acute epigastric pain 急性胃脘痛

1. acute epigastric pain急性胃脘痛 Zhang Yinglan MD,  Associate chief physicianEmergency DepartmentLonghua Hospital Affiliated Shanghai University of TCM

2. definition A sudden severe pain occurs in the epigastic region. Accompanying symptoms may include nausea, vomiting or even faint with cold limbs.

3. 胃脘痛源出《内经》，并被称之为“心痛”，如《素问．六元正纪大论》即谓：“木郁之发，民病胃脘当心而痛，上支两胁，膈咽不通，食饮不下”。胃脘痛源出《内经》，并被称之为“心痛”，如《素问．六元正纪大论》即谓：“木郁之发，民病胃脘当心而痛，上支两胁，膈咽不通，食饮不下”。 • 《丹溪心法．心腹痛》始谓“心痛即胃脘痛”。 The Inner Canon of Huangdi“ cardiac pain” Danxi‘s experiential therapy“cardiac pain is epigastric pain”

4. Relavant diseases • acute  gastritis • prolapse of gastric mucosa • acute perforation of gastroduodenal ulcer  • acute perforation of gastric cancer • acute gastric dilatation • acute stomach volvulus • …

5. pathogenesis • external pathogen attacking the stomach • food injury • emotional disturbance • constitutional deficiency of the spleen and stomach

6. stomach-qi stagnation stomach-qi failing to descend blockage pain 不通则痛

7. External pathogen attacking the stomach • External cold, summer-heat or dampness may attack stomach stomach qi stagnation pain

8. Food injury • an improper diet , binge eating , over ingestion of fatty, spicy or sweet food and excessive consumption of alcohol affect the descending of stomach-qi pain

9. Emotional disturbance • worry, emotional stress or anxiety may damage liver and spleen • liver-qi stagnation then overact on the stomach • dysfunction of the spleen in transport ，stomach-qi stagnation

10. Constitutional deficiency of the spleen and stomach • an improper diet, overexertion or chronic illness may cause the spleen yang or stomach yin deficiency • faliure of yang-qi to warm the stomach collaterals • stomach yin deficiency may cause malnourishment of the stomach

11. Diagnostic key points   • no obvious gender or seasonal difference • characteristics ：sudden onset, severe pain • inducing factors：food injury, outrage, external infection • involved organs: spleen, stomach, liver • pathogenic nature: more excess syndrome than the deficiency

12. Excess syndrome • Gastric fullness and distention, belching with a foul breath, acid reflux, vomiting of undigested food, burning of the stomach, irritability, incomplete bowel movement, the pain can be alleviated by vomiting or flatus • Tongue: red with a yellow greasy coating • Pulse: slippery, wiry and rapid

13. Deficiency syndrome • Sudden, intermittent, acute abdominal cramping pain that can be aggravated by cold but alleviated by warmth, preference for hot drinks • Tongue: pale with a white coating • Pulse: deep and tight

14. Differential diagnosis

15. Relative examination • Blood test increase in the number of white blood cell and  left shift(核左移）indicate the gastric pain caused by infection • Abdominal X-ray • gastrointestinal prolapse of gastric mucosa胃黏膜脱垂症 • acute perforation of gastric or duodenal ulcer胃及十二指肠溃疡急性穿孔 • acute gastric dilatation急性胃扩张 • acute volvulus of stomach急性胃扭转

16. Emergency treatment in TCM

17. routine treatment • Stay in bed, temporary fasting, monitoring vital signs for 24h, open venous access • Acupuncture analgesia or use auricular acupuncture • Hot compress with a warm pack

18. Syndrome differentiation and treatment • Pattern： excess • Pathogenesis：evil-qi affecting the stomach • Treatment principle： heat-clearing and damp-drying， protect the stomach and relieve the pain • Formula：modified Ban Xia Xie Xin Tang(半夏泻心汤）

19. Patented Chinese medicine： • Tetrahydropalmatine injection（延胡索乙素针）2ml im qd/bid • Compound Rhizoma Corydalis injection（复方延胡注射液） 2ml im qd/bid • Paederia scandens injection（鸡矢腾注射液) 2-4ml im tid

20. Acupuncture treatment • PC 6(neiguan)、ST 36(zusanli）、RN 12(zhongwan) • Apply reducing manipulation

21. Syndrome differentiation and treatment • Pattern: deficiency • Pathogenesis：deficient cold in the middle yang and evil-cold stagnation • Treatment principle：warm yang, dissipate cold and relive pain • Formula：modified Fu Zi Li Zhong Tang(附子理中汤）

22. Modifications: for severe pain, combine with Wu Zhu Yu(吴茱萸 evodia rutaecarpa ）, Bi Ba (荜茇piper longum） • Patented Chinese medicine： • Fu Zi Li Zhong Wan (附子理中丸) 6g tid po • Xiang Sha Yang Wei Wan(香砂养胃丸) 9g tid po

