Consensus on Epigastralgia Diagnosis and Treatment of Chinese Medicine (2017)

Epigastralgia is one of the most common syndromes in internal medicine of Traditional Chinese Medicine(TCM). Many upper gastrointestinal diseases such as peptic ulcer, chronic gastritis, functional dyspepsia and so on can induce the symptom of epigastralgia. In September 1983, National Symposium on Spleen and Stomach Disease was held by China Association of Chinese Medicine of Physicians, and programmed Diagnosis and evaluation standard of stomachache (draft)[1]. In 1993,Clinical research guideline of new drugs for traditional Chinese medicine on epigastralgia was promulgated by Ministry of Health of the People's Republic of China[2].In 1994, Criteria of diagnosis and therapeutic effect of diseases and syndromes in traditional Chinese medicine including diagnosis basis, classification of syndromes,effective evaluation criteria of epigastralgia was successively made by State Administration of Traditional Chinese Medicine[3-4]. In 2011, the professional standard Guidelines on the diagnosis and treatment of epigastralgia was released by the Spleen and Stomach Disease Branch of China Association of Chinese Medicine[5]. Although the above standards and guidelines have been released,the disease characteristics, diagnosis and treatment,and clinical evaluation of epigastralgia have not been completely summarized and existed problems, such as deficiency of consensus. With the development of medical science and improvement of modern diseases research,classification of syndromes and treatment have changed,thus further renewal on the basis of related standards and guidelines is required to satisfy the demand for medical science research and clinical practice.

In August 2014, the drafting group of expert consensus on epigastralgia diagnosis and treatment was established by the Spleen and Stomach Disease Branch of China Association of Chinese Medicine in Hefei.According to the principle of evidence-based medicine,drafting group extensively collected evidence-based information, and organized domestic experts of spleen and stomach diseases to summarize and discuss a series of pivotal issues, including classification of syndromes,differentiation treatment, diagnosis and treatment procedures, therapeutic evaluation and so on, then gained the preliminary draft of consensus, finally made 3 rounds of voting according to the international general Delphi method. In September 2015, the draft of consensus was voted for the first time in Chongqing, and modified by panel according to expert opinions. In December 2015, the revised draft of consensus was voted for the second time in Beijing. In June 2016, core expert review conference was held by the Spleen and Stomach Disease Branch of China Association of Chinese Medicine in Xiamen, and the draft of consensus was voted for the third time by more than 20 well-known experts from all around the country. The draft of consensus was obtained fully discussed and modified. In July 2016, the draft of consensus was further discussed, revised and examined by experts at 28thNational Symposium on Spleen and Stomach Disease in Harbin. In September 2016, expert finalization conference was held and consensus was finally formulated in Beijing. Voted at the conference:① Absolutely agreed; ② Agreed, reserved part opinion;③ Agreed, reserved greater opinion; ④ Disagreed,reserved part opinion; ⑤ Absolutely disagreed. The definition of passing of the resolution: ＞2/3 person chose① or ＞85% person chose ①+②. The full text will be published as follows, for domestic and international reference, and can be perfectly improved in the clinical application, as expected.

SUMMARY

Epigastralgia refers to disease and syndrome with main symptom of pain which primarily illness by the stomach cavity near pit of the stomach place

In clinical practice, epigastralgia is a common disease and syndrome, and a main symptom as well, often accompanied with epigastric fullness, anorexia, vomiting,gastric discomfort, acid regurgitation, belching, and other symptoms.

Epigastralgia begins from Huangdi's Cannon of Medicine, used to be replaced by "cardiac pain"

