Un-herb-of #1 ... Marcus' Case

I’ve been kicking around Chinese medicine on this sub for a couple of months, but what about sharing some actual cases? I’m starting with the case below, because I have many before-and-after images of a particular patient’s tongue. I think you might find these images fascinating, but note that they are images of tongues, which not everyone finds comfortable. I’m also including the herbs that I used and exactly what happened next. I’m sure some of this will be completely new to you. Are you game?

The Case
Marcus (not his real name) is a sixty-year-old man who and had multiple problems. Constipation and acid reflux held sway on his life for nearly thirty years. Below is a list of his symptoms and diagnoses, but what really bothered Marcus was his recent diagnosis of Barrett’s esophagus, which is a form of pre-cancer.

Diagnoses and conditions
-IBS-C
-GERD
-esophagitis
-hiatal hernia with lower esophageal sphincter deterioration
-Barrett’s esop

Marcus’ case was pretty severe, but many cases on this sub have some of these diagnoses, concurrent with a SIBO diagnosis. Did Marcus have a SIBO diagnosis? It was not confirmed, but he may have. In Chinese Medicine, we do not often pursue that diagnosis and yet have ways of treating it. Note the antibiotic and microbiome modulating properties of herbs, noted below.

Drugs and Supplements
Omeprazole - 40mg qd (max dose)
Large list of herbs and supplements that I won't document here

Symptoms
-hard, dry stool; bowel movements every 2-3 days
-bloating, especially after eating
-burning in stomach and esophagus, worse at night, but without bringing up of acid
-strong appetite, especially at night
-gnawing feeling in stomach that improves after eating
-dry mouth but easily quenched thirst
-irritability and short temper, especially when not eating
-frequent pain in the upper abdomen “solar plexus” - sore, raw feeling
-heat flushing at night, especially in upper abdomen
-excessive phlegm stuck in throat - thick and clear when expelled
-sometimes light-headed or dizzy
-easily fatigued
-poor and interrupted sleep
-inflamed gums
-hesitant urination

Tongue (see image below): red, peeled, deep midline crack with transverse cracks; midline crack almost to tip; slightly swollen, esp. middle. Lips (and perhaps tongue) are also purple.

Pattern Assessment
-Stomach heat with steaming of fluids and yin vacuity
-Qi and phlegm stagnating and binding with stasis
-Spleen qi vacuity

Prescription
Modified Yu Nu Jian - “Jade Woman Decoction” (rationale for herbal formula below)
Note: dosages are in grams of 5:1 powdered extracts, per week:

|| || |Shi gao (Gypsum)|12.4- yes, gypsum is the main ingredient| |Mai Dong (Ophiopogon)|12.4| |Di huang (Rehmannia)|9.9| |Shan Yao (Dioscoria)|9.9| |Zi su zi (Perilla seed) |5.4| |Zhi mu (Anemarrhena)|5| |Mu dan pi (Moutan) |2.5|

Result
Modified Yu Nu Jian was prescribed for two weeks. After that time, Marcus reported that the herbs were helping “a lot.” Specifically he had:

-Improved mood, sleep, and energy
-Bowels moving daily
-Less pain in the abdomen
-Less bloating
-Continued hunger in the middle of the night
-Much less burning stomach at night; less feeling of heat at night
-Continued dry mouth at night
-Decreased phlegm in throat
-Urine flowing better

Marcus also started lowering the dose of his PPI (Omeprazole). From all of this information, I adjusted the formulation by adding a couple of herbs, and prescribed it for another two weeks. I have three pictures of Marcus’ tongue. The first image is at the start of treatment, the second image is after two weeks, and the last image is after four weeks. Notice that the first picture looks an old, dried out, piece of meat. We say that it lacks "spirit."

Week 0

Week 2

Week 4

After four weeks of taking herbs, Marcus reported that nearly all of his symptoms were gone. His mood and spirit were greatly improved. We reduced his dose of herbs and decreased our appointments to once per month. Because Marcus has a diagnosis of Barrett’s esophagus and physical damage to his esophageal sphincter (the closing of which holds in stomach acid), he has continued with me for many months. I’ve made adjustments to his formula as well. Twice, I’ve changed it completely. His Omeprazole use is down to once per week. Below is a recent image of his tongue. You can see that it has become a more normal color (pale red). The tongue is less stiff and dried out looking, the mid-line crack has become more shallow, and papillae are starting to return to the surface. The lips are also less purple. His wife called me up the other day and thanked me! She said that I gave Marcus himself back.

