Professor Xudong Tang's experience in the treatment of gastroesophageal reflux

Bo Li, Yonghui Pang, Xuejiao Wang, Xudong Tang

1.Beijing hospital of traditional Chinese medicine affiliated to capital medical university,Beijing,China;

2.Beijing Institute of Traditional Chinese Medicine, Beijing, China;

3.Shangzhuang Community Health Service Center,Haidian District,Beijing,China;

4.Beijing University of Traditional Chinese Medicine,Beijing,China;

5.Xiyuan Hospital,Chinese Academy of Traditional Chinese Medicine, Department of Gastroenterology,Beijing,China.

Abstract

Key words: Gastroesophageal reflux disease,Xudong Tang,Integrated traditional Chinese and Western Medicine

Background

Gastroesophageal reflux disease (GERD) is defined as reflux of gastric contents (including duodenal fluid) into the esophagus to produce symptoms or complications [1].GERD includes three clinical subtypes: non-erosive reflux disease (NERD),reflux esophagitis (RE) and Barrett esophagus.The best treatment of GERD in modern medicine is still controversial.The current treatment of GERD patients is based on the frequency and severity of symptoms,and upper gastrointestinal endoscopy [2].

An epidemiological survey of 5000 people aged 18-70 years in Beijing and Shanghai showed that the incidence of symptoms of GERD was 8.97%,the prevalence of GERD was 5.77%,and the incidence of reflux esophagitis was 1.92%.GERD is not uncommon [3,4].

Professor Tang,Xiyuan Hospital,Chinese Academy of Traditional Chinese Medicine,has been engaged in clinical and scientific research of spleen and stomach diseases for a long time [5,6,7].He has accumulated rich experience in the treatment of spleen and stomach system diseases.The author has served side by side and gained a lot.Now,the experience of Professor Tang in the treatment of GERD is summarized as follows:

Clear diagnosis is the key to treatment.

Gastroscopy is encouraged to clarify the condition and course of the disease. When patients go to the hospital to see a doctor, doctors are most concerned about two issues: one is the most uncomfortable symptom,that is,complaint,and the other is the course of the disease. If the patient's illness lasts only two or three days,he is younger than usual.It is temporary dyspepsia,which can be observed without gastroscopy for the time being.If you are older and have a longer course of disease,gastroscopy is recommended for diagnosis. Gastric contents include duodenal fluid.When reflux enters the esophagus,it is gastroesophageal reflux disease.Only the damage of esophageal mucosa caused by acid (alkali) reflux is called RE [8].

Endoscopy can confirm the diagnosis of negative non-erosive gastroesophageal reflux disease (NEGD) or positive RE.For the definite diagnosis of reflux esophagitis,taking PPI drugs such as rabeprazole is the international common treatment method.The relief of symptoms after taking it further verifies reflux esophagitis.However,the efficacy of NEGD western medicine treatment is not significant,so we can choose TCM syndrome differentiation and treatment.

Classification of reflux esophagitis

There are two kinds of reflux esophagitis,one is strong acid reflux,gastric acid returns to the esophagus to stimulate the formation of esophagitis; the other is acid-free or weak acid reflux.The gold standard for detecting gastric acid reflux is 24-hour Ph monitoring,which monitors the location of the most acid reflux and the time of acid reflux.The pathogenesis of different kinds of reflux in traditional Chinese medicine is quite different: if it is acid and heartburn,the syndrome differentiation of traditional Chinese medicine is liver and stomach depression and heat, Lianzhu pill is the main force.No acid or weak acid reflux,clinical manifestations are belching,throat discomfort,liver depression and qi stagnation are the main symptoms of traditional Chinese medicine.Huagan Decoction and Banxia Houpu Decoction are selected. This is also a good demonstration of the combination of traditional Chinese and Western medicine [9].