Plain Conversation Major Discussion on the Progress of the Six Climatic Changes recorded that:"wood growing outward, pain in the gastric cavity located in cardiac, involve in hypochondrium, stagnation in diaphragm and pharynx, digestive food cannot downward going", Plain Conversation Discussion on the Most Important and Abstruse Theory recorded that:"Jueyin stays in power, wind pathogen dominates, pain in the gastric cavity located in cardiac". The theory of etiology and pathology for epigastralgia on the Huangdi's Cannon of Medicine laid the foundation of research and treatment in epigastralgia for subsequent medical experts. In Han Dynasty, Zhang Zhongjing created Dajianzhong Decoction, Fuzi Jingmi Decoction, Shaoyao Gancao Decoction, Wuzhuyu Decoction, Xiaojianzhong Decoction and Huangqi Jianzhong Decoction, which were and are still of great importance in treatment of epigastralgia. In Tang Dynasty, Sun Simiao proposed the concept of nine kinds of cardiac pain in Valuable Prescriptions for Emergency Cardiac and Abdominal Pain. In Song Dynasty, Yan Yonghe further explained the concept of nine kinds of cardiac pain. In Jin and Yuan periods, Li Gao established independent chapter of "epigastralgia" in Lanshi Micang, in which author differentiated between epigastralgia and cardiac pain,and created Caodoukou Decoction, Shensheng Fuqi Decoction, Mahuang Doukou Pill. In Danxi's Experiential Therapy, Zhu Danxi said: "the patients with spleen disease, vomiting after meal, abdominal distension and belching, epigastralgia, distress below the heart", in which clearly pointed that cardiac pain actually belonged to epigastralgia, and the disease was mainly focused on spleen and stomach.

In modern medicine, the epigastralgia is common in upper gastrointestinal diseases

Many diseases can contribute to epigastralgia,such as acute (chronic) gastritis, peptic ulcer, functional dyspepsia, gastroptosis, gastric mucosa prolapse and so on. Gastric cancer, hepatitis, cholecystitis, pancreatitis,pneumonia, myocardial infarction could induce epigastric pain, which does not belong to the range of this disease and syndrome, but can be treated in reference to this consensus opinion.

ETIOLOGY AND PATHOLOGY

The main causes of epigastralgia

The main causes of epigastralgia can be summarized as invasion of the stomach by exopathogen, improper diet, emotional depression and maladjustment of work and leisure, or drug induced damage, or feeble spleen[6-7].

Invasion of the stomach by exopathogen such as cold, heat, dampness cause qi stagnation. Improper diet causes food accumulation, mainly damages the spleen and stomach, leading to disorders of ascending and descending of qi. Anxiety and anger impairing the liver makes hyperactive liver-qi invade the stomach to cause stagnation of qi and blood, thus leading to gastropathy.Feeble spleen and stomach failure to transport and transform nutrients, disorder of qi in ascending and descending or yang deficiency in the middle jiao, cold easily affects and then becomes feeble spleen and stomach, again causes food accumulation, dysfunction of qi transforms pathogenic heat, cause insufficiency of stomach-yin.

"Stagnation causes pain" and "undernourishment causes pain" are main pathology

The stomach corresponds to yang-earth, likes moisture and dislikes dryness. Its function is mainly to receive food and transform food into chyme. It is appropriate for the stomach-qi to descend. When impaired, the stomach-qi can stagnate and can cause epigastralgia, which is so-called "stagnation causes pain"[8-9]. Insufficiency of natural endowment combined with dystrophy after birth causes feeble spleen and stomach; or yang deficiency of the spleen, endogenous yin-cold; sufficiency dryness of stomach, failure to moisten and nourish the stomach, which is so-called"undernourishment causes pain".

Disease position in stomach, predominantly relates to liver and spleen

Liver-qi invades the spleen and stomach, excessive wood over-restricting earth, or stagnation of pathogen in middle-jiao, wood depression and undeveloped; or accumulation of liver heat results in burning stomachyin; or blood stasis in liver, failure to moisten and nourish the stomach, so stomach disease always relates to liver.Spleen and stomach live together in middle-jiao, form an exterior-interior relation, coordination of ascent and descent, thus spleen disease always involves in stomach,and stomach disease affect spleen as well. For example,immoderate diet and fatigue damage can result in spleenstomach disease[10-11].

Severe epigastralgia accompanies with hematochezia, haematemesis, even blood collapse;epigastralgia for long time leads to blood stasis

Epigastralgia at early stage is involved in excess syndrome. Chronic disease is involved in interlocking of deficiency-excess syndrome or deficiency syndrome.The deficiency mainly belongs to feeble spleen and stomach, and excess mainly belongs to qi stagnation,retention of food, blood stasis. Interlocking of deficiencyexcess mainly belongs to feeble spleen and stomach with dampness or stasis and so on. The pathology of epigastralgia is complex, which can transform and become changed syndrome. Stomach excessive heat,forcing blood disordered flow, or blood stasis, blood leaks out, or qi deficiency leads to impeded flow of blood,failure to dominate blood, which causes hematochezia and haematemesis. Excessive bleeding can lead to syndrome of collapse of qi due to hemorrhage, even threaten life.Spleen and stomach failure to transport and transform nutrients, endogenous dampness, accumulation of heat results in acute and sudden burning pain in stomach and aversion to press; or chronic diseases are involved in blood. The stomach-qi stagnates and adversely rises,which result in vomiting and regurgitation. Epigastralgia for long time, invades blood system from qi system,leads to blood stasis, and stasis blood accumulates in the stomach induces "zheng ji" ("abdominal mass")[12-13].

