1. Department of Emergency Longhua Hospital Affiliated to SHUTCM
ACUTE ABDOMINAL PAIN
Cao Min
Department of Emergency
Longhua Hospital Affiliated to SHUTCM

2. 【Objectives】
Make a good command of diagnosis process of acute abdominal pain.
Make a good command of diseases manifested as acute abdominal pain.
Make a good command of first-aid treatment of acute abdominal pain in TCM.

3. Overview

4. 【Definition】
Abdominal pain refers to the pain occurring in the region between the stomach and pubic bone. It can be one of the symptoms associated with transient disorders or serious diseases.

5. Abdominal Cavity
Da fu (大腹)：pertains to the general area of the abdomen that is referred to as below the stomach and above the pubis.
Xiao fu (小腹)：refers to the central area between the umbilicus and pubic bone.
Shao fu (少腹)：refers to as the bilateral lower abdomen.
Qi fu (脐腹)：refers to the area around the umbilicus.

6. Causative Factors An improper diet Constitutional yang-qi deficiency
External pathogenic factors
Emotional disturbance
Other factors

7. Pathogenesis Disharmony of Qi dynamic of Zangfu-organs
Disnourishment of the channels

8. External pathogenic factors
All the six pathogens can cause abdominal pain when they invade the abdomen. Wind-cold will cause qi stagnation and blockage of the channels, thus resulting in abdominal pain. Summer heat or heat transformed from the long-retained abdominal cold or retention of dampness-heat can also block qi dynamic of fu-viscera, causing abdominal pain.

9. An improper diet
Sudden and excessive drinking and eating will damage the spleen and stomach, causing retention of food. Overeating greasy, sweet and acrid food will produce dampness-heat in gastrointestine. Eating unclean food or raw and cold food will result in retention of cold-dampness. All these pathogens will damage the spleen and stomach and hinder the descent of fu-qi, causing abdominal pain.

10. Emotional disturbance
Anger and depression will cause stagnant liver qi, which may lead to pain. Worry and over-thinking will damage the spleen or the stagnant liver attacks the spleen, causing the disharmony of the liver and spleen and the unsmoothness of the descent of fu-qi. Then, abdominal pain ensues. In addition, long-time qi stagnation will give rise to blood stasis, which can also be caused by trauma and abdominal operation. The blood stasis in the abdomen will certainly cause abdominal pain.

11. Constitutional yang-qi deficiency
The constant weakness of the splenic yang or the damage of the splenic yang by overeating cold food or herbs may cause the retention of cold-dampness, which will gradually damage the splenic yang. The extremely deficient splenic yang will fail to warm up zangfu-organs, thus causing abdominal pain. Renal yang deficiency due to a protracted disease will fail to warm up, thus causing deficient cold in zangfu-organs and lingering abdominal pain.

12. In conclusion, cold, heat, deficiency, excess, qi and blood are responsible for the occurrence of abdominal pain and they are mutually related and combined. Cold may turn into heat. Qi stagnation will turn into blood stasis. The combination of cold and heat or the combination of excess and deficiency is very common.
The excess type of abdominal pain is caused by unsmoothness in the circulation of qi and blood in zangfu-organs and the blockage of the channels due to the attack of cold and heat, emotional upsets, improper diet, trauma and parasitosis. The deficient type of abdominal pain is caused by inability to warm up zangfu-organs and channels and inability to circulate qi and blood due to deficiency of qi and blood and weakness of yang-qi.

13. Diagnostic Steps

14. Inquiry Accompanied symptoms Site of pain Nature & Severity
Medical History
Shao fu
Da fu
Xiao fu
Qi fu
Cutting pain
Burning pain
Dull pain
Blunt pain
Colic pain
Drilling pain
Vomiting
Fever
Diarrhea
Bloody stool
Hematuria
Shock
Similar attack
Surgery
Menstruation
Trauma
Exposure to poisons ……

15. Physical Examination
Inspection

16. Physical Examination Palpation
The key point of palpation is to observe the site and severity of tenderness, pain, and muscle tension.
Palpation

17. Physical Examination Percussion Shifting dullness Liver dullness
Percussion drum sound
Percussion pain
Percussion

18. Physical Examination Auscultation
Pay more attention to the bowel sounds.
Auscultation

19. Laboratory examination
blood routine
blood gas analysis
pancreatic function
biochemical tests
Abdominocentesis 腹腔穿刺 术
Abdonimal X-ray
B-type ultrasound
CT scan
EKG
Endoscopy

21. 消化道穿孔

22. 单纯性小肠梗阻

23. 肾结石侧位与脊柱重叠

24. Diagnostic Basis

25. Abdominal pain is located in the region between the epigastrium and the hairy pubic region. The pain is not very severe. The affected region is soft with slight tenderness and muscular tension and rebound tenderness don’t exist.
The disease usually has a slow onset. Improper diet, emotional upsets and the attack of cold can induce or worsen abdominal pain.
Abdominal X-ray and B-type ultrasonic examination and lab examination will be beneficial to the diagnosis and differential diagnosis.
Abdominal pain caused by surgery and gynecology and other diseases of internal medicine should be removed.

