid yin descending Diarrhea water & dampness flow down into intestine

Treatment Based on Differentiation of Syndrome 1. Main points of differentiation of syndrome : Clinically, differentiation of syndrome is made based on fulminant diarrhea and protracted diarrhea, deficiency and excess, cold and heat. (Ⅰ)Differentiation of deficiency and excess: Excess: sudden, short , frequent, abdominal pain with tenderness, pain relieving after diarrhea; Deficiency: slowly, long, intermittent, abdominal pain with preference for pressing, pain exacerbation after defecation.

(Ⅱ)Differentiation of cold and heat:

(III) Differentiation of colour and property of stool: Damp-heat: yellow and brown, viscous stool with odor, feeling of burning heat in the anus; Cold-dampness: green-gray or green-black stool, clear, dilute or watery stool, not obvious odor; Overeating: loose stool, viscous and odor stool with undigested food; Hyperactive liver-Qi invading the spleen: loose stool with normal colour, occasional attack, and attack due to emotional factors; Deficiency of spleen: loose stool with undigested food, deterioration after tiredness or meal; Deficiency of kidney: white and clear stool, even indigested food, and more occurrence of diarrhea before dawn.

Ⅱ. Differentiation of Diarrhea and Dysentery Less amount & difficulty Rectal tenesmus Severe pain Pain with discharge

Ⅲ. Therapeutic Principle Strengthening the spleen and resolving dampness Fulminant diarrhea: dispel dampness and dry the spleen. Protracted diarrhea: strengthening the spleen and warming Yang, and regulating the liver and the kidney

(Ⅰ) Fulminant Diarrhea 1. Diarrhea of cold-damp type （or diarrhea of wind-cold type ） Main symptoms: acute and fulminant attack, clear and dilute, even watery stool, paroxysmal pain and diarrhea with bowel sound. Accompanying symptoms: often seen exterior syndrome of wind-cold with dampness, such as aversion to cold, fever, heavy head and tiredness, general soreness, fullness in the stomach, anorexia, no thirst or viscous mouth with discomfort. Tongue and pulse: thin and white or white greasy fur, weak and slow or floating and tense pulse.

Therapeutic principle: Relieving exterior syndrome to dispel cold, turbid transmission and removing dampness by diuresis. Prescription: Wei Ling Decoction[284] combined with modified Huo Xiang Zheng Qi Powder[134] Atractylodes rhizome (CangZhu), magnolia bark(HouPu), tangerine peel——regulating qi and resolving dampness; Cinnamom twig, bighead atractylodes rhizome(BaiZhu), Alisma Oreintale(泽泻ZeXie）, poria, Umbllate Pore（agaric猪苓）——removing dampness by diuresis, warming yang to disperse water.

2. Diarrhea of Damp-heat Type( or Diarrhea of Summer-heat and Dampness Type) Main symptoms: immediate diarrhea after abdominal pain, acute and sudden diarrhea or discomfort in diarrhea, yellow -brown and viscous stool with odor. Accompanying symptoms: feeling of burning heat in the anus, restlessness, thirst, short and scanty dark urine. Tongue and pulse: reddish tongue with yellowish and greasy fur,slippery and rapid or weak and rapid pulse

Therapeutic principle: Clearing heat and removing dampness. Prescription: Modified Ge Gen Qin Lian Decoction[101]. pueraria root(葛根GeGen）—— resolving muscular pain and clearing away heat, raising lucid and relieving diarrhea; scutellaria root (黄芩HuangQin)and coptis (黄连HuangLian)——bitter taste with cold in property, having functions of clearing away heat and dry-transformation by removing dampness and being good at relieving diarrhea. Fresh liquorice ——mild sweet taste and has the function of regulating the middle-Jiao

3. Diarrhea due to impairment of overeating Main symptoms: immediate diarrhea after abdominal pain, odor stool, pain relieving after diarrhea. Accompanying symptoms: Fullness in the stomach, belching with the foul of undigested food, loss of appetite. Tongue and pulse: Thick and greasy fur on the tongue,slippery pulse.

