TCVM Approach to Megacolon and Megaesophagus

1. TCVM Approach to Megacolon and Megaesophagus

2. “Mega-” Introduction • If normal directional motion is inhibited in a tubular organ • A type of Qi Deficiency • May be a congenital disharmony • Yang Jing Deficiency if associated with other signs of Yang Deficiency • Yin Jing Deficiency if associated with other signs of Yin Deficiency

3. “Mega-” Introduction • “Directional” or propulsive Qi Deficiency • May be acquired • Exogenous Pernicious influences • E.g. distemper virus, trauma, toxins, poor quality foods for that species or individual constitution • Endogenous Pernicious influences • E.g. hypothyroidism, systemic lupus erythematosus, hypoadrenocorticism, myasthenia gravis • Remember that “sthenia” means “full” or “excess” • “asthenia” means “empty” or “weak” or “deficient”

4. “Mega-” Introduction • “Directional” Qi Deficiency • May be associated with concurrent Blood or Yin Deficiency • Subsequent Dryness fails to lubricate either ingesta or feces • Megaesophagus swallowing inhibited • Regurgitate dry ingesta • Megacolon defecation inhibited • “Cannot float the boat in a dry river”

5. Megaesophagus and Megacolon: Types of Wei Syndromes? • Wei means “withered” in Chinese to describe the withering of muscles • Classical Wei or Atrophy Syndrome is a condition characterized by a weakness of the four limbs, progressively leading to atrophy, a limp state of muscles and tendons, an inability to walk properly and eventually paralysis • This weakness generally occurs without pain • So are these “Megas” localized Wei?

6. Wei Syndrome Pattern Differentiation • Heat in the Lungs injuring Yin fluids- Excess • Invasion of Damp-Heat- Excess • Invasion of Cold-Dampness- Excess • Stomach and Spleen deficiency- Deficiency • Spleen and Heart collapse- Deficiency • Liver and Kidney deficiency- Deficiency • Blood Stasis in the channels- Combination of Excess and Deficiency

7. Relationship Between Pattern and Pathoetiology • Wind-Heat causes only Lung-Heat injuring Yin fluids • External Dampness leads to Damp-Heat or Cold-Dampness • Irregular Diet causes the patterns of Damp-Heat, Cold-Dampness and Stomach-Spleen deficiency • Excessive sex and overwork cause the patterns of Kidney-Liver deficiency and Blood stasis in the channels • Trauma causes the pattern of Blood stasis in the channels • Shock leads to the pattern of Heart-Spleen collapse

8. “Mega-” Primary treatment principles • Tonify global and local Qi • Assist directional Qi Flow • Increase Moisture • Tonify Yin • Increase Body Fluids • Nourish Blood • Invigorate Blood

9. Megaesophagus: Pattern Differentiation • Qi Deficiency or Yang Deficiency • may be seen with hypothyroidism, systemic lupus erythematosus, hypoadrenocorticism, myasthenia gravis, poor quality foods for that species or individual constitution • Blood Deficiency +/- Blood Stagnation • may be seen with trauma, toxins, poor quality foods for that species or individual constitution • Heat Patterns • may be seen with distemper infection or other febrile diseases

10. Megaesophagus Treatment • Physical assistance with raised feeding station and soft, highly digestible foods • Suggest slow-cooked foods based upon Bian Zheng (see following lecture) • Acupuncture based upon global and local Patterns • Herbal Formula based upon global and local Patterns

11. Megaesophagus: Qi Deficiency • Clinical Signs • Fatigue, weight loss, muscle mass loss, decreased/depressed back Shu points • Tongue • Pale, moist • Pulse • Feeble, especially middle and upper jiao

12. Megaesophagus: Qi Deficiency • Acupuncture: Use electro-AP!! • PC 6 master of the chest • CV 17 front Mu of the upper Sea of Qi • CV 12 front Mu for the Stomach (esophagus “belongs to” the Stomach) • BL 13, 14, 15 as local Shu for upper Sea of Qi • LI 4, LIV 3 to move Qi • LI 10, ST 36, CV 6 to nourish Qi • LI 1, LU 11, ST 45 to clear fullness of the chest in the region of the Heart

13. Megaesophagus: Qi Deficiency • Spleen Qi Deficiency • Si Jun Zi Tang or Four Gentlemen Decoction • the chief herb Panax ginseng ren shen is sweet, warm and tonifies Spleen Qi • the deputy herb Atractylodis macrocephalae bai zhu is bitter, warm and strengthens Spleen Qi and dries Dampness

