Liver Course Online CEUs
Part One: 30 Liver Disorders according to Wang Xu-Gao
Biography of Wang Xu-Gao:
Wang Xu-Gao (1798-1862), also know as Wang Tai-Lin or Wang Tui Si Ju Shi, was a famous Chinese medicine physician of the Qing Dynasty born in the Yangtze River Delta town of Wuxi in Jiangsu Province. As a child he read widely the Chinese classical literature, and was fortunate to be blessed with a photographic memory. At the age of 12 he began to study medicine with his mother’s brother, Gao Jin-Ting. He studied for ten years… (more in actual continuing education course material)
Overview of Liver in Chinese Medicine
The Liver’s form is yin (blood, essence, yin), but its function is yang (Liver qi, yang, and fire). For convenience we can divide Liver function and pathology into yang/qi and yin/blood:
• Liver Yang/Qi
-Liver Qi Excess: easy angry, feel very stressful.
-Liver Qi Counter-flow and Attacking Spleen: loss of appetite, nausea, belching, hiccups, vomiting, gastro-esophageal reflux disorder (GERD), heartburn, breast tenderness or breast lumps, flank pain, shortness of breath, pain in sides of lower abdomen, abdominal bloating.
- Liver Qi Counter-flow Easily Transforms to Fire: Zhu Dan-Xi wrote, “when qi is excessive it transforms into fire, and when fire moves is gives rise to wind. Symptoms: migraine headaches with throbbing arteries on head and neck, red eyes, photophobia, easy angry, heartburn and gastro-esophageal reflux, bitter mouth, dry cough from liver fire drying Lung. Pulse: wiry, rapid, forceful, especially in the left guan/middle position. Tongue: red, especially red on sides, yellow coat. Also, because fire can give rise to internal wind, shaking may be present.
- Liver Qi Depression and Binding…. (more in actual course materials)
• Liver Yin/Blood
Here there are two main categories: Liver Blood Insufficiency, and Liver Blood Stagnation.
- Liver Blood Insufficiency
Dizziness, especially when tired; depression, grief; “eye dizziness” especially when standing up; pale face and tongue: cold hands and feet; tired and fatigued; floaters which get worse with fatigue; nails: cracking, wrinkling, dry, fragile and easily broken; dry thin hair, hair-loss; copious dreams, always feel tired in dreams, dream of climbing but can never get to the top/destination, or running away from scary things such as a tiger or lion, or wake from falling in dream, sad dreams, dreaming that you can’t attain something, or that something is out of reach or just not enough energy to get it.
- Liver Blood Stagnation
Dark or dark red lips, face, and tongue; headaches or chest pain with needling/sharp sensation which is more severe in evening/night but less severe after sleep and in the morning. Menstruation- pain before menstruation, flow doesn’t start easily and often only spotting until day 2 or 3; purple flow with copious clotting. Skin dry, rough, and with purple or brown pigment spots. Cold hands and feet. Dark area under eyes. Tongue black/purple spots, dark red with thick or enlarged dark/black sublingual veins. Pulse, choppy.
In addition, long-term blood stagnation can lead to blood heat with symptoms such as hot-flashes, restlessness, easy sweating especially… (more in actual course material)
•Chapter 1: Liver Qi Eight Methods
1.1 Soothe the Liver and Regulate Qi
This method is designed for Liver qi stagnation solely affecting the Liver organ and/or Liver channel. There exists only qi stagnation with no accompanying blood stagnation.
Symptoms: flank discomfort or pain, sighing, depression. Pulse: wiry, slow. Tongue normal.
• Cu Xiang Fu Vinegar-fried Rhizoma Cyperi Rotundi, 6-9 grams.
• Yu Jin Tuber Curcumae, 6-9 grams.
• Zi Su Geng Perillae Ramulus, 4-6 grams.
• Chao Qing Pi Fried Pericarpium Citri Reticulatae Viride, 4-6 grams.
• Qing Ju Ye Folium Citri Reticulatae, 3-5 grams.
This is a basic formula to move Liver qi. It is neither hot nor dry and can be used for most anybody. Cu Xiang Fu Vinegar-fried Rhizoma Cyperi Rotundi moves Liver qi, especially on the flanks. Vinegar processing helps guide the herb to the Liver channel.
