Name: Wu.

Sex: Male.

Age: 57 years.

Occupation: A retired driver.

Chief Complaint: Pain of right upper abdomen for 1 day.

History of Present Illness : One day ago, the patient got a pain in his right upper abdomen caused by eating some greasy food. The pain was a constant dull pain, involving the back and the right shoulder. Then he went to the emergency department of a hospital for treatment. After some relative clinical examination, the illness was diagnosed as "Cholecystitis, Gallstones," he was treated by intravenous dripping " Benzylpenicillin, Amikacini, Gentamycini, VitK1, Cefotaxime Sodium," and intramuscular injecting "Anisodamine, Atropine, Phenergan. "But there was no curative effect on him. Meanwhile he got high fever and vomited twice. Then he came to me for treatment on January 28,1999. Through asking his history of illness closely, it was found that he Had gotten "Cholecystitis, Gallstones" for more than 10 years. In the recent half a year, the abdominal pain occurred frequently, but it could be relieved by intravenous dripping antiinflamatory drugs and intramuscular injecting "Anisodamine" or "Atropine" every time. In addition, he usually kept his appetite, sleeping, defecation and urination normal all along. There was not other complaint.

Physical Examination: The temperature was 39. 8?. The patient was weak with an acute painful complexion. The body was wet by his excessive sweating, he was groaning and moaning mntinously. The pulse was thready and taut. The tongue was dark purple with a greasy layer of watery fur. The heart and lungs were all normal. The abdomen was flat and soft, there was muscular tension at the part of the right upper abdomen.

Murphy's sign was positive. The right upper abdomen couldn't be palapted because of the severe pain. The swollen gallbladder could be palpated easily. Jaundice couldn' t be found all over the body. The sclera wasn't icteric and congestive. There wasn't other abnormal sign.

Examination of Ultrasonogram B: The size of the gallbladder was 10.lcm × 2.9cm, the thickness of the gallbladder wall was 1.1era,the echo of the posterior wall wasn't distinct, opaque dark area of fluid whose deepth was 0.6cm was explored in the outside of the gallbladder wall. There was a mass of strong echo whose length was 1. 7cm in the gallbladder, there were some pieces of strong echo whose length were from 0.3cm to 0.5cm at the bottom of the gallbladder. The width of the choledochus was 0.5cm. All those results showed there were gallstones and purulent cholecystitis.

Lab Test: The result of blood routine examination was as below: WBC 11.3×109/L, N 0.88, L 0.12.

Diagnosis: Acute Purulent Cholecystitis; Gallstones.

Differentiation: This disease, in TCM, belongs to the category of "XieTong"(hypochondriac pain). As usual, eight or nine such cases out of ten were caused by dampness-heat of liver and gallbladder, but the pathogenesis of this case was just contrary to the common cases. The pathogenesis of this case was just retention of damp phlegmin the interior organs, it obstructed the eo11aterals of the gallbladder, so that the circulation of gallbladder-qi became unsmooth, then the function of the gallbladder-Yang was inhibited. However, gallbladder is a rigidity organ under normal conditions, its attribute is Yang-wood according to the Five-element theory, it controls the dipersive effect and the power of decision. In this case, the function of the gallbladder-Yang was inhibited by the pathogenic dampness phlegm, so that there was a failure of the gallbladder to control the dipersive effect, and the stagnation of the gallbladder-qi was caused. Then the patient got the hypochondriac pain.

Therapeutic Principle: Invigorating the gallbladder-Yang, clearing away the pathogenic damp phlegm and destroying the dirty substance, activating the gallbladder-qi and removing blood stasis, dispersing the Yin evil.

Recipe:

DangShen,Pilose Asiabell Root 20g

BaiZhu,Bighead Atractylodes Rhizome 15g

FuLing, Tuckahoe 15g

ZhiFuZi,Prepared Aconite Root 6g

Hu0Xiang,Agastache Aerial Parts 10g

PeiLan, Eupatorium 12g

ZhiKe,Fruit of Citron 12g

ChenPi,Tangerine Peel 9g

SuGeng,Perilla Stem 15g

DanShen,Red Sage Root 25g

JiangHuang,Turmeric Rhizome 18g

JiNeiJin,Membrane of Chicken's Gizzard 15g (to be decocted earlier)

BaiShao,White Peony Root 15g

ZhiganCao,Prepared Liquorice Root 6g

YuJin,Curcuma Root 15g (to be decocted earlier)

All the above drugs were to be decocted in water for oral taking. 5 doses were prescribed. Cold and greasy food was forbidden.

Effect Observation: After taking the 1st dose, the abdominal pain was relieved greatly. After taking the 2nd dose, the pain disappeared, but there was tenderness at the part of the right upper abdomen yet. It indicated that the circulation of the gallbladder-qi had been smooth while the remnant of the pathogenic damp phlegm was there yet. The treatment should be continued. After taking the 5 doses, the patient became well as normal. Reexamination of ultrasonogram B showed the size of the gallbladder was 6.2cm×2.0cm, the thickness of the gallbladder wall was 0.6cm, there wasn't opaque dark area of fluid in the outside of the gallbladder wall. The width of the choledochus was 0.5cm. All these signs showed that the size of the swollen gallbladder became normal, the hydrops of the gallbladder wall disappeared, the pura in the outside of the gallbladder wall disappeared too. In addition, there were not shadows of the little stones in the gallbladder. The shadow of the big stone in the gallbladder became less than before, its length became 1.5cm. All these signs indicated the circulation of the gallbladder-qi was smooth and most of the pathogenic damp phlegm was removed. However,because the patient's tongue was still dark purple with a thick layer of white fur and the pulse was thready and soggy, then it's necessary to continue eliminating the damp phlegm evil, activating qi and warming the gallbladder-Yang.

Recipe:

DangShen,Pilose Asiabell Root 30g

BaiZhu,Bighead Atractylodes Rhizome 15g

FuLing, Tuckahoe 18g

ZhiFuZi,Prepared Aconite Root 6g

FaBanXia,Pinellia Tuber 6g

YiYiRen,Coix Seed 30g

ZhiKe,Fruit of Citron 12g

ChenPi,Tangerine Peel 15g

HuoXiang,Agastache Aerial Parts 15g

PeiLan,Eupatorium 12g

JiNeiJin,Membrane of Chicken's Gizzard 18g (to be decocted earlier)

WuJin,Curcuma Root 15g (to be decocted earlier)

DanShen,Red Sage Root 25g

JiangHuang,Turmeric Rhizome 18g

ZhiGanCao,Prepared Liquorice Root 6g

All the above drugs were to be decocted in water for oral taking. 5 doses were prescribed. Cold and greasy food was forbidden.

After taking the decoction, the patient got well completely, the tongue became light red with a thin layer of white fur. The pulse became regular and normal. After 1 year' s follow up, the illness didn' t recur. Then it' s ending.

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