26. Diagnosis of Common Diseases Associated with Abdominal Pain in Western Medicine

27. 1 Gastric and Duodenal Ulcer Perforation
The risk factors are medical history of ulcers, violent mood and over fatigue.
Sudden severe tearing or cutting pain in the upper abdomen can quickly diffuse to all over the abdomen, with nausea and vomiting
There may be tenderness and rigidity rebound tenderness, muscular rigidity making the abdomen like a plank. And reduce the liver dullness, shifting dullness and reduced or disappeared bowel sounds.
The X-ray shows the shadow of subdiaphragmatic free air. The white blood cells often increased in peripheral blood.
Gastric and Duodenal Ulcer Perforation

28. 2
The common risk factors are the medical history of cholecystitis or cholelithiasis, overeating and high-fat diet.
The sudden severe pain in the upper abdomen can radiate to back, with abdominal distention, nausea, vomiting, fever and jaundice. In severe cases, there may be peritonitis, tachycardia and hypotension, and even shock.
Grey Tuner’s sign or Cullen’s sign.
Serum and urine enzymes are the most important way to diagnosis. Ultrasound, CT and MRI indicate the extent of the lesion, as the criteria of severity classification and prognosis of the disease.
Acute Pancreatitis

29. 3
The pain is typically started from the middle upper abdomen or umbilical region. Then transfers to the right lower abdomen after 6~8 hours, with nausea, vomiting, and even poisoning symptom in severe cases.
Tenderness at Macburney’s point is an important sign of the disease. Rebound tenderness, muscular rigidity, and the reduced or disappeared bowel sound suggest that the infection goes worse. There may be some pathological changes like fester, gangrene or perforation.
Blood routine test shows leukocytosis. Abdominal X-ray and type-B ultrasonic examination are helpful to diagnose.
Acute Appendicitis

30. 4 Acute Gastroenteritis
Acute Gastroenteritisis usually caused by unclean food.
Paroxysmal colic in the upper abdomen or around the belly button, with vomiting or diarrhea.
Soft abdomen without fixed tenderness, hyperactive bowel sounds.
Large amount of leukocyte in the stool.
Acute Gastroenteritis

31. 5 Biliary Tract Infection and Cholelithiasis
It can be commonly occurred among the middle aged female. The onset of is closely associated with greasy food.
The clinic manifestations are severe colic in the upper and middle abdomen, which is characterized by paroxysmal intensification and radiating to the shoulder and back.
Ultrasonic examination shows high echo and shadow of gall stone.
Biliary Tract Infection and Cholelithiasis

32. 6
The manifestations are pain, vomiting, distension and blockage.
Paroxysmal colic mainly locates at middle abdomen or the obstruction site. In the early stage, the vomitus is food or gastric juice; and the abdominal distension is related to obstruction site.
Rectal touch, X-ray and the barium enema can help to diagnose.
Acute Ileus

33. Pattern Identification & Treatment

34. Key Points in Pattern Identification
Nature
Characteristics
Excess
Sudden onset, the pain is aggravated with pressure, abdominal distension and vomiting.
Deficiency
Dull and lingering pain with a preference for rubbing and pressure.
Cold
Sudden, uninterrupted, abdominal muscle spasmodic, cramping pain that can be alleviated by warmth but aggravated by cold.
Heat
Alternating mild and severe abdominal pain with a localized sensation of heat in the painful area of the abdomen which can be alleviated by cold. Constipation may also occur.
Qi stagnation
Alternating mild and severe abdominal distending pain with no fixed location, coupled with chest or hypochondriac discomfort and abdominal distension. The distending pain can be alleviated by belching or flatus.
Blood stasis
Uninterrupted stabbing pain in the left or right flank with a fixed location and tenderness. The pain becomes worse at night. Patients may have a dark and gloomy complexion.
Food injury
Abdominal fullness and pain with frequent belching. The pain can be alleviated after belching or the passing of stool.