23. Acupuncture and moxibustion： • ST 36(zusanli）、RN 12(zhongwan) • Apply reinforcing manipulation and moxibustion can be combined • Twice a day, 30min each time

24. Comprehensive treatment

25. For relive pain： • atropine 10mg q4-6h im(阿托品） • 654-2 10mg q6h im • morphine or  dolantin （吗啡或杜冷丁）

26. Anti-nausea  • metoclopramide 10mg tid po（甲氧氯普胺） • domperidone 10mg tid po（多潘立酮） • mosapride 5-10mg bid/tid po（莫沙必力） • acupuncture zusanli（ST 36）、neiguan（P6) • H2 receptor antagonist（cimetidine西米替丁、 ranitidine雷尼替丁、famotidine法莫替丁）or proton pump inhibitor （奥美拉唑Omeprazole 80mg + NS 100ml qd ivgtt）

27. Acupuncture and moxibustion • warm acupuncture therapy   • moxibustion with salt or ginger on CV 8 (Shenque)、 RN 12(zhongwan) • auricular acupuncture：sympathetic（交感）、subcortex（皮质下）、stomach Moderate stimulus ， retaining the needle for 10-30 minutes，once a day

28. Acupoint injection • atropine 1ml to the ST 36(zusanli）、RN 12(zhongwan) • Acupressure • sensitive spot in processus spinosus of vertebra thoracica （T3-T5） • bilateral ST 36(zusanli、ST34（liangqiu）

29. Anti-infective therapy • Maintaining water and electrolyte acid-base balance  • Emetic therapy • inducing vomiting（探吐） • San Sheng San（三圣散）

30. Hot compress  Radish Seed（莱菔子）、 ginger 、 scallion

31. Surgical operation

32. Use pulse-activating injection（生脉注射液）or Shenfu injection（参附注射液） 20-40ml ivgtt • Antishock therapy • Supporting treatment

33. Prevention & Lifestyle • Maintain a peaceful mind and keep a regular lifestyle • Avoid thick tea, coffee, cigarette, alcohol, andspicy food • See a doctor immediately in the case of severe pain

34. Diagnosis of Common Diseases Associated with Abdominal diseases in Western Medicine

35. Gastric and duodenal ulcer perforation • 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（board-like rigidity）. And reduce the liver dullness, shifting dullness and reduced or disappeared bowel sounds • The X-ray shows the shadow of subdiaphragmatic free air.

37. Acute Gastroenteritis、gastro spasm • Inducing factors: eat unclean food , Improper diet , have a cold • Paroxysmal colic in the upper abdomen, with vomiting or diarrhea. • Soft abdomen without fixed tenderness, hyperactive bowel sounds • Analgesic or spasmolytic can relieve pain

38. Acute pancreatitis • 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.

39. Acute appendicitis • 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.

41. General peritonitis • Primary site • High temperature， infection-toxic manifestations， obvious peritoneal irritation sign， general gut cavity distension and it can not be released after the gastrointestinal decompression， disappeared bowel sound • Abdominal diagnostic puncture：pus

42. Mechanical intestinal obstruction • Paroxysmal colic pain, hyperactive bowel sounds, spurting and frequent vomit, vomitus  contain Intestinal content（  excrement stink  ） • Gastrointestinal decompression can not relive the pain • Abdominal X-ray shows extensive trapezoid fluid level

44. Acute cholecystitis • acute pain in the right upper abdomen, with fever，nausea and vomit， there may be tenderness and rigidity , rebound tenderness, muscular rigidity, Murphy's sign (+), • Blood routine test shows leukocytosis, Ultrasonic examination shows high echo and shadow of gall stone.

45. Murphy's sign

46. Gallstones • Abdominal pain, back pain, fever, jaundice, high level of amylase • Trilogy of Charcot : the severe paroxysmal colic pain in the upper or right upper abdomen , obstructive jaundice, chill and fever indicate patient with the common bile duct stones • B-ultrasound 、 CT scan, X-ray

47. Acute gastric dilatation • The acute and extremely dilatation of the upside of the stomach and duodenum • There are a large amount of gas， fluid and food retention in the stomach， there may be abdominal distention, abdominal pain and vomit，which will perhaps lead to the  peripheral circulatory failure • Overeatingor in the initial stage of the postoperation，the abdominal distention can not be relived after vomit, with severe abdominal bulge, succussion splash(+), suck out  plenty of liquids after insert the stomach tube

48. Coronary disease（  angina or acute myocardial infarction） • Middle-aged person • Medical history of  hypertension, atherosclerosis, history of angina onset

49. Ectopic pregnancy rupture • Women at the age of 26-35, has the history of menopause,  irregular little vaginal bleeding, • Acute onset, the lower abdomen pain, tenderness • vaginal examination shows obvious  cervix pain, a full posterior fornix, an obvious cervical tenderness • Noncondensing blood can be sucked out by abdominocentesis or puncture of posterior fornix • HCG and B-ultrasound

50. Thanks for your attention