Yu Jin ?? Tuber Curcumae moves Liver qi and relaxes the mind. Zi Su Geng Perillae Ramulus moves Liver qi, especially in chest and stomach regions. Chao Qing Pi Fried Pericarpium Citri Reticulatae Viride strongly moves qi on the flanks and ribs. Qing Ju Ye Folium Citri Reticulatae goes to the grandchild vessels (sun mai) and moves the Liver qi without damaging the yin. It is especially good for the chest region, and particularly effective for breast pathology (nodules, bloating, pain, tenderness) and PMS.
Note: for this situation, Chai Hu is considered too up-bearing, Dang Gui too warm, and Bai Shao too astringent and stagnating.
Stagnation with Heat: red face, dry mouth, restlessness, constipation, insomnia, red lips and eyes. Tongue red sides. Pulse rapid. Add:
• Mu Dan Pi Cortex Radicis Moutan, 4-6 grams.
• Jiao Shan Zhi Zi Blackened Fructus Gardeniae Jasminoidis, 3-5 grams.
Mu Dan Pi Cortex Radicis Moutan clears heat from the blood and the Liver. Jiao Shan Zhi Zi Charred Fructus Gardeniae Jasminoidis clears heat from the three burners. The charred/blackened form is used here to mitigate its cold nature as the raw form easily damages the Stomach. Together these clear deficient and excess heat from the blood.
With Cold: PMS accompanied with feeling cold, symptoms worse if eat cold foods, easy diarrhea especially during menstruation. Pulse deep, slow. Tongue pale dark. Add:
• Wu Zhu Yu Fructus Evodiae Rutaecarpae, 1-2 grams.
• Ai Ye Artemisiae Argyi Folium, 4-6 grams.
• Pao Jiang Blast-Fried Rhizoma Zingiberis, 2-3 grams.
Wu Zhu Yu and Ai Ye both warm and expel cold from the Liver Jueyin channel. Pao Jiang warms and expels cold from the lower burner.
With phlegm dampness, add:
• Ban Xia Qu Rhizoma Pinelliae Tematae Massa Medica Fermentata, 6-9 grams. Absorbs dampness and improves digestion (can substitute with Fa Ban Xia Rhizoma Pinelliae Tematae and Shen Qu Massa Medica Fermentata 6-9 grams each).
• Fu Ling Sclerotium Poriae Cocos, 6-9 grams.
If dampness is more severe with such symptoms as puffiness and swelling during menstruation, mucous in the throat, puffy eye bags, swollen hands and legs, add:
• Zhi Cang Zhu Processed Rhizoma Atractylodis, 4-6 grams.
• Chao Chen Pi Fried Pericarpium Citri Reticulatae, 3-5 grams.
Epigastric bloating, add:
• Hou Po Cortex Magnoliae Officinalis, 4-6 grams.
Mental depression due to Qi stagnation, add flowers:
• Mei Gui Hua Flos Rosae Rugosae, 2-3 grams.
• Yue Ji Hua Flos Et Fructus Rosae Chinensis, 2-3 grams.
Both should be added to decoction during last five minutes of cooking.
Mental depression with flank pain, add:
• Ba Yue Zha Fructus Akebiae Trifoliatae, 4-6 grams.
• Suo Luo Zi Semen Aesculi, 4-6 grams.
These regulate qi without damaging the yin.
Mental depression with blood stasis, the menstruation does not begin easily, add:
• Ling Xiao Hua Flos Campsitis, 3-5 grams.
With the appropriate presentation, this method can be used to treat bio-medically defined disorders such as PMS, hepatitis, depression, and menopause.
1.2 Course the Liver and Free the Network Vessels
This is a very useful method, and particularly if method 1.1 doesn’t work, one can try this method as it not only moves qi but invigorates blood in the small vessels. The pathomechanism here is Liver qi stagnation with blood stagnation in the grandson vessels, the cardinal symptom being flank pain accompanied by itchiness that can at times be severe.
- Xuan Fu Hua Tang… (more in acutal course)
•Chapter 2: Liver Wind Five Methods
Review of theory:
Liver wind, Liver yang, Liver fire, and Liver qi are all somewhat related. The following quotes illustrate this quite well: “When qi is excessive it transforms into fire”, and, “When fire is extreme it gives rise to wind.”