Several months later

Rationale for the pattern differentiation and choice of herbal formula
This part may be challenging, but I’m including it for those interested:

From Marcus’ symptoms and tongue image, I could tell that he was severely dry, to the extent that internal tissue had been malnourished and damaged. Especially, symptoms that worsen at night point in this direction. The damage was fueled by internal heat, which was also rather severe. It had especially affected Marcus’ upper digestive tract, evident by the long crack down the mid-line of his tongue and the loss of coating on his tongue. The primary vacuities were qi and yin (of the spleen, stomach, and intestines), but Marcus also had severe stagnation of qi, which was causing phlegm to become stuck in his throat. Between the vacuity and stagnation of qi, and the inadequate fluids, motility in the intestines was poor. These stagnations were further worsening his heat, which was condensing fluids and driving the condition in a circle. A mild stagnation of blood was evident from Marcus’ purple lips. Note that Spleen qi vacuity with phlegm, qi, heat, and blood stagnation (to the point that they become entangled) is a grouping of patterns we associate with cancer.

With gypsum as the principle herb, the main strategy was to strongly clear heat first, then later focus more fully on improving the quality of yin and qi. There were other strategies utilized, as well.

Treatment principles
Clear and drain fire, enrich yin, boost qi, regulate qi, transform phlegm, and quicken blood, in that order. Focus on the stomach and intestines.

Yu Nu Jian treats Yin Vacuity due to Stomach Fire. If you are interested, you can read about it here. However other patterns, in Marcus’ assessment, were not fully represented by that formula, and at least one herb called “niu xi” needed to be removed because it clears damp-heat in the lower abdomen (and would further dry the intestines). The gap between this classical formula and Marcus' personal condition led to the modifications. As Marcus' condition shifted and changed, and after I saw the result of the first formula, I made further changes. Today, Marcus is doing very well. We have somewhat shifted his formulation away from treating his digestive issues and are working on trying to correct his Barrett's esophagus (or at least prevent it from becoming worse).

Related research
It is impossible to find (or conduct) research that precisely pertains to all of the details in an individual case. This is part of the limitation of research and why so many people on the SIBO sub become adept at personal experimentation. It is also impossible to summarize all of the research that is, at least, relevant to Marcus' case.

There are four studies on Yunu-Jian (this is how it is spelled in research) on PubMed. However, is it the same formula, since I removed one of it's ingredients? Anyway, the research covers Yunu-Jian's use for diabetes related heart insufficiency, gum disease, and Graves' disease. Notice that gum disease pertains to this case but the other research may not. This is explained by the principle: "same treatment, different disease; same disease, different treatment."

Numerous studies can be found for each of the herbs in Marcus' formula, and remember that the formula did not remain the same, it was constantly changed to reflect new information and changes in Marcus' condition. Numerous studies can be found on all of these herbs, at different levels of examination - invitro, invivo, omics, pharmacological, etc. There is research on their effect on the microbiome of the large intestine (but not the small intestine), and most of these herbs have some or marked antibiotic effects.

I hope you have found this case interesting and that it has given some perspective on how pattern differentiation and Chinese medicine treatment work. Please let me know in the comments.

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I am a Doctor of Oriental Medicine, and I am interested in treating more SIBO and IBS patients in my private practice. The information that I share on this sub is meant to be caring. It is genuine, well regarded in Asia, and it relates to my personal experience. At this point, no DOM or Acupuncturist in the US has a private practice specializing in digestive problems, and this is entirely for cultural (not medical) reasons. I'm here to help out and to break through barriers that, I believe, are keeping many of you sick. No offense intended. I don't have all of the answers, but I do have quite a lot to share. If you live in the US (where I practice), I hope you will feel free to DM to schedule a consultation. If you are lurking on this sub, it would be great to hear from you, too. My fees are reasonable and my experience is extensive.