SYNDROME DIFFERENTIATION[14-17]

Pathogenic cold affecting the stomach syndrome

Main symptoms: 1) sudden attack of stomachache;2) pain becoming much severer after cold. Accompanying symptoms: 1) aversion to cold; 2) preference for warm.Tongue and pulse: pale tongue and white coating; wiry and tight pulse.

Food retention injuring the stomach syndrome

Main symptoms: 1) distending pain and worse by pressure; 2) fetid eructation. Accompanying symptoms:1) nausea and preference for vomiting; 2) anorexia; 3)aversion to food smell; 4) fetid flatus or stools. Tongue and pulse: thick greasy tongue coating; wiry and slippery pulse.

Liver-stomach disharmony syndrome

Main symptoms: 1) fullness and pain in the stomach;2) fullness in hypochondrium. Accompanying symptoms:1) occurring and aggravation due to dysthymia; 2)vexation; 3) frequent belching; 4) preference for deep sighing. Tongue and pulse: red pale tongue and white coating; wiry pulse.

Damp-heat accumulation in the spleen-stomach syndrome

Main symptoms: 1) distension and pain in the abdomen and stomach; 2) thirst or bitter taste.Accompanying symptoms: 1) no desire for drink; 2)anorexia; 3) nausea or vomiting; 4) yellow and short urine. Tongue and pulse: red tongue with yellow greasy coating; slippery pulse.

Interlocking of cold and heat syndrome

Main symptoms: 1) fullness and pain in the stomach,pain becoming more sever after cold; 2) thirst or bitter taste. Accompanying symptoms: 1) anorexia; 2) gastric discomfort; 3) nausea or vomiting; 4) borborygmus; 5)loose stools. Tongue and pulse: pale tongue and yellow coating; wiry, slippery and thready pulse.

Stasis of blood in the stomach syndrome

Main symptoms: 1) needling pain in the stomach with fixed position and tenderness. Accompanying symptoms: 1) pain becoming more sever at night; 2)blackish complexion. Tongue and pulse: dark tongue with ecchymosis, petechia on the tongue; wiry and knotted pulse.

Insufficiency of stomach-yin syndrome

Main symptoms: 1) vague pain in the stomach; 2)hunger without a desire to eat. Accompanying symptoms:1) dry mouth and thirst; 2) emaciation; 3) tidal fever.Tongue and pulse: red tough with scanty coating or cracked tongue without coating; thready pulse.

Deficiency cold in the spleen-stomach syndrome

Main symptoms: 1) vague pain in the stomach,preference for warm and pressure; 2) pain relieving after taking meal. Accompanying symptoms: 1) mental fatigue;2) aversion to cold and cold limbs; 3) tastelessness and saliva; 4) loose stools; 5) appetite decrease. Tongue and pulse: pale tough or teeth prints on the margin; thin and white coating; deficient and weak pulse or slow and moderate pulse.

Syndrome diagnosis: need essential main symptoms,add two accompanying symptoms, refer to tongue and pulse.

CLINICAL TREATMENT

Treating target of epigastralgia is to relieve symptom, restore function of spleen-stomach,and prevent disease progression

Epigastralgia can be seen in the digestive system diseases, including organic and functional disease.The target of functional disease is to relieve symptom,improve quality of life; the target of organic disease such as peptic ulcer, chronic gastritis is to relieve symptom,prevent disease progression and recurrence.

