A Classic Case of Dialectical Treatment of Diabetes Complicated with Diarrhea in the Elderly

Zeyu ZHANG, Lingyun ZHOU

Guizhou University of Traditional Chinese Medicine, Guiyang 550000, China

Abstract As a common chronic disease of the elderly, diabetes endangers both physical and mental health of the elderly. Diarrhea is a common complication of diabetes and causes great inconvenience to patients’ daily life. Professor Zhou Lingyun from Chief Physician, Department of Geriatrics, Second Affiliated Hospital of Guizhou University of Traditional Chinese Medicine has been engaged in clinical practice for many years and is good at treating miscellaneous diseases in geriatric internal medicine. She has unique thinking and experience in the diagnosis and treatment of diabetic diarrhea. Professor Zhou Lingyun believed that the pathogenesis of diabetic diarrhea in the elderly is the deficiency of spleen and stomach qi and dampness. She is good at using Modified Sijunzi Decoction to nourish qi, invigorate the spleen and dispel dampness, so as to treat diabetic diarrhea. This paper introduced and analyzed a classic case of Professor Zhou Lingyun’s treatment of diabetic diarrhea in the elderly.

Key words Diabetes, Diarrhea, Traditional Chinese medicine (TCM) treatment

1 Introduction

Diabetes is a systemic and chronic metabolic disease. Its etiology may be a decrease in insulin receptors present in cells or decreased receptor sensitivity, or a complete lack of insulin. Diabetes is the result of a combination of genetic and environmental factors. Diabetic complications have become one of the major diseases threatening human life and health all over the world, which has attracted the worldwide attention[1]. With diabetes for a long time, patients with substandard and unsatisfactory blood sugar control will often have complications. Initially, diarrhea was considered as one of the less frequent complications of diabetes. However, recent studies have shown that the incidence of diarrhea in diabetes patients ranges from 4% to 22%[2]. Diarrhea, as a manifestation of the digestive system, is the result of the effects of diabetic autonomic neuropathy, and is regarded as a common chronic complication of diabetes[3]. The most common clinical manifestation is an increase in the frequency of defecation. The frequency of defecation in severe patients can reach more than 20 times daily, and the defecation frequency in mild cases can be 4-5 times daily. The fecal matter is also unusual. The most common ones are undigested food in stool or sloppy stool, and sometimes watery changes in stool quality can be seen[4]. Diarrhea has incoherent, repeated, and very persistent characteristics[5]. Its pathogenesis is often complex rather than clear at a glance, and it is often delayed and difficult to heal[6]. At present, it is believed that the pathogenesis of diabetic diarrhea may be related to the acceleration of intestinal peristalsis, intestinal hormone secretion imbalance, electrolyte imbalance, bile acid absorption disorder, and intestinal flora disturbance caused by visceral autonomic neuropathy[7]. Modern Western medicine has no specific treatment for diabetic diarrhea, while traditional Chinese medicine (TCM) has certain advantages in the treatment of diarrhea[8]. Diabetic diarrhea has no corresponding disease name in traditional Chinese medicine, but it can be attributed to the syndrome of "wasting-thirst" and "diarrhea"[9].