Drug reduction methods for discontinuation of GERD

In clinical treatment of GRED,the phenomenon of improvement and recurrence after discontinuation of medication is often seen. Repeated treatment lasts about two years.Professor Tang's clinical use of step-down drug reduction therapy is common and effective.There are three kinds of Western medicine for the treatment of reflux esophagitis in modern medicine. The first is to neutralize gastric acid and mucosal covering agent,such as bismuth potassium citrate capsule.The second is H2 receptor blocker,that is,Tidine.The third is PPI inhibitor,which has the strongest effect,such as rabeprazole,omeprazole and other drugs.If the strongest rabeprazole and other effects are still not significant, it is recommended to use integrated traditional Chinese and Western medicine to treat.Patients taking rabeprazole should not stop taking it suddenly,and they should be treated with traditional Chinese medicine on the basis of differentiation of symptoms and signs.For example,patients with GRED of liver-stomach depression-heat type,whose clinical characteristics are that the condition is closely related to mood,and the symptoms of anxiety,anger,acid-regurgitation and heartburn are aggravated.Adding Lianzhu pill to add or subtract drugs [10].Decoction and Western medicine,two fists fight together,so as to achieve the purpose of reducing gastric acid fundamentally.After a period of time,H2 receptor blocker combined with Decoction was used to treat the disease,and then the western medicine was withdrawn gradually.After another month or so,some patients could finally get rid of the western medicine.For acid-free and weak acid reflux,the effect of Western medicine is not significant at this time.Considering the treatment of Decoction such as Huagan Decoction [11],the main function is to invigorate the spleen,soothe the liver and regulate qi.

Characteristic prescriptions of TCM treatment

The main symptoms of GERD are stomachache and acid reflux.According to its clinical manifestations,CERD belongs to the category of "stomachache,acid vomiting,noise,vomiting,choking" and so on.The etiology of this disease can be generally classified into two aspects: mental factors and dietary irregularities.Such as worry and anger,long depression and puzzlement,injury to the liver,liver Qi is not comfortable,transverse offensive stomach,stomach Qi lost its harmony and fall,resulting in epigastric pain,or stomach Qi upside down and acid vomiting,or vomiting.Whatever swallows acid belongs to the liver wood,it turns straight into acid.Covering cold makes Yang Qi unsatisfactory,Qi unsatisfactory makes Qi depressed and hot,while heat is sour.However,there are also those who are not sour because of cold.They are all wood Qi depressed,fumigating wet soil,or swallowing or spitting.Another is eating too much,stomach (moonlight) congestion,bad temper and sour,is the extreme depression, hot and humid steaming. Such as wine vats are too sour.But it's always the result of wood.It can be seen that although CERD can be divided into cold and heat,it should be based on the liver when it is treated.If the delay does not heal,there may be liver depression and fire invading the stomach,damaging the stomach Yin and bitter mouth,hunger but no appetite; burning the stomach collaterals and vomiting blood,black stool; long-term pain and veins,qi stagnation and stasis,so the pain is fixed and refused to press,and even veins broken and bleeding.Spleen and stomach live together in the middle focal point,which is connected by membranes,one viscera and one Fu organ,and each other is exterior and interior.They are the main ascending and descending factors. Therefore,stomach diseases mostly involve the spleen,and spleen diseases can also be involved in the stomach.Improper diet,abnormal hunger and satiety,insufficient spleen transport ability or weakened gastric acceptance and maturation function can lead to impaired mid-Jiaoqi,or stomachache or obstruction of stomach qi,or vomiting and acid vomiting due to upsidedown of stomach qi [12-14].So Professor Tang believes that although CERD is manifested in the stomach,it is closely related to the liver and spleen.It is marked in the stomach and originally in the liver.Its basic pathogenesis is upstream stomach-qi inversion,which should be treated mainly by soothing liver and invigorating spleen,lowering stress and stomach.

Psychological evaluation results showed that about 40% of the subjects with gastroesophageal reflux disease had depression/anxiety,most of them were mild to moderate,and the proportion was significantly higher than that of the general population [15].Overseas studies have found that the comprehensive mental health index of GERD patients has been significantly improved while completely relieving heartburn and other symptoms,which confirms that the symptoms of GERD patients are significantly affected by psychological and emotional state [16].

Ganwei Baihe Decoction [17,18] is derived from Dr Dong's experience in the treatment of spleen and stomach diseases. It consists Chaihu (Bupleuri Radix)10g,Huangqin (Astragali Radix) 10g,Baihe (Lilium brownii) 15g,Danshen (Salviae Miltiorrhizae Radix et Rhizoma) 15g,Wuyao (Linderae Radix) 10g,Chuanlian (Toosendan Fuctus) 10g,Yujin (Curcumae Radix) 10g.The functions is soothing liver and regulating qi,clearing stomach and activating blood circulation,and treating stomach,duodenal ulcer, chronic gastritis, duodenitis and gastric neurosis.Those with stagnation of Qi and blood stasis and stagnation of heat in liver and stomach.