Treating principle of epigastralgia is"unobstruction", and the main treatment is to"regulate function of the stomach and relieve pain"[8,18]

"Stagnation causes pain" is considered the main pathology of epigastralgia, and obstruction-removing therapy is widely used in clinical, spleen-stomach recover the reception and transformation and coordinate ascent and descent, regulate qi and blood, thus curing the pain.Warming and dispelling cold methods for the patient with congealing cold; promoting digestion and eliminating indigestion methods for the patient with retention food;soothing liver and regulating qi methods for the patient with retention food qi stagnation; activating circulation of blood methods for the patient with stasis of blood; and dredging collaterals by pungent and moist drug should be used for that involved in collaterals. Epigastralgia is always involved in stagnation of qi, pungent and fragrant drugs are added for regulating function of the stomach and relieving pain[19].

Treatment based on syndrome differentiation

Therapeutic principle of pathogenic cold affecting the stomach syndrome: warming stomach and dispelling cold, regulating qi and relieving pain. Prescription:modified Liangfu Pill (Liangfang Jiye) combined with Xiangsu Powder (Formulas of the Administration of People's Welfare Pharmacy). Chinese medicine:Rhizoma Alpiniae Officinarum, Cyperus rotundus L,Purple Common Perilla, Pericarpium Citri Reticulatae,fried Radix Glycyrrhizae. Modified: Flos Caryophylli,Rhizoma Ligustici Chuanxiong are added for patient with aversion to cold and headache; Massa Medicata Fermentata, Endothelium Corneum Gigeriae Galli are added for patient with anorexia.

Therapeutic principle of food retention injuring the stomach syndrome: promoting digestion and eliminating indigested food, regulating function of the stomach and relieving pain. Prescription: Baohe Pill(Danxi's Experiential Therapy) or Zhishi Daozhi Pills(Differentiation on Eendogenous). Chinese medicine:Fructus Crataegi, Massa Medicata Fermentata, Rhizoma Pinelliae, Poria, Pericarpium Citri Reticulatae, Semen Raphani, Fructus Hordei Germinatus, Citrus aurantium L., Radix et Rhizoma Rhei, Radix Scutellariae, Rhizoma Coptidis, Rhizoma Atractylodis Macrocephalae,Rhizoma Alismatis. Modified: Fructus Amomi Villosi,Semen Arecae are added for patient with distension in the stomach and abdomen; Natrii Sulfas is added for patient with constipation; Purple Common Perilla, Herba Schizonepetae are added for patient with fullness in the chest.

Therapeutic principle of liver-stomach disharmony syndrome: regulating the qi and relieving depression,regulating function of the stomach and relieving pain.Prescription: Chaihu Shugan Powder (Yixue Tongzhi).Chinese medicine: Pericarpium Citri Reticulatae, Radix Bupleuri, Rhizoma Ligustici Chuanxiong, Cyperus rotundus L., Citrus aurantium L., Paeonia lactiflora Pall., Radix Glycyrrhizae. Modified: Lignum Aquilariae Resinatum, Flos Inulae are added for patient with frequent belching; Os Sepiellae seu Sepiae, calcined Concha Ostreae are added for patient with acid regurgitation;Radix Codonopsis, fired Rhizoma Atractylodis Macrocephalae are added for patient with fullness in the stomach and hypochondrium and diarrhea.

Therapeutic principle of damp-heat accumulation in the spleen-stomach syndrome: clearing heat and removing dampness, regulating qi and regulating function of the stomach. Prescription: Lianpo Decoction(The Theory of Cholera). Chinese medicine: Cortex Magnoliae Officinalis, Rhizoma Coptidis, Rhizoma Acori Tatarinowii, Rhizoma Pinelliae, Semen Sojae Preparatum,Fructus Gardeniae, Rhizoma Phragmitis. Modified:Caulis Bambusae in Taenia, Pericarpium Citri Reticulatae are added for patient with nausea and vomiting; Massa Medicata Fermentata, Fructus Setariae Germinatus,Fructus Hordei Germinatus are added for patient with anorexia; Semen Coicis, Herba Eupatorii are added for patient with sluggishness of the body and white greasy coating.

Therapeutic principle of interlocking of cold and heat syndrome: acrid opening and bitter descending,regulating function of the stomach and relieving distension. Prescription: Banxia Xiexin Decoction(Treatise on Cold-induced Diseases). Chinese medicine:Rhizoma Pinelliae, Radix Scutellariae, Rhizoma Zingiberis, Radix Ginseng, fried Radix Glycyrrhizae,Rhizoma Coptidis, Fructus Jujubae. Modified: Semen Coicis, Herba Eupatorii are added for patient with dampness of the body and sever greasy taste in mouth;Fructus Citri Sarcodactylis, Citrus medica L. are added for patient with fullness in the stomach and hypochondrium.