Often accompanied by red and burning eyes with yellow discharge accumulating in the mornings. Excess wind/fire often presents with more symptoms of heat on the upper body and head. Pulse: forceful, jumpy, wiry, rapid; Tongue red, purple red sides.
Deficient wind/fire often presents with more heat symptoms in the trunk, and less so on the head than Excess wind/fire. Pulse: deep, thin, deficient (??,?,?). Tongue: purple-red, dry, not much coat or mapped-coat, cracks. Disorders such as Parkinson’s, MS, ALS, poor balance, neurological diseases, and neurosis often belong to this category.
Common symptoms of Liver Wind:
Easy or often dizzy; shaking and tremors; eyes twitching; migraine headaches with pounding and throbbing; red eyes, nose, face, ears, neck; sensation of ants crawling on or needles pricking the skin; spasms; lower leg cramps.
Common disorders associated with Liver Wind:
Disorders such as multiple sclerosis (MS), amyotrophic lateral sclerosis (ALS), Parkinson’s disease, Alzheimer’s, and Tourette syndrome may be related to liver wind. Idiopathic shaking, dizziness and vertigo are generally related to liver wind, and elderly or weak people easily develop these types of disorders.
2.1 Cool the Liver and Extinguish Wind
This method is designed to treat early stage or excess Liver wind.
Symptoms: always feeling hot; red face and eyes; easy angry; all symptoms worse with hot weather or after taking hot-natured foods such as alcohol, spicy, etc.; head feels bloated; headaches in which the head feels bloated and distended, aggravated if pressure is applied to head, but generally no sharp pain; throbbing blood vessels. Pulse: wiry and forceful, especially left guan and cun positions. Tongue: fresh red, especially sides, and dry yellow coat.
Base formula… (look forward to much more in the actual course material)
Part Two: Chronic Hepatitis in Chinese Medicine
Biomedical Fundamentals of Chronic Hepatitis:
Chronic hepatitis (CH) refers to a group of liver disorders of varying cause and severity in which hepatic inflammation and necrosis persist for at least 6 months. Several categories are recognized, including chronic viral hepatitis, drug-induced chronic hepatitis, and autoimmune chronic hepatitis, however, some cases are cryptogenic.
Liver Profile Tests:
Any biomedical discussion of chronic hepatitis requires basic understanding of the laboratory tests commonly used to diagnose liver disease. For this reason we begin with a review.
The typical liver profile test includes:
• Alanine aminotransferase (ALT or SGPT)
• Aspartate aminotransferase (AST or SGOT)
• Alkaline phosphatase (AP)
• Gamma Glutamic Transpeptidase (GGT or GGTP)
• Prothrombin time (PT)
• Platelet count
Liver Enzyme Tests:
Different cells contain different enzymes depending on the function of the cell. When there is damage to cells, or cellular necrosis, their enzymes leak into the serum, causing elevated serum levels. Liver cells contain large amounts of alanine aminotransferase (ALT or SGPT), aspartate aminotransferase (AST or SGOT), alkaline phosphatase (AP), and gamma glutamic transpeptidase (GGT or GGTP). Therefore… (more in actual course material)
Alanine aminotransferase (ALT or SGPT) and aspartate aminotransferase (AST or SGOT):
ALT and AST are enzymes present primarily in liver, heart, kidney, pancreas and skeletal muscle cells. When there is damage to these cells, ALT and AST are released into the bloodstream and elevated levels can be detected in serum lab tests. ALT is mainly present in the liver, with lesser amounts found in heart, kidney, and skeletal muscle cells, whereas AST is present in comparable amounts in other cells. Therefore ALT is more specific for liver disease, whereas AST may also be elevated in other conditions such as myocardial infarction, acute pancreatitis, bruised kidney, etc.
ALT normal range is 5-40 IU/L.
AST normal range is 5-40 IU/L.