Therapeutic Principle: removing food retention and promoting digestion. Prescription: Modified Bao He Pill[19]. Scutellaria root and coptis root are added for clearing away heat and eliminating dampness

(II) Chronic diarrhea 1. Diarrhea of the spleen deficiency type Main symptoms: loose stool, watery stool or diarrhea, times of defecation increases after eating a little fat or tiredness, even with undigested food. Accompanying symptoms: sallow complexion, fatigue and weakness of extremities, or thin in the body, loss of appetite, fullness in the stomach, bowel sound. Tongue and pulse: pale tongue,enlarged tongue with thin and white fur,fine and weak pulse.

Therapeutic principle: Strengthening the spleen and supplementing qi. Prescription: Modified Shen Ling Bai Zhu Powder[242]. Si Jun Zi Decoction is the basis of this prescription——supplementing Qi and strengthening the spleen； hyacinth bean (BianDou), Chinese yam(ShanYao), lotus seed, fried coix seed(苡仁） —— eliminating dampness and regulating the spleen; amomum fruit（砂仁） ------ promoting the functional activity of the spleen and stomach; tangerine peel for activating flow of Qi and regulating the middle-jiao; root of balloon flower(桔梗JieGeng） for raising the sinked clear Qi.

Fu Zi Li Zhong Decoction [92]plus evodia fruit (WuZhuYu) and bark of Chinese cassia tree(肉桂） are used for warming the middle-iiao and dispelling cold in the patient with failure the spleen-Yang, excessive Yin and cold in the body,cool pain in the stomach ，a bowel sound, cool extremities.

2. The hyperactive liver-Qi attacking the spleen Main symptoms: Abdominal pain and diarrhea after emotional disorder, and slight relieving of abdominal pain after defecation, and diarrhea again after abdominal pain. Accompanying symptoms: fullness in the chest and hypochondrium, belching, loss of appetite, bitter mouth and acid regurgitation, shallow complexion, tiredness and weakness. Tongue and pulse: reddish tongue with thin and white or thin and yellowish fur, taut and fine pulse

Therapeutic principle: Depressing the hyperactive liver-Qi and supporting the spleen. Prescription: Modified Tong Xie Yao Fang[281]. white peony root (BaiShao)—— for nourishing the liver; ledebouriella root（防风FangFeng） ——dispel the hyperactive liver-Qi and regulate the spleen and eliminate dampness; bighead atractylodes rhizome（白术）——strengthen the spleen to eliminate dampness and relieve diarrhea; tangerine peel ——promote functional activity of Qi,and regulate the middle-jiao.

3. Deficiency of the kidney-Yang Main symptoms: Diarrhea before dawn, loose stool, even with undigested food, and comfort after diarrhea. Accompanying symptoms: vague pain in the navel-abdomen, aversion cold, bowel sound, cool body and extremities, soreness and cold pain in the loin, impotence, damp and cool scrotum in male, and delayed menstrual cycle with oligomenorrhea in female. Tongue and pulse: enlarged and pale tongue,with white, moist and slippery fur,and deep and slow pulse.

Therapeutic principle: warming the kidney and strengthening the spleen Prescription: Modified Si Shen Pill(Pill for four miraculous drugs)[266]. psoralea fruit (补骨脂BuGuZhi）—— warm and supplement fire of the gate to relieve diarrhea； nutmeg（肉豆寇RouDouKou）and dogwood fruit（medicinal evodia fruit吴茱萸WuZhuYu） —— warm the spleen and dispel cold； schisandra fruit (五味子WuWeiZi）——astring to arrest diarrhea； ginger and jujube —— strength the spleen and regulate the middle-jiao.

Combination with Fu Zi Li Zhong Decoction[92] for strengthening power of warming and reinforcing the spleen and kidney in the patient of obvious dysfunction of the spleen-Yang

pomegranate rind（石榴皮ShiLiuPi）, Chinese nut-gall (五倍子WuBeiZi) and hawthorn fruit(山楂ShanZha) ——sour in property and function to astringe and arrest diarrhea, are added for the long duration of chronic diarrhea