Therapeutic principle of stasis of blood in stomach syndrome: promoting blood circulation to remove blood stasis, regulating function of the stomach and relieving pain. Prescription: Danshen Decoction (Popular Formulas in Verse) combined with Shixiao Powder (Formulas of the Administration of People's Welfare Pharmacy).Chinese medicine: Radix Salviae Miltiorrhizae, Pollen Typhae, Faeces Togopteri, Lignum Santali Albi, Radix Notoginseng, Radix Notoginseng. Modified: Rhizoma Corydalis, Rhizoma Curcumae Longae are added for patient with sever stomachache; Radix Astragali seu Hedysari, Ramulus Cinnamomi are added for patient with cold limbs, pale tough and deficient pulse; Radix Rehmanniae Recens, Radix Ophiopogonis are added for patient with dry mouth and throat, uncoated and smooth tongue.

Therapeutic principle of insufficiency of stomachyin syndrome: nourishing yin and inducing body fluid,supplementing stomach and relieving pain. Prescription:Yiwei Decoction (Identification of Warm Disease)combined with Shaoyao Gancao Decoction (Treatise on Cold-induced Diseases). Chinese medicine: Radix Glehniae, Radix Ophiopogonis, Radix Rehmanniae Recens, Rhizoma Polygonati Odorati, Radix Paeoniae Alba, Radix Glycyrrhizae. Modified: Rhizoma Coptidis,Fructus Evodiae are added for patient with gastric discomfort; Fructus Evodiae, Flos Rosae Rugosae are added for patient with sever fullness and pain in the stomach; Fructus Cannabis, Fructus Cannabis are added for patient with stool dry and difficult to pass.

Therapeutic principle of deficiency cold in the spleen-stomach syndrome: nourishing qi and invigorating spleen, warming stomach and relieving pain. Prescription:Huangqi Jianzhong Decoction (Synopsis of Golden Chamber). Chinese medicine: Radix Astragali seu Hedysari, Ramulus Cinnamomi, Radix Paeoniae Alba,Radix Glycyrrhizae, Fructus Hordei Germinatus, Fructus Jujubae, Rhizoma Zingiberis Recens. Modified: Rhizoma Atractylodis Macrocephalae, Rhizoma Pinelliae Preparata are added for patient with full of sputum; Os Sepiellae seu Sepiae, calcined Concha Ostreae are added for patient with acid regurgitation; Radix Aconiti Lateralis Preparata,Pericarpium Zanthoxyli are added for patient with cold body and limbs, lassitude waist and knee.

Treatment of Chinese patent medicine

Qizhi Weitong Granule: soothing liver and regulating qi, regulating function of stomach and relieving pain. It is used for liver qi stagnation, fullness in the chest and stomach, pain in the stomach.

Dalitong Granule: clearing heat and relieving depression, regulating function of stomach and descending adverse qi, promoting circulation and eliminating digestion. It is used for fullness induced by accumulation of heat in the liver and stomach. Symptom:fullness in the stomach, belching, poor appetites,accumulation heat in stomach, acid regurgitation, pain in stomach and abdomen, and patient of dynamical obstruction of functional dyspepsia with above symptom.

Weisu Granule: regulating qi and relieving distension, regulating function of stomach and relieving pain. It is used for stomach of qi stagnation. Symptom:fullness and pain in stomach, involved in hypochondrium,relieving after belching and flatus, aggravating after depression and angry, chest oppression and reduction of repast, unsmooth defecation, and patient of chronic gastritis with above symptom.

Moluodan: regulating function of stomach and descending adverse qi, invigorating spleen and relieving fullness, activating circulation of blood and relieving pain.It is used for chronic atrophic gastritis, the symptoms of stomachache, fullness, distension, anorexia, belching, etc.

Compound Tianqi Weitong Capsule: relieving hyperacidity and alleviating pain, regulating qi and removing stasis, warming middle and strengthening spleen. It is used for hyperacidity, epigastralgia, gastric ulcer, duodenal ulcer, and chronic gastritis.