14. Megaesophagus: Qi Deficiency • Spleen Qi Deficiency • Si Jun Zi Tang • assistant herb Poria cocos fu ling is sweet, bland and leeches out Dampness and mildly Tonifies Spleen Qi • the envoy Glycyrrhiza uralensis gan cao is warm, sweet and warms and regulates the middle burner • modify with Hou Po magnolia bark to promote Qi flow, transform Dampness, relieve food stagnation, direct rebellious Qi downward for a stifling sensation in the chest • Or modify with Platycodon jie geng resolve phlegm and guide other herbs to upper burner

15. Megaesophagus: Blood Deficiency • Clinical Signs • Dry fur, dry pads, firm, dry stools, decreased firmness in back Shu points • Tongue • Pale, dry, may have slight lavender hue • Pulse • Weak, thin, especially middle and upper jiaos

16. Megaesophagus: Blood Deficiency • Acupuncture: Use electro-AP!! • PC 6 master of the chest • CV 17 front Mu of the upper Sea of Qi • CV 12 front Mu for the Stomach for post-heaven Blood • BL 17, 18 to engender Blood • LI 4, LIV 3 to move Qi with Blood • SP 10, ST 36 to engender Blood and benefit Spleen and Stomach • LI 1, LU 11, ST 45 to clear fullness of the chest in the region of the Heart

17. Megaesophagus: Blood Deficiency • Tao Hong Si Wu Tang Four Substances Decoction with Peach Kernel and Safflower • Shu di huang prepared rehmannia • Dang gui angelica sinensis • Bai shao yao white peony • Chuan xiong ligusticum • Tao ren peach kernel • Hong hua safflower • Nourish Blood, promote Blood circulation, removes Blood Stasis

18. Megaesophagus: Blood Stagnation • Clinical Signs • Pain in chest, front Mu and back Shu points, uncomfortable lying in ventral recumbency • Tongue • Lavender, usually slightly pale and dry • Pulse • Wiry, choppy, commonly thin

19. Megaesophagus: Blood Stagnation • Acupuncture: Use electro-AP!! • LI 4, LIV 3, LIV 14 to move Blood • PC 6 master of the chest, reduce stagnation • CV 17 front Mu of the upper Sea of Qi • BL 17, 18, SP 10 to engender and circulate Stagnant Blood • CV 12, GB 21, GV 1 to descend Qi • LI 1, LU 11, ST 45 to clear fullness of the chest in the region of the Heart

20. Megaesophagus: Blood Stagnation • Xue Fu Zhu Yu Tang Remove Stasis from the Mansion of Blood Decoction • Tao ren peach kernel • Hong hua safflower • Dang gui angelica sinensis • Sheng di huang prepared rehmannia • Chuan xiong ligusticum • Chi shao yao red peony • Chuan niu xi cyathula • Jie geng platycodon • Chai hu bupleurum • Zhi ke bitter orange • Gan cao licorice • Promotes the circulation of Blood and Qi, removes Blood Stasis, relieves pain

21. Megacolon: Pattern Differentiation • Qi Deficiency • seen with chronic poor quality foods for felids in general or individual constitution • Blood Deficiency +/- Blood Stagnation • seen with trauma, poor quality foods for that species or individual constitution • Heat Patterns • may be seen with chronic Stagnation of Qi or Blood • Yin Deficiency • usually a consequence of Chronic Heat • Mixed Qi and Blood Deficiency • is very common

22. Megacolon: Primary treatment principles • Tonify global and local Qi • Assist directional Qi Flow • Tonify Qi of all Bowels (i.e. Stomach System) • Increase Moisture • Tonify Yin • Increase Body Fluids • Nourish Blood

23. Megacolon: Qi Deficiency • Clinical Signs • Firm to moderate stools that are difficult to expel, thin, small muscles, easily fatigued • Tongue • Pale, normal to moist • Pulse • Weak, deep

24. Megacolon: Qi Deficiency • Acupuncture • BL 20, 21, ST 36 and CV 12 to nourish the Spleen and Stomach • ST 37 lower He Sea for Large Intestine • BL 25, ST 25 back Shu and front Mu for Large Intestine • TH 6, TH 5 empirical points for moving the Qi of the intestines for constipation

