Cao Min Department of Emergency Longhua Hospital Affiliated to SHUTCM CRITICAL DIARRHEA Cao Min Department of Emergency Longhua Hospital Affiliated to SHUTCM

OBJECTIVES Be familiar with the definition, etiology and pathogenesis of critical diarrhea. Make a good command of diagnosis and syndrome differentiation of critical diarrhea. Make a good command of the clinical comprehensive treatment of critical diarrhea in both western medicine and traditional Chinese medicine.

Definition Critical diarrhea refers to an increased frequency of bowel movements with loose or watery stools. The onset is acute and the course is short sometimes with exterior syndrome. It usually results from dampness of excess type and the function disorders of spleen and stomach. Diarrhea may happen during any season but it is more common in the summer.

ETIOLOGY & PATHOGENESIS- external pathogenic factors Critical diarrhea can occur after external invasion of the six pathogenic factors, but is more common after being invaded by summer-heat, dampness, wind-cold and heat. Among these, dampness is particularly frequent because it easily hinders spleen-earth. Since spleen prefers dryness to dampness; , dampness can affect the spleen’s function of raising the clear. The clear and the turbid are not separated, leading to diarrhea. In addition, the external dampness is often combined with cold, heat, wind-cold and summer-heat to form cold-dampness, dampness-heat, dampness of the wind-cold and summer-heat type, which, then, will internally attack the body, causing diarrhea.

ETIOLOGY & PATHOGENESIS-improper diet Overeating will cause food retention. Overeating sweet and greasy food may produce dampness-heat. Overeating raw and cold food will cause attack of the middle-jiao by the pathogenic cold. Thus, food retention, cold-dampness and dampness-heat will impair the function of the spleen and stomach in transformation and transportation, causing the disorders of descendance and ascendance and the occurrence of diarrhea.

ETIOLOGY & PATHOGENESIS In a word, the most important characteristic of critical diarrhea is splenic deficiency with excessive dampness. Among the external pathogenic factors, the dominant one is the dampness evil, without which, the others cannot lead to diarrhea. And the spleen deficiency is the key among the internal damage causes. The spleen is affected first and then diarrhea can occur. The key to the pathogenesis is excess of dampness and spleen deficiency. The external dampness is much easier to damage the spleen while the spleen deficiency will cause the dampness of the internal type. The attack by the external pathogenic factors and internal damage have close relationship and so do the external dampness and the internal dampness. Dritical diarrhea is located at the spleen, stomach, large and small intestine. The main affected organ is the spleen, but it is also related to other organs.

MAJOR SYMPTOMS sudden diarrhea with an increased frequency of bowel movements, several or even more than ten bowel movements a day, loose or watery stools that may contain undigested food, or bloody water , or green, or darkish yellow and sticky.

ACCOMPNYING SYMPTOMS abdominal pain, fatigue, dizziness, shortness of breath. pale or sallow complexion, subsidence of two eyes, thirst with desire to drink or without urine, cold limbs, or convulsion.

Diagnostic Basis of Critical Diarrhea Diarrhea may manifest with three, five or even more than ten bowel movements a day with loose, watery stools. Associated symptoms may include abdominal distention or pain, intestinal gurgling and a poor appetite. The onset may be sudden or insidious. Diarrhea with sudden onset is often associated with a history of excessive food intake or eating unclean food. Chronic or intermittent diarrhea is often associated with external pathogens, improper diet or emotional disturbances. Laboratory examinations contribute to diagnosis.