Dongfang Weiyao Capsule: soothing liver and regulating function of stomach, regulating qi and activating circulation of blood, clearing heat and relieving pain. It is used for stomachache, belching, acid regurgitation, gastric discomfort, lost appetite, irritable and annoying induced by liver-stomach disharmony and stasis heat obstructing collaterals, and patient of chronic gastritis, gastric ulcer with above symptom.

Jinweitai Capsule: regulating qi and activating circulation of blood, regulating function of stomach and relieving pain. It is used for anxious chronic gastroenteritis, ulcer induced by stagnation qi of liverstomach, damp-heat accumulation in collaterals.

Jinghua Weikang Capsule: regulating qi and dispelling cold, cleaning heat and removing stasis. It is used for interlocking of cold and heat syndrome, and fullness and pain in stomach, belching, acid regurgitation,gastric discomfort, bitter taste induced by stagnation qi and blood stasis; patient of duodenal ulcer with above symptom.

Yanshen Jianwei Capsule: strengthening spleen and regulating function of stomach, mildly regulating cold and heat, removing distension and relieving pain. It is used for chronic atrophic gastritis of deficient root and excessive superficial, interlocking of cold and heat syndrome. The symptoms of distension of stomach, pain, poor appetite,belching, acid regurgitation, body tired fatigue, and so on.

Sanjiu Weitai Particle: clearing heat and drying dampness, emolliating the liver and relieving pain. It is used for stomach induced by heat-dampness staying inside, qi stagnation and blood stasis. The symptom of dull pain in stomach and abdomen, distention and acid regurgitation, gastric discomfort and lost appetite; or patient of superficial gastritis, erosive gastritis, atrophic gastritis with above symptom.

Stomach Restoring Pill: strengthening spleen and supplying qi, activating blood and detoxification. It is used for chronic atrophic gastritis and precancerous lesions, adjuvant therapy of gastric cancer postoperative,chronic superficial gastritis belong to deficiency of spleen-stomach.

Biling Weitong Particle: promoting qi and activating blood, regulating function of stomach and relieving pain. It is used for epigastralgia induced by qi stagnation and blood stasis; patient of chronic gastritis with above symptom.

Weikang Capsule: promoting qi and strengthening spleen, removing stasis and stopping blood, relieving hyperacidity and alleviating pain. It is used for epigastralgia, pain with fixed position, acid regurgitation and gastric discomfort, and patient of ulcer, chronic gastritis with above symptom.

Xiangsha Pingwei Particle: invigorating spleen and drying dampness. It is used for distention and pain in stomach.

Buzhong Yiqi Granule (Pill): strengthening the middle and benefiting qi, ascending yang and sending up the lucid yang. It is used for body tired fatigue, fullness in abdomen and lost appetite, chronic diarrhea induced by deficiency in spleen-stomach and collapse of middle qi.

Ganhai Weikang Capsule: strengthening spleen and regulating function of stomach, astringenting and alleviating pain. It is used for gastric and duodenal ulcer,chronic gastritis, reflux esophagitis induced by deficiency of spleen and qi stagnation.

Anweiyang Capsule: strengthening the middle and benefiting qi, detoxifying and promoting granulation. It is used for gastric ulcer, duodenal ulcer, sustained treatment of healed ulcer. And it has preferable therapeutic effect for syndrome of deficiency cold and qi stagnation.

Fuzi Lizhong Pill: warming middle and strengthening spleen. It is used for deficiency cold in the spleen-stomach, cold pain of stomach and abdomen,vomiting and diarrhea, and cold limbs.

Wenweishu Capsule: warming stomach and invigorating stomach, regulating qi and alleviating pain.It is used for stomachache induced by deficiency cold in middle-jiao, the symptom of cold pain in stomach,abdominal distension, belching, lost appetite and deficient food, aversion to cold and weakness; patient of chronic atrophic gastritis, superficial gastritis with above symptom.

Xuhan Weitong Granule: reinforcing qi and strengthening spleen, warming stomach and relieving pain. It is used for stomachache induced by deficiency in the spleen-stomach, the symptom of vague pain in the stomach with more sever after cold and hungry,preference for warm and pressure, patient of chronic atrophic gastritis, duodenal ulcer with above symptom.

Xiaojianzhong Capsule (Particle): warming middle and invigorating deficiency, relieving spasm and pain. It is used for deficiency in spleen-stomach, pain in stomach and abdomen, preference for warm and pressure, gastric discomfort and acid regurgitation, deficient food, gastric and duodenal ulcer.