Many physicians contend that the lesions of wasting-thirst are attributed to the spleen, lungs and kidneys, and the pathogenesis of the disease is that the spleen fails to function properly[10]. In TCM, diabetes combined with diarrhea can be classified as "wasting-thirst" and "diarrhea". In clinical manifestations, both deficiency and excess can be seen. As recorded inDanxi’sExperientialTherapy, wasting-thirst is like diarrhea should be treated firstly with stir-fried Atractylodis Macrocephalae Rhizoma and Paeoniae Radix Alba. This also reflects the importance of strengthening the spleen for the treatment of diabetes and diarrhea. In addition, Professor Zhou Lingyun Professor Zhou Lingyun from Chief Physician, Department of Geriatrics, Second Affiliated Hospital of Guizhou University of Traditional Chinese Medicine stated that deficiency of qi and blood, weakness of the five internal organs, aging, and degeneration are the unique physiological characteristics of the elderly. Among the manifestations of aging in the five viscera (a collective term for the heart, liver, spleen, lung and kidney), the spleen and kidney have the most significant changes in aging. The elderly often suffer from various diseases, which can cause great damage to the spleen and stomach over a long period of time, resulting in dysfunction of the spleen and stomach transport and transformation, and dampness retained inside. Furthermore, diabetes is mostly a long-term disease and leads to the consumption of yin essence. In addition, the patient is combined with some other factors, such as: emotional disturbance, cold food, invasion of dampness,etc., it will cause huge damage to the spleen and stomach. In the long run, it will have detriment to yin affects yang, spleen disease damages the kidneys, resulting in deficiency and weakness of kidney yang. Then, the life gate fire is not sufficient to transport spleen-earth. When the spleen loses the warming of kidney yang, it will not decompose water and food. Undigested water and food leads to water becoming dampness and food obstruction, dampness will be retained inside, clear (the food essence and water) and turbid (the waste matter) will not be separated and accordingly leading to diarrhea. Therefore, in terms of treatment of diabetes diarrhea, fortifying the spleen and replenishing qi, resolving dampness to stop diarrhea are the key points.

2 Records of the case

Ms. Ye, 87 years old, has diarrhea and watery stool in the past one year, about 6-7 times daily, no symptoms such as abdominal distension or pain, ineffectual and painful straining at stool, tarry stool, nausea, vomiting, fever, and fear of cold. After oral administration of Montmorillonite Powder, Sophora Alkaloids Tannate Capsules and Loperamide Hydrochloride Capsules, the above symptoms were not significantly relieved. Past history: more than 12 years of history of "type II diabetes and peripheral neuropathy". Now she was given "insulin glargine combined with insulin aspart subcutaneous injection" to control blood sugar, and she stated that the blood sugar control was basically acceptable. Physical examination: pale tongue, white slimy fur, and sunken pulse; no tenderness, rebound tenderness, muscle tension in the whole abdomen; negative Murphy sign, no tenderness in Mcburney point; bowel sounds 5 times/min.

First visit: TCM diagnosis: diarrhea due to diabetes, syndrome belongs to spleen and stomach qi deficiency and dampness retained inside, the treatment adopted boosting qi, fortifying the spleen, and dispelling dampness. Prescription: 30 g of Codonopsis Radix, 15 g of bran stir-fried Atractylodis Macrocephalae Rhizoma, 30 g of Dioscoreae Rhizoma, 10 g of Amomi Fructus, 15 g of Poria, 10 g of Platycodonis Radix, 15 g of stir-fried Lablab Semen Album, 10 g of Zingiberis Rhizoma, 10 g of Glycyrrhizae Radix Et Rhizoma Praeparata Cum Melle, 6 g of Aucklandiae Radix, 15 g of bran stir-fried Coicis Semen. A total of 3 pairs, decocted in water for taking, one dose daily, equally dividing the warm decoction into three parts, and taking one part each time.

Second visit: the patient complained that after taking the first prescription, the number of stools was reduced and the yellow loose stools were found 3 times yesterday, no such symptoms as abdominal pain, nausea and vomiting, ineffectual and painful straining at stool, tarry stool, fever, and fear of cold. Prescription: removed Glycyrrhizae Radix Et Rhizoma and Aucklandiae Radix, and added 10 g of Citri Reticulatae Pericarpium on the basis of the first prescription.

Third visit: the patient complained that yellow loose stools were found 2 times yesterday, and no symptoms such as abdominal pain, nausea and vomiting, ineffectual and painful straining at stool, tarry stool, fever, and fear of cold. Prescription: the same as the second prescription.