RELATIVE DISEASES in WESTERN MEDICINE acute gastroenteritis (Bacteria ,virus) food poisoning irritation syndrome of intestines malabsorption syndrome intestinal tuberculosis ulcerative colitis

LABORATORY EXAMINATION Blood routine test Fecal occult blood testing Stool cultures to detect bacteria

DIFFERENTIAL DIAGNOSIS — DYSENTERY Both diarrhea and dysentery are located at intestines. And both of them have abnormal changes in the form and frequency of stools. Dysentery is marked by mucus and blood in the stools, tenesmus and abdominal pain. Diarrhea is marked by an increased frequency of bowel movements with loose or watery stools. For a patient with dysentery, abdominal pain is often accompanied by tenesmus. The pain is not relieved after bowel movements. For a patient with diarrhea, abdominal pain is often accompanied by intestinal gurgling, without tenesmus. The pain is relived after a bowel movement. Dysentery is caused by stagnation of qi and blood in the intestines while diarrhea is caused by functional disorders of spleen and stomach. Diarrhea can turn into dysentery and vice versa. The former means aggravation and difficulty to be cured while the latter means a mild case and easiness to be cured.

DIFFERENTIAL DIAGNOSIS — CHOLERA Cholera is marked by the coexistence of vomiting and diarrhea. It usually has an acute onset, rapid development and severe conditions. The vomitus is undigested food. The stools are either like yellow water or like rice water. The accompanying symptoms include fever and chillness. Some cases will have the signs of fluid consumption with symptoms of emaciation, or spasms, abdominal angina. Some patients will have the signs of yang deficiency including a pale complexion, depressed eyes, sweating and cold limbs.

Conditions Abdominal pain Bowel movements Fecal test Diarrhea Abdominal pain is often accompanied by intestinal gurgling. The pain is relieved after a bowel movement. Smooth passing of loose, clear or watery stools. White blood cells may be present. Cholera Sudden abdominal pain followed by vomiting and diarrhea. In severe cases, muscle spasms or abdominal colic may also occur. Yellow, watery or rice-water stools. Vibrio cholerae(+) by stool culture. Dysentery Abdominal pain is often accompanied by tenesmus. The pain is not relieved after bowel movements. increased frequency of bowel movements with difficulty passing stools. stools contain mucus or blood. Large amount of red blood cells and pus.

Identification of the nature according stools characteristics Cold-dampness Thin,clear and watery stools with a foul odor Damp-heat Loose yellow stools with a fetid odor Food retention Loose stools containing undigested food,smelling like rotten eggs

EMERGENCY TREATMENT in WESTERN MEDICINE Maintain the acid-base balance of water and electrolyte: Fluid infusion Monitor the blood pressure Potassium and sodium supply

MERGENCY TREATMENT in WESTERN MEDICINE Critical diarrhea caused by food poisoning: Emetic Gastric lavage Catharsis Antidote drugs

MERGENCY TREATMENT in WESTERN MEDICINE Antidiarrheal therapy: Loperamide (易蒙停): 2mg, tid, po Smectite (思密达): one packet, tid, po

Treatment based on Pattern Identification Cold-dampness diarrhea with clear or even watery stools in severe cases, abdominal pain with intestinal gurgling, gastric fullness, poor appetite, white and greasy tongue coating, soggy and moderate pulse. When accompanying with wind-cold, there may be acute critical diarrhea, aversion to cold, fever, headache, body aches. Pale with a white tongue coating, floating pulse. Method: Removing dampness with aromatic herbs, releaving the exterior syndrome to disperse cold. Prescription: Huoxiang Zhengqi San or Weiling Tang

Huoxiang Zhengqi San or Weiling Tang monarch 藿香 Dispel cold and release the exteriorDispel cold and release the exterior ministers 紫苏 白芷 大腹皮 Regulate qi and relieve gastric fullness 厚朴 assistants 半夏曲 Harmonize the stomach and decend stomach-qi 橘皮 甘草 Resolve dampness and strengthen the spleen 白术 茯苓 桔梗 Enhance the effect of other herbs in relesasing the exterior For severe exterior cold,add jingjie and fangfeng to remove wind and dissipate cold For watery stools,add cheqianzi and zexie to resolve dampness," treating diarrhea with diuretics"

Treatment based on Pattern Identification Dampness-heat abdominal pain, urgent defecation, or a feeling of incomplete evacuation, yellow-brown stools with a foul odor, a burning sensation around the anus, feverish sensation, thirst, scanty and yellow urine. yellow and greasy tongue coating, rapid and soft or slippery pulse. Method: Clearing heat to disperse dampness. Prescription: Gegen Huangqin Huanglian Tang.