35. Key Points in Pattern Identification
Site
Zang-fu organs or channels
Shao fu (少腹): Left or right flank
Liver channel
Da fu (大腹): General abdomen
The spleen and stomach
Xiao fu (小腹): Central lower abdomen
Urinary bladder, large and small intestines

36. Cold invasion 寒邪内阻 Method: Warm the middle jiao and dissipate cold.
sudden, acute abdominal cramping pain that can be aggravated by cold but alleviated by warmth, no thirst, loose stool or normal bowel movements, clear and profuse urine. Normal color or pale with white and greasy coating. Deep and tight pulse.
Method: Warm the middle jiao and dissipate cold.
Prescription: Modified Liang Fu Wan and Zheng Qi Tian Xiang San.
良附丸合正气天香散加减

37. Accumulation of damp-heat 湿热壅滞
abdominal pain, the pain is aggravated by pressure, chest tightness and discomfort, constipation or loose stool and incomplete stools, restlessness, thirst with a desire to drink water, sweating and dark-yellow urine. Red with a yellow greasy coating. Slippery and rapid pulse.
Method: Clear heat, resolve the dampness and unblock qi of the large intestine.
Prescription: Modified Da Cheng Qi Tang. 大承气汤加减

38. Food retention 饮食积滞
abdominal fullness, distention and pain, the pain is aggravated upon palpation but alleviated after the passing of stool; other symptoms may include a poor appetite or aversion to food, nausea, vomiting, acid reflex, belching with a foul breath, constipation, or loose stools containing undigested food. Greasy tongue coating. Slippery pulse.
Method: Promote digestion, regulate qi and relieve pain.
Prescription: Modified Zhi Shi Dao Zhi Wan. 枳实导滞丸加减

39. Liver qi stagnation 肝郁气滞
distending and migrating abdominal pain that radiates to the hypochondriac region and lower lateral sides of the abdomen, the pain can be alleviated by belching or flatus and aggravated by outbursts of anger. Slightly red tongue with a thin white coating. Wiry pulse.
Method: Soothe the liver, regulate qi and relieve pain.
Prescription: Modified Chai Hu Shu Gan San. 柴胡疏肝散加减

40. Blood stasis 瘀血内停
persistent, severe, stabbing fixed abdominal pain. Dusky and purple tongue, thin and choppy pulse.
Method: Move the blood, resolve stasis, harmonize the collaterals and relieve pain.
Prescription: Modified Shao Fu Zhu Yu Tang. 少腹逐瘀汤加减

41. Deficient cold in the middle Jiao 中虚脏寒
chronic, dull, intermittent abdominal pain that can be alleviated by warmth, pressure, or rest but aggravated by cold, hunger or fatigue; a poor appetite, a bridge-pale complexion, loose stools , reluctance to speak, shortness of breath, cold intolerance and cold extremities. Pale and swollen with a thin, white and moist coating. Deep and thin pulse.
Method: Warm the middle Jiao, tonify the spleen, release the spasms, and relieve pain.
Prescription: Modified Xiao Jian Zhong Tang. 小建中汤加减

42. Emergency Treatment in Western Medicine

43. T P R BP Quick Evaluation
Give symptomatic treatment according to situation.
Critical cases: Saving life before treating disease.
Moderate critical cases: Combined with the diagnosis and treatment. Improve the patient's condition and get a surgical consultation immediately. Prepare for emergent surgery or some related treatment.
Common cases: Looking for potential life-threatening factors, such as peptic ulcer, gastroenteritis and urinary calculi.

44. Stabilizing The Vital Signs And Giving Supportive Treatment
Anti shock, correct electrolyte and acid-base imbalance.
Use antibiotics effectively to control infection, especially for those with acute abdominal pain accompanied by fever.
Supply nutrition to those who are in fasting and gastrointestinal decompression.
Use analgesics cautiously. Enema and laxatives cannot be used if the intestinal necrosis or perforation are not excluded.

45. Removing The Risk Factor
Indications of Laparotomy:
Suspected persistent bleeding in the abdominal cavity;
Suspected intestinal necrosis or intestinal perforation with severe peritonitis;
After close observation and active treatment, abdominal pain is not relieved, abdominal signs and the whole body condition do not improved, but even get worse.

46. Emergency Treatment in Traditional Chinese Medicine

47. Treatment Principle：Moving the blockage.
夫通则不痛，理也；但通之之法，各有不同。调气以和血，调血以和气，通也；下逆者使之上行，中结者使之旁达，亦通也。虚者，助之使通，寒者温之使通，无非通之之法也。若必以下泻为通，则妄矣。
——《医学真传》
Treatment Principle：Moving the blockage.

48. Moving the blockage
The general principle for an abdominal pain is to move the blockage, because “when there is blockage, there is pain”. When the blockage is removed, the pain is gone. Blockage can be removed by different methods according to different causes.

49. Internal Medication Retention enema of purgative herbal decoctions.
Academician Wu Xianzhong in Tianjin Nankai Hospital established the “Chinese and Western medicine dialectical combination of disease differentiation” methods. He determined the “purgative Law” as the representative of “acute abdomen Eight” treatment rules.
Rhubarb(大黄) preparation was used in treating the acute pancreatitis.
天津南开医院吴咸中院士建立了“中医 辩证与西医辨病相结合”的临床研究方 法，确定了以“通里攻下法”为代表的 “急腹症八法”的治疗法则。
Retention enema of purgative herbal decoctions.