As the occurrence and development of GERD,Qi stagnation is one of its important pathogenesis,so we take Bupleurum Chinense,Tulip of cool,Qi stagnation of long-term fire,blood stasis of long-term heat [19].We take Huangqin (Scutellariae Radix ) to clear up the heat of liver and stomach.Chaihu (Bupleuri Radix) and Huangqin (Scutellariae Radix) are compatible with each other,and use them to harmonize the surface and the interior, coordinate the ascent and descent, and the pivot machine works,so as to achieve the goal of "getting the upper Jiao Tong, getting the lower fluid,and harmonizing the stomach qi".Although Wuyao (Linderae Radix) is warm,but it is not dry,it can smoothly reduce the adverse gas of the chest and diaphragm and which mutually restrains its disadvantages and promotes its strengths, and does not damage the Qi and Yin.Long-term illness into collaterals,qi stagnation and blood stasis,collateral damage and blood injury,so with Danshen (Salviae Miltiorrhizae Radix et Rhizoma),Yujin (Curcumae Radix) to promote blood circulation,remove blood stasis and create new.Deficiency due to long illness should be remedied.However,warming and tonifying stagnate the stomach,and nourishing drugs hinder the spleen. Therefore,Danshen (Salviae Miltiorrhizae Radix et Rhizoma) and Yujin (Curcumae Radix) are used to tonify the stomach and nourish the stomach and yin.This prescription on meridian tropism enters the spleen and stomach, or goes through the liver meridian.As a result,it is not dry and not greasy,and can achieve multicoordinated,specimens take into account,adjust and supplement,and match properly.It not only alleviates the illness quickly,but also is suitable for long-term service,so as to achieve the goal of radical cure.Addition or subtraction: upper abdominal pain has a definite location but refuses to press,tongue dull or bruised spots add Taoren (Persicae Semen) 10g; abdominal pain and black stool add Puhuang (Typhae Pollen) 15g; constipation add Huomaren (Cannabis sativa L.) or Gualou (Trichosanthis Fructus) 15-20g; dry mouth and throat,dry stool,red tongue,less zinc,pulse Shashen (Adenophorae Radix) or Maidong (Ophiopogonis Radix) 15g,or Shengdi (Rehmanniae Radix) 12g,Guolou (Trichosanthis Fructus) 15g; Taizishen (Pseudostellariae Radix) 15g,Baizhu (Atractylodis Macrocephalae Rhizoma ) 12g.

Clinical pharmacological studies have shown that the obvious effect of Ganwei Baihe Decoction on gastroesophageal reflux may be related to the intervention of TNF-alpha and IL-1 production.Some scholars believe that after taking Ganwei Baihe Decoction,gastric mucosal G cells secrete Gas gradually decreased,parietal cells secrete H + also decreased,leading to the weakening of inflammatory response,and then through some mechanism,the expression of NFkappa B gradually decreased,further reducing inflammatory factors such as TNF-alpha and IL-8,so that inflammatory cells also gradually decreased [20-22].

Dr Tang inherited Dong's thought of spleen and stomach,and his clinical thinking of treating GRED was mostly based on Dong's.On the basis of summing up the experience of predecessors,especially Dong's famous veteran TCM in the treatment of spleen and stomach diseases.Dr Tang summed up that reflux esophagitis was always treated with Lianzhu pill combined with Huagan Decoction according to many years' clinical experience:

Huanglian (Coptidis Rhizoma) 6g Wuzhuyu (Evodiae Fructus) 2g Chaihu (Bupleuri Radix) 12g Qingpi (Citrus reticulata Blanco) 10g Chenpi (Citri Reticulatae Pericarpium) 10g Zhebeimu (Fritillariae Thunbergii Bulbus) 15g Danpi (Moutan Cortex) 10g Zhizi (Gardeniae Fructus) 10g Baishao (Paeoniae Radix Alba) 15g Sharen (Amomi Fructus) 6g Haipiaoxiao (Sepiae Endoconcha) 15g Zhigancao (Glycyrrhizae Radix et Rhizoma) 10g