Gegen Huangqin Huanglian Tang monarch 葛根 Clear the heat and ascend the clear ministers 黄芩 Clear heat and dry dampness 黄连 assistants 甘草 hamonize middle jiao and coordinate the other medicine For severe dampness with chest or abdomal fullness and either an absence of thirst or thirst with no desire to drink,combined with pingweisan to dry the dampness and soothe chest. For severe heat with alterating abdomial pain and a dry,bitter mouth, add pugongying 、lianqiao、kushen、jinyinhua to clear heat and remove toxins.

Treatment based on Pattern Identification Food retention abdominal pain that is relieved after a bowel movement, intestinal gurgling, stools containing undigested food that smell like rotten eggs, gastric or abdominal fullness, foul breath, and poor appetite. Dirty turbid or thick and greasy tongue coating, slippery pulse. Method: Promoting digestion to relive stagnation. Prescription: Baohe Wan.

Baohe Wan monarch 山楂 Help digest greasy food ministers 神曲 Promote digiestion and improve hangovers 莱菔子 Decends qi and Promote digiestion assistants 半夏 Regulate qi ,hamonize stomache,decend qi and resolve dampness 陈皮 茯苓 连翘 Clear heat and resolve dampness For Food retention transform heat,add huanglian to clear heat and relieve diarrhea For spleen deficiency,add baizhu,and biandou to strength spleen and resolve dampness For severe diarrhea,add fulin and cheqianzi to resolve dampness For current vomitting ,add dingxiang and baidoukou to hamonize stomache and Decends qi For gastric or abdominal fullness and distension due to food retension add 枳实导滞丸 to Promote digiestion, clear heat and resolve dampness accoding to the principle of “treating diarrhea with purgatives”

External therapies Method indication Full the umbilians with powdered white peper,cover it with medical tape, change it once every day Diarrhea due to cold dampness Mix powdered wubeizi with vinegar to make a thick paste ,spread it on an adhesive plaster and cover the umbilicus Chronic Diarrhea Mix a fine powder of baizhiand ganjiang with honey to make a thick paste,apply to the umbilicus after cleaning it with alcohol, ignite a moxa stick and warm the umbilicus Diarrhea due to deficiency of the spleen and kiddney

Integrative Treatment in TCM Acupunture treament of critical diarrhea Main points: BL 25 (大肠俞), ST 25 (天枢), ST 37 (上巨虚), BL 27 (小肠俞), ST 39 (下巨虚), ST 36 (足三里)

Summary chart on syndrome differentiation and acupuncture treatment for critical diarrhea Syndromes Acupuncture points cold dampness NR 12 (中脘), ST 21 (梁门), SP 9 (阴陵泉), RN 4(关元) Dampness heat ST 44 (内庭), RN 9 (水分), LI 11 (曲池) Food retention LI 4 (合谷),BL 20 (脾俞), RN 11 (建里) BL 21 (胃俞), RN 12 (中脘)

Life Modification & Prevention Eat bland food, avoid over-eating, and stay away from cold, uncooked food. Choose an appropriate lifestyle or the weather and the season and keep the abdominal area warm. Maintain a peaceful mind and exercise appropriately.

CASE STUDY A 43-year-old female with obese figure. 6 month ago, she started to lose weight gradually without obvious reason. 4 days ago, after catching a cold, she suffered diarrhea, which were over 30 times a day. The stools were clear and watery, with undigested food. She also felt fullness and stuffiness at the epigastric region, retching, no desire to drink and eat, dysphoria and restlessness. The routine blood, urine and stool tests shows no abnormal change. Amikacin, Metronidazole and Potassium supplement didn’t work. And the disease even gradually got worse. Symptoms at present: Extremely mental fatigue, pale complexion, depression of the eyes, abdominal pain with cold feeling, vomit immediately after drinking, borborygmus. Tongue: Pale tongue with dry and yellow coating. Pulse: A deep and thready pulse.