Acupuncture and moxibustion therapy

Acupuncture at the foot-yangming meridian, footjueyin meridian, foot-taiyin meridian, and the Ren meridian. Prescription: Zusanli (ST36), Liangqiu (ST34),Gongsun (SP4), Neiguan (PC6), Zhongwan (CV12).Matching acupoints: Liangmen (ST34) is added for patients with cold in stomach; Neiting (ST44) is added for patients with heat in stomach; Qimen (LR14), Taichong(LR3) are added for patients with depression in liver;Qihai (CV6), Pishu (BL20) are added for patients with deficiency cold in stomach-spleen; Sanyinjiao (SP6),Taixi (KI3) are added for patients with insufficiency in stomach-yin; Xuehai (SP10), Geshu (BL17) are added for patients with blood stasis. Operation: filiform needle puncture, acupuncture reduction manipulation is used for deficiency syndrome, puncture reinforcement manipulation is used for excess syndrome, and moxibustion is suitably used for patients with cold in stomach or deficiency cold in stomach-spleen.

Moxibustion at Zhongwan (CV12), Qihai (CV6),Shenque (CV8), Zusanli (ST36), Pishu (BL20), Weishu(BL21) by with moxa stick or ginger-partitioned moxibustion (Zhongwan (CV12), Qihai (CV6),Shenque (CV8), Zusanli (ST36) also by needle warming moxibustion), which are used for pathogenic cold affecting the stomach and deficiency cold in stomachspleen.

External treatment

External application

External application therapy is used for stomachache of deficiency cold in stomach-spleen. Cortex Cinnamomi and Flos Caryophylli are ground into powder and covered with gauze, then external application of above gauze is used for Zhongwan (CV12) at each 10-20mins. Fructus Evodiae is mixed by white spirits and divided into several drug bags by cloth, then steamed for 20mins, drug bag is pressed for abdomen, subumbilical, sole center while hot, changed when it becomes cold, 2 times per day, for 30mins; or change time is decided by degree of pain relief. Except syndrome of deficiency cold in stomachspleen, other syndromes of stomachache get poor curative effect by above therapy.

Massage therapy

The method of promoting qi and relieving pain is used, such as single-finger meditation pushing, rubs the law, the pressing, the spot law, the rubbing and so on.Point location and body part: Zhongwan (CV12), Tianshu(ST25), Ganshu (BL18), Pishu (BL20), Weishu (BL21),Sanjiaoshu (BL22), Jianzhongshu (SI15), Shousanli(LI10), Neiguan (PC6), Hegu (LI4), Zusanli (ST36),Qihai (CV6), gastral cavity ministry, back, shoulder and costal regions.

The flowchart in the diagnosis and treatment of epigastralgia

The details are shown in Figure1.

CURATIVE EFFECT OF EVALUATION

Pain assessment scales

Epigastralgia can be evaluated by frequency and degree of pain and impact in live. Visual Analog Scale (VAS) was used to estimate the degree of pain[20];clinician of spleen-stomach disease-reported quantization standard of outcome symptom was used to evaluate the frequency of pain.

Visual Analog Scale (VAS)

Figure 1. Flowchart in the diagnosis and treatment of epigastralgia

Table 1. Clinician of spleen-stomach disease-reported quantization standard of outcome symptom

The method is used to evaluate pain, and widely appiled in China. The VAS is a straight horizontal line vernier caliper of 10cm length, pain feeling were marked on the linevernier caliper ranging from 0 to 10, the "10" end is defined as the extreme limits of the pain, inversely, the "0" end is represented as painless. In clinical practice, patients mark the position in the back of vernier calipe which used to represent the degree of pain. And then doctors score according to the position of vernier calipe marked by patients. Pain severity is assessed using VAS (1-2="excellent"; 3-5="good";6-8="general"; ＞8= "bad").

Epigastralgia-clinician of spleen-stomach diseasereported quantization standard of outcome symptom

Epigastralgia is measured from five aspects,including frequency, duration, degree, impact on work and life, drug intervention. The total scores are about the range of 0-15: (3-point ordinal scale in each aspect:0="none"; 1="mild"; 2="moderate"; 3="severe"). The details are shown in Table 1.

