A 60 year old female came to the clinic for help with ulcerative colitis accompanied by diarrhea and bleeding in the stool. She said, “I would like to lessen my use of medicines”. She has suffered from ulcerative colitis with diarrhea and bleeding in stool for about 10 years. She has diarrhea or soft stool, and bowel movements 3 to 4 times a day; she also has bleeding with dark or fresh blood in the stool once 2 to 3 weeks or month and she often visits the ER to stop the bleeding. She always feels fatigued and coldness of the body, poor sleep and abdomen pain, sometimes fullness of the abdomen. She has stress and depression. This condition gets worse with bleeding in the stool. She has had blood tests that showed a sed rate of 63 by modified westergren (Reference Range < or= 30mm/h) on 3/19/2008. She was diagnosed by her western medical doctor as having ulcerative colitis. She has been taking medicines for about 10 years, such as Cnolazal, Entocort EC, Rowasa Enema and Azathiorine, which cannot control diarrhea and/or bleeding in the stool, however. Examination showed that abdomen pain got worse with hand pressure on the upper and lower abdomen, dry skin with pale and shallow on the face, thinness of the body. Her tongue presented a dark color and was dry, with teeth marks on the tongue body, with thin and white on the tongue coating; her pulse was weak and deep; her BP was 120/80mmHP, weight was 103 LBs.
By Traditional Chinese Medicine standards, her diagnosis is spleen yang deficiency with Qi unable to control blood in the middle abdomen. The treatment principle used is to strengthen sleep, warm spleen yang, tonify spleen Qi and stop bleeding.
Points includes Ren4, 6, 10, 12, SP6, 12, ST36, 25, LI4, DU20; once a week for acupuncture treatment.
Chinese herbal formula is modified from Li Zhong Tang. It is 50g power of an herb Rx for one week, to be taken orally 3 times a day, 2g per time, max with about 2c.c warm water. The herbs included Dang Shen, Huang Qi, Gan Jiang, Bai Zhu, Sha Yao, Fu Ling, Da Huang, Ce Bai Ye, San Qi, Mai Ya, Shen Qu and Chen Pi.
The treatment for following visits will be employed by modifying some points of acupuncture protocol and herbs in the herbal formula according to progression. After 9 weeks of treatment, her condition was improved about diarrhea and abdomen pain, and the times of bleeding in stool reduced from 3 to 4 times to 1 to 2 times a month, and most other symptoms were improved; after 16 weeks of treatment, the bleeding in stool stopped, BMS once a day and weight increased 5 lbs. from 103 to 108.
The patient continued to visit once a week or sometimes once every two weeks for acupuncture treatment and to refill her Chinese herbal formula. After about 24 weeks of treatments, it was reported that blood tests showed the sed rate of 26 by modified westergren (Reference Range < or= 30mm/h) on 9/19/2008. She started to reduce and eventually stop the use of Western medicines by her Western doctor. Her weight increased to 113Ibs (from 103Ibs). Her tongue presented a pale red color and was moist with a thin white coating. Her pulse was thin.