25. Megacolon: Qi Deficiency • Si Jun Zi Tang or Four Gentlemen Decoction • Panax ginseng ren shen is sweet, warm and tonifies Spleen Qi • Atractylodis macrocephalae bai zhu is bitter, warm and strengthens Spleen Qi and dries Dampness • Poria cocos fu ling is sweet, bland and leeches out Dampness and mildly Tonifies Spleen Qi • Glycyrrhizae uralensis gan cao is warm, sweet and warms and regulates the middle burner • Modify with Rhubarb da huang as a bitter, cold herb to move the bowels and dispel stasis

26. Megacolon: Qi Deficiency • Fan Xie Ye (I8001) • Fan Xie Ye senna leaf • Sweet, bitter, cold • Enters the Large Intestine Channel • Drains downward and guides out stagnation • For constipation due to heat accumulation in the Intestines • Contains anthraquinone glycosides • Hepatic metabolites stimulate pelvic ganglion • Purge Large Intestine, resolve food stasis

27. Megacolon: Blood Deficiency • Clinical Signs • Hard, dry stool, dry hair, dry and flakey skin • Tongue • Pale and dry • Pulse • Thin, weak

28. Megacolon: Blood Deficiency • Acupuncture • BL 20, 21, ST 36 and CV 12 to nourish post-heaven Blood production via SP/ST • BL 17 and SP 10 to nourish Blood • ST 37 lower He Sea for Large Intestine • BL 25, ST 25 back Shu and front Mu for Large Intestine • TH 6, TH 5 empirical points for moving the Qi of the intestines for constipation

29. Megacolon: Blood Deficiency • Dang Gui Cong Rong (A0250) • Dang gui angelica sinensis • Rou cong rong cistanche • Qu mai dianthus • Shen qu massa fermentata • Fan xie ye senna leaf • Hou po magnolia • Mu xiang saussurea • Xiang fu zi cyperus seed • Zhi ke bitter orange • Tong cao tetrapanax • Moisten Large Intestine, resolve impacted Large Intestine

30. Megacolon: Dryness due to Heat • Clinical Signs • Constipation with hard stool difficult to expel, frequent urination • Tongue • Dry, yellow coating • Pulse • Deep, rapid or floating and choppy

31. Megacolon: Dryness due to Heat • Ma Zi Ren Wan Hemp Seed Pill • Huo ma ren cannabis seed • Xing ren apricot seed • Shao yao peony • Zhi shi immature bitter orange • Hou po magnolia cortex • Da huang rhubarb • Moisten the Intestines, drains Heat, promotes Qi movement, unblocks the bowels

32. Megacolon: Yin Deficiency • Clinical Signs • Constipation, thirst • Tongue • Dry, red • Pulse • Thin and slightly rapid or weak and feeble • Consequence of warm-febrile disease in weak or Yin Deficient patient

33. Megacolon: Yin Deficiency • Acupuncture • BL 25, ST 25 back Shu and front Mu of Large Intestine • SP 6, KI 3, , CV 4, BL 23 to nourish the Yin • TH 6, ST 37 to unblock the Large Intestine

34. Megacolon: Yin Deficiency • Zeng Ye Tang Increase the Fluids Decoction • Xuan shen scrophularia • Mai men dong ophiopogon • Sheng di huang fresh rehmannia • Generates fluids, moistens dryness and unblocks the bowels

35. Megacolon: Stagnation with Heat • Clinical Signs • Severe constipation and flatulence, focal distention and abdominal fullness, abdominal pain which increases with pressure, tense and firm abdomen • Tongue • Dry, yellow or dry and dark coating • Pulse • Deep, excessive

36. Megacolon: Stagnation with Heat • Acupuncture • Ren 4 tonifies Yin and fluids • LI 11 clears Heat in the Large Intestine • ST 37 lower He Sea for Large Intestine to harmonize LI • ST 44 clears Stomach Heat • LI 2 clears Large Intestine Heat • SP 6, KI 6, Ren 12 promote body fluids

37. Megacolon: Stagnation with Heat • Da Cheng Qi Tang Major Order the Qi Decoction • Da huang rhubarb • Mang xiao mirabilitum • Zhi shi immature bitter orange • Hou po magnolia cortex • Vigorously purges Heat accumulation

38. Conclusion • Megaesophagus and Megacolon are predominantly types of localized Qi Deficiency • Although heritable (Jing) factors may be involved, Exogenous Pathogens and poor quality foods are root cause • Blood Deficiency with or without Blood Stagnation may be a complicating factor • Acupuncture and Herbal formula based upon Pattern Differentiation may improve quality of life