Curative effect evaluation on the individual symptom of epigastralgia except for stomachache[21-22]

The main symptom of epigastralgia includes epigastric distention, anorexia, gastric discomfort,nausea, vomiting, acid regurgitation, belching, except for stomachache. The above individual symptom can be evaluated by patient reported outcomes (PRO), which divided discomfort symptom of patients into 4 levels: 1)0 level: no symptom, score 0 point; 2) no impacting on work and life, score 1 point; 3) moderate symptom, partial impacting on work and life, score 2 points; 4) partial impacting on work and life, and hard to insist on working,score 3 points.

After treatment, curative effect evaluation of individual symptom is divided into four levels: 1)clinical cure: original symptom disappeared; 2) markedly effective: original symptom improved 2 level; 3) effective:original symptom improved 1 level; 4) ineffective:original symptom did not improve or aggravated.

Standard of curative effect evaluation on syndrome of epigastralgia

Calculation by nimodipine method: efficacy index=[(pre-treatment integral- post-treatment integral)/pretreatment integral]×100%. The index is divided into four levels: clinical cure, markedly effective, effective,ineffective. 1) clinical cure: main symptom and sign completely or basically disappeared, efficacy index to four levels: clinical curmain symptom and sign significantly improved ＜95%; 3) effective: main symptom and sign significantly became better 30% better index＜70%; 4)ineffective: main symptom and sign did not improve or aggravated, efficacy index＜30%.

Quality of life assessment

At present, health survey scales, such as Chinese version of the SF-36 scales, have been widely used to evaluate quality of life in China[23].

MEASURES OF PREVENTION AND NURSING CARE

Occurrence of stomachache is closely related with emotional depression, improper diet, excessive cold or warmth, excessive fatigue. Thus, in order to prevent it, the patients should regulate spirit, adjust diet, keep warmness,and strike a proper balance between work and rest. If stomachache is severe with difficulty to cure, the patient should take fluid or half-fluid meal, eat small and frequent meals, light food, and easily to be digested; avoid foods with coarse fiber, strong tea, coffee, smoking and drinking,spicy of inducing factors; cautiously use western medicine like salicylic acid, adrenocortical hormone and so on.

Project leader: Zhang Shengsheng

Consensus authors: Zhang Shengsheng, Zhou Qiang

Consensus experts: Ding Xia, Ma Qun, Wang Fengyun, Wang Bangcai, Wang Ruxin, Wang Chuijie,Wang Chunsheng, Wang Xianbo, Wang Min, Niu Xingdong, Ye Song, Tian Xudong, Tian Yaozhou, Feng Peimin, Zhu Shengliang, Zhu Ying, Ren Shunping, Liu Li, Liu Youzhang, Liu Fengbin, Liu Huayi, Liu Qiquan,Liu Jianshe, Liu Shaoneng, Liu Dexi, Qi Yuzhen, Jiang Yuyong, Sun Yuxin, Su Juanping, Li Junxiang, Li Diangui, Li Yong, Li Zhenhua, Li Qiangou, Li Pei, Li Huizhen, Yang Shenglan, Yang Jinxiang, Yang Cuilan,Shi Zhaohong, Wu Yaonan, He Xiaohui, Yu Zeyun, Wang Longde, Wang Hongbing, Wen Mingqi, Shen Hong,Zhang Xiaoping, Zhang Shengsheng, Zhang Lei, Chen Suning, Chen Diping, Lin Shouning, Jin Xiaojing, Zhou Zhenghua, Zhou Qiang, Zheng Yu, Shan Zhaowei, Zhao Wenxia, Zhao Yuming, Zhao Luqing, Hu Ling, Zha Ansheng, Qin Danping, Jiang Liyun, Yuan Hongxia, Dang Zhongqin, Xu Jinkang, Xu Jianzhong, Tang Xudong,Tang Zhipeng, Tao Lin, Huang Minghe, Huang Shaogang,Huang Guihua, Huang Hengqing, Huang Suiping, Liang Chao, Dong Mingguo, Shu Jin, Zeng Binfang, Xie Sheng,Xie Jingri, Lu Guangchao, Cai Min, Pan Yang, Xue Xilin,Wei Wei.

ACKNOWLEDGEMENTS

This work was financially supported by the Clinical Medicine Development Project of Beijing Municipal Administration of Hospitals (Spleen and stomach disease of traditional Chinese Medicine): ZYLX201411