Choose according to the specific situation, if it is sour and heartburn,it belongs to liver and stomach depression and heat, Lianzhu pill is the main force; if it is belching,liver depression and Qi stagnation,Huagan Decoction is selected.When the number of feces is more sparse,the spleen yang deficiency is Ganjiang (Zingiberis Rhizoma) 6g,instead of Wuzhuyu (Evodiae Fructus).If the degree is more serious,it is Paojiang (Zingiber offi cinale Rosc) 10g.Another special attention is to the differentiation of the time of sour and heartburn.if it is before meal noisy mainly,increase the dosage of Huanglian (Coptidis Rhizoma),Danpi (Moutan Cortex),Zhizi (Gardeniae Fructus).And give the half an hour after breakfast and dinner to take medicine.If after meal abdominal distension is the main reason,when liver depression is partial,add Xiangfu (Cyperi Rhizoma) 10g and Zisugeng (Perillae Folium) 10g.Change can never be separated from its ancestral line.On the basis of the main pathogenesis,it can be added or subtracted according to the symptoms.

Examples of Examination Cases

Record date: 2016-01-09

Main complaint: acid reflux after sleeping at night for more than 5 years.Present medical history: 5 years ago,tired work,after rushing,there was acid burning heart,no stomachache.On July 8,2013,gastroscopy showed reflux esophagitis.Pathology showed normal gastric mucosa and HP was negative.In June 2015,24-hour dynamic PH impedance test showed gastroesophageal reflux.Immediately: every night after 2:00 to 3:00 am acid reflux wake up,after self-relief,have taken PPI gastric motility drugs and acid inhibitors and gastric mucosal protective drugs,no effect.After exercising,it improved slightly.Dare not eat cold,easy to be anxious and angry,can be controlled,stool once a day,not sparse,no thirst.

Four Diagnosis: Red tongue and white coating; Slippy pulse

Diagnosis

Diagnosis of TCM:

1.Deficiency of Spleen and Stomach and Cold;

2.Liver Depression and Spleen Deficiency Syndrome

Diagnosis of Western Medicine:

1.Gastroesophageal reflux; 2.Chronic gastritis

Therapeutic Principle: Huagan Decoction,Lianzhu Pill

Prescription

Taizishen (Pseudostellariae Radix)15g Chaobaizhu (Atractylodis Macrocephalae Rhizoma) 15g Paojiang (Zingiber offi cinale Rosc) 10g Zhishi (Fructus Aurantii) 12g Heye (Folium Nelumbinis) 10g Qingpi (Citrus reticulata Blanco) 10g Chenpi (Citri Reticulatae Pericarpium) 10g Mudanpi (Moutan Cortex) 10g Chaozhizi (Gardeniae Fructus) 10g Baishao (Paeoniae Radix Alba) 15g Huanglian (Coptidis Rhizoma) 10g Wuzhuyu (Evodiae Fructus) 2g Haipiaoxiao (Sepiae Endoconcha) 30g Sharen (Amomi Fructus) 10g Zhigancao (Glycyrrhizae Radix et Rhizoma) 10g

A total of 7 doses,decocted water,one dose a day,two sub-doses

This patient used Huagan Decoction,Lianzhu pill and Sijunzi decoction, Lianzhu pill in the treatment of liver and stomach depression and heat,combined Huagan Decoction in the treatment of irritability and other symptoms,in addition,patients with acid reflux mostly concentrated in the night from 1:00 to 2:00,foot Jueyin liver meridian when ordered,according to this more can be diagnosed as liver problems,the two sides together.Because of the signs of improvement after exercise,consider the life habits,such as working pressure and sedentary,which lead to poor Qi,compatibility with Zhishi (Fructus Aurantii).Obvious performance of cold deficiency in the spleen and stomach that dare not eat cold.Taizishen (Pseudostellariae Radix),Baizhu (Atractylodis Macrocephalae Rhizoma) invigorate spleen and invigorate deficiency.while Zhengqi is sufficient,pathogenic can not be dried.These drugs play different roles in treating the TCM symptoms of gastroesophageal reflux.Diseases do not come according to textbooks,often without the most typical symptoms,cold and heat are often miscellaneous and need to be carefully examined and differentiated.From the mechanism of Western medicine to the differentiation of symptoms and signs of traditional Chinese medicine,must be closely linked.