Alkaline phosphatase (AP):
Alkaline phosphatase is an enzyme produced in the biliary tract, intestines, kidneys, placenta and bone. Because of this, elevated alkaline phosphatase levels are not specific to disorders of the biliary tract and must be combined with other tests to determine etiology. A common method used to assess etiology is to test GGT, which will be elevated in case of liver disorder…. (look forward to much more in the actual continuing education course material)
Classification of Chronic Hepatitis:
Classification of CH is based on three parameters:
2. Histological activity (grade).
3. Degree of progression (stage).
Classification by Cause is divided into four categories:
1. Chronic viral hepatitis: caused by HBV, HCV, HBV+HDV, and possibly some other unknown viruses.
2. Autoimmune hepatitis: further subdivided into types 1, 2, and 3, according to serological distinctions.
3. Drug-associated chronic hepatitis.
4. Cryptogenic hepatitis: includes all cases of unknown cause.
Classification by Grade is based on histological assessment of the liver biopsy for necroinflammatory activity. Important histological features such as periportal necrosis (including piece-meal necrosis, and/or bridging necrosis), intralobular necrosis, portal inflammation, and fibrosis, are assessed and given a score depending on severity. Depending on the presence and severity of these features, CH is graded mild, moderate, or severe. The most commonly used scoring system is the Histologic Activity Index (HAI, or Knodell-Ishak Score).
Classification by Stage reflects the level of progression of the disease and is based on the degree of fibrosis as follows:
0 = no fibrosis
1 = mild fibrosis
2 = moderate fibrosis
3 = severe fibrosis, including bridging fibrosis
4 = cirrhosis
Chronic Viral Hepatitis:
Chronic viral hepatitis is caused by hepatitis B virus (HBV), hepatitis C virus (HCV), and by simultaneous infection of HBV and hepatitis D virus (HDV). Both forms of enterically transmitted viral hepatitis, hepatitis A virus (HAV) and hepatitis E virus (HEV), are self-limiting and do not cause chronic hepatitis. Hepatitis G virus (HGV) is transmitted through blood and blood products, but it is unclear whether it causes clinical hepatitis.
Chronic Hepatitis B:
Risk of developing chronic HBV infection from acute HBV infection varies. Infection at birth carries a 90% risk of chronicity. Young adults and people with healthy immune system function have only a 1% risk of developing chronic infection. Most adult cases, however, never had a recognizable episode of clinically apparent acute HBV infection. The degree of liver injury (grade) in cases of chronic HBV is highly variable, ranging from none to severe. Histological features are important prognosticators in chronic HBV infection of adults. One long-term study showed five-year survival rates of 97% in patients with mild grade chronic HBV infection, 86%... (look forward to much more in the actual continuing education course material)
Chronic Hepatitis D:
Hepatitis D virus (HDV) is dependant on HBV for its replication and expression, so is only found in combination with HBV infection. While HDV coinfection does not increase the likelihood of acute HBV infection becoming chronic, it does increase the severity of acute hepatitis B. Furthermore, in patients with chronic hepatitis B infection, coinfection with HDV more often than not leads to more severe liver disease… (look forward to much more in the actual continuing education course material)
Chronic Hepatitis C:
Infection with HCV leads to chronic hepatitis in 50 to 70% of cases, although when cases in which aminotransferase levels return to normal after acute HCV infection are included, the rate is 85-90%.
Chronic HCV infection may lead to cirrhosis in as many as 50% of cases. However, despite the high risks of chronic infection and progression of the disease, the long-term prognosis for most patients is fairly good, with approximately 60% of patients asymptomatic and without clinical sequelae, and approximately 25% of patients progressing to end-stage cirrhosis. One of the best indicators of prognosis is liver histology. In cases where mild necrosis and inflammation… (look forward to much more in the actual continuing education course material)
Features of Viral Hepatitis: blood panel table… (Look forward to much more in the actual continuing education course material- a complete blood test is presented with normal ranges and explanations included to easy reading of the blood test.)
Chronic Hepatitis in Chinese Medicine:
Chronic hepatitis (CH) in Chinese Medicine (CM) has historically fallen under the scope of a number of different diseases such as flank pain, jaundice, vacuity taxation, etc. The pathogenesis is generally attributed to external factors (damp-heat epidemic toxin) and internal factors (depressed emotions and anger damaging the liver, improper diet) leading to disharmony of the viscera and bowels, and damage of yin, yang, qi and blood. The general pathomechanism involves deficiency of zheng-qi with persistent attack by evil-qi, on top of which develop damp-heat, qi stagnation, blood stagnation, phlegm knotting, and deficiency of yin, yang, qi and blood, all of which affect the functions of the zang-fu, particularly the Liver, Gallbladder, Spleen, Stomach, and Kidneys.