50. Internal Medication
Prof. Zhu Peiting used the basic method of “regulating qi stagnation, detoxification, purgative method”. For heavy-infected patients, using the principles combined with clearing away heat, toxic material and purgative, strengthening body resistance and eliminating evil.
Detoxification not only compensates for the disadvantage of antibiotics, but also reduces poisonousness.
Purgative method can improve respiratory function as well as reduce the absorption of toxins. It can also increase the bile flow and relax the sphincter.
朱培庭灵活运用“理气解郁、清热解毒、通里攻下” 基本治法。感染较重者，特别注意采用清热解毒与通 里攻下并进，扶正与驱邪相结合的原则。清热解毒可 弥补单用抗生素的不足，还具有减毒作用；通里攻下 可改善呼吸功能，减少毒素吸收，增加胆汁流量和松 弛括约肌。临床使用可明显降低手术率。

51. External Medication Topic administration of Si Huang Shui Mi (四黄水蜜).
Use package of Chinese herbs or hot water bag.

52. Body Acupuncture & Electro-acupuncture
Main points:
Shangwan, Zhongwan, Liangmen, Tianshu, Qihai, Guanyuan, Zusanli, Hegu and Neiguan
Reducing Manipulation.

53. Summary chart on syndrome differentiation
and acupuncture treatment for abdominal pain
Syndromes
Acupuncture points
Internal cold retention
RN 12 (中脘), RN 8 (神阙), ST 36 (足三里), SP 4 (公孙)
Accumulation of damp-heat
RN 12 (中脘), ST 36 (足三里), ST 39 (下巨虚),
ST 44 (内庭), LI 11 (曲池), LR 13 (章门)
Food retention
ST 25 (天枢), RN 12 (中脘), ST 36 (足三里),
ST 44 (内庭), BL 20 (脾腧), BL 21 (胃腧)
Liver-qi stagnation
RN 17 (膻中), LR 3 (太冲), PC 6 (内关), GB 34 (阳陵泉)
Blood stasis
RN 12 (中脘), RN 6 (气海), ST 36 (足三里), SP 10 (血海), BL 17 (膈腧)
Deficiency and cold in the middle Jiao
BL 20 (脾腧), LR 13 (章门), BL 23 (肾腧), RN 4 (关元)

54. Balance Acupuncture Main points: Adjunct points:
Stomach ache point (胃痛穴)
Abdominal pain point (腹痛穴)
Adjunct points:
Nausea and vomiting + Chest pain point (胸痛穴)

55. Acupoint Injection Biliary Ascariasis: 0.5mg atropine at Jiuwei.
Biliary Colic: 4mg vitamin K3 at Gallbladder Point.
Appendicitis: 1ml safflower injection at Appendix Point.

56. Prevention & Lifestyle

57. Case Study
A 23-year old male was seen because of abdominal pain for one day. The patient stated that one day prior to the treatment, he felt abdominal pain after supper, which became worse gradually and caused him to be restless and roll all over in bed.
The pain was slightly alleviated a half an hour later after he had taken some pain killers. Upon inquiry, the patient said that because of their graduation from the university, he had his classmates were so excited that they had gone out to drink alcohol. He had continued celebrating in the evening at home. After dinner, he also had eaten some fruit and dessert. As a result, he suffered an attack of abdominal colic pain.

58. Case Study
At the time of treatment, he presented with symptoms including epigastric fullness and pain, poor appetite and nausea, belching with a fetid odor and acid regurgitation, thirst, loss of appetite, and constipation. His urine was normal.
He had had a history of hyperphagia, however, the recent attack turned out to be the most serious one.
The examination showed that the patient had an acute sickly complexion, a foul breath and frequent hiccups. His blood pressure was 110/65 mmHg, and heart rate 90 times/min. In addition, he showed local tenderness on palpation and bowel sounds could be heard on auscultation.
His tongue was red with a yellow, greasy coating.
His pulse was forceful and slippery.

59. Case Study Diagnosis: Excess syndrome due to food retention.
Method: Promote digestion, regulate qi and relieve pain.
Prescription: Modified Zhi Shi Dao Zhi Wan.
Selected points:
RN 12 (zhongwan), ST 21 (liangmen), ST 25 (tianshu), RN 6 (qihai), ST36 (zusanli), ST 44 (neiting), GB 34 (yanglingquan), PC 6 (neiguan), RN (zhongli), SP 6 (sanyinjiao)

60. Contact with me
Tel:

61. Thanks for your attention