However, as all CM physicians know, any given disease can present in many different ways and CM pattern diagnosis can vary greatly. Therefore, use of Differentiation of Pattern to Determine Treatment, is always essential. In the Wang Xu-Gao course I’ve included some bio-medically defined illnesses, including hepatitis, which at times may fit the patterns for which the methods were designed. That said, one must always be careful to avoid pre-conceived notions about the CM nature of any given bio-medically defined illness, as the variation in CM patterns can be surprising. Regarding CH, one reference lists the following as typical patterns:
• Liver Depression and Qi Stagnation
• Liver Depression and Spleen Deficiency
• Liver and Gallbladder Damp Heat
• Liver and Kidney Yin Deficiency
• Qi and Blood Stagnation
• Spleen and Kidney Yang Deficiency
It is worth noting here that “etcetera” is added to the end of the list, as it would be absurd to limit hepatitis to this or any other set of parameters.
The same book then goes on to discuss the ideas and experience of many different CM physicians, and there is a great amount of diversity. Of course, these doctors also include formulas with modifications, etc., and the types of herbs employed vary substantially. Interestingly, significant overlap exists between the ideas in the book and Wang Xugao’s 30 Methods, suggesting that a thorough understanding and flexible application of Wang’s methods would serve well in the treatment of CH. Furthermore, the wide spectrum of patterns, methods, and herbs described in this book reminds us that Pattern Differentiation is essential to proper diagnosis and treatment of CH, and that looking for the “magic-bullet” herb to reduce viral-load, or lower liver enzymes, etc., is not the way of CM.
That said, there are theories, methods, formulas, and herbs, which are particularly useful in the treatment of CH, but again, only when used in accordance with Pattern Differentiation. Following is a discussion of a handful of these.
Specific Chinese Medicine Theories and Methods for Diagnosis and Treatment of Chronic Hepatitis:
• Qi stagnation with blood stagnation in the blood network vessels:
Dr. Fang Xing states that long term illness of any type, including CH, can lead to stagnation of qi, and blood stagnation in the blood network vessels. In these cases, Fang suggests the use of invigorating the blood and transforming blood stasis method. Once stagnant blood has been removed, new blood can generate, pathogenic qi can be expelled, and zheng qi can regenerate.
• Dan Shen…. (look forward to much more in the actual continuing education course material)
• Discussion of Herbs Effective Against Chronic Hepatitis:
There are many herbs which are reportedly effective against hepatitis, and chronic viral hepatitis specifically. Following is a list of some of these.
• Ji Gu Caoi:
Nature: Sweet, cool, non-toxic.
Actions: Clears heat and removes toxins, soothes the Liver and invigorates blood, stops pain.
Indications: hepatitis with jaundice, liver cirrhosis with ascites.
Dosage: 9-15 grams.
• Hu Zhang Radix Et Rhizoma Polygoni Cuspidati:
Nature: Bitter, sour, cool.
Channels entered: Liver, gallbladder, and lung channels.
Actions: Invigorates the blood and transforms blood stasis, clears heat and removes dampness.
Indications: acute or chronic hepatitis.
Dosage: 9-15 grams.
• Tian Ji Huang…. (look forward to much more in the actual continuing education course material)
Discussion: There have been reports of the effectiveness of Wu Wei Zi to reduce elevated serum ALT levels in chronic hepatitis. However, this is a non-traditional application based on biomedicine, not Chinese medicine. While research does show Wu Wei Zi can reduce elevated serum ALT, Professor Wu Bo-Ping counters that the sour, astringent nature of Wu Wei Zi retains pathogenic factors in the body, thus soon after administration is ceased ALT tends to rise again. Therefore, Professor Wu does not recommend Wu Wei Zi be applied…. (look forward to much more in the actual continuing education course material)
To view the Table of Contents click here: Liver Continuing Education Course