Fourth visit: the patient complained that there was no diarrhea and occasionally bloating in recent days. Prescription: added 10 g of Magnoliae Officinalis Cortex, 10 g of Scutellariae Radix, increased Poria to 20 g, and reduced Lablab Semen Album to 15 g on the basis of the above prescription.

Fifth visit: the patient complained that there was no diarrhea in recent days, and bloating symptom was improved significantly. Prescription: adjusted the prescription to 30 g of Pseudostellariae Radix, 15 g of stir-fried Atractylodis Macrocephalae Rhizoma, 15 g of Poria, 10 g of Citri Reticulatae Pericarpium, 10 g of stir-fried Lablab Semen Album, 10 g of Amomi Fructus, 10 g of Zingiberis Rhizoma, 6 g of Pinelliae Rhizoma Praeparatum, 15 g of Lilii Bulbus, 10 g of Aucklandiae Radix, 6 g of Bambusae Caulis In Taenias, and 6 g of Glycyrrhizae Radix Et Rhizoma. Until now, the patient’s condition was stable, and the diarrhea has not recurred since then.

3 Discussion

This case was a typical case of diabetes combined with diarrhea. Diabetes has a long course and cannot be cured for a long term. In addition to improper diet, invasion of external pathogen, emotional depression, weak viscera and bowels, the spleen and stomach are damaged, then spleen fails in transportation, small intestine, large intestine conduction loses the function, accordingly leading to diarrhea. The patient has lived in a humid area in the southwest of China for a long time, and the diet was not proper, and the food with fat, sweet and thick taste was not controlled, which are easy to lead to invasion of dampness. With invasion of external pathogens, qi will get deficient. Diabetes has a long course, and it is difficult to control. In the long run, spleen will be damaged, and diarrhea will occur. Thus, the pathogenesis can be attributed to deficiency of spleen and stomach qi. As stated inCollectedSupplementtoPattern:Diabetes, the essence of five viscera lies in the spleen, only when spleen is vigorous, kidney and heart will work normally, and healthy spleen brings transformation of fluid-humor, which elaborates the importance of invigorating the spleen in the treatment of diabetes. The treatment principle of this patient was benefiting qi, invigorating spleen, and dispelling dampness. The basic prescription for this patient adopted Sijunzi Decoction, which consisted of Ginseng Radix Et Rhizoma, Poria, Atractylodis Macrocephalae Rhizoma, and Glycyrrhizae Radix Et Rhizoma. Codonopsis Radix is neutral in nature. Codonopsis Radix and Ginseng Radix Et Rhizoma have functions of benefiting qi and fortifying the spleen. If not greatly tonifying the original qi, Codonopsis Radix is often clinically used to take the place of Ginseng Radix Et Rhizoma[11]. Besides, in this case, the price of Ginseng Radix Et Rhizoma is high, to reduce the medical costs for the patient, we used Codonopsis Radix to take the place of Ginseng Radix Et Rhizoma. In Sijunzi Decoction, Codonopsis Radix is the sovereign medicinal. Codonopsis Radix is warm in nature and sweet in nature and has functions of fortifying the spleen and benefiting the lung. Atractylodis Macrocephalae Rhizoma is minister medicinal. Atractylodis Macrocephalae Rhizoma is warm in nature and bitter in taste, has functions of fortifying the spleen and drying the dampness, so it can strengthen the function of benefiting qi. Poria is assistant medicinal in this prescription. Poria is neutral in nature and sweet in taste and has functions of fortifying the spleen and resolving the dampness. Combined with Atractylodis Macrocephalae Rhizoma, Poria can greatly enhance the function of fortifying the spleen and dispelling the dampness. In the prescription, Glycyrrhizae Radix Et Rhizoma Praeparata Cum Melle functions as boosting qi and warming the middle. It can harmonize all medicinal materials in the prescription, so it is used as assistant medicinal. Codonopsis Radix, Poria, Atractylodis Macrocephalae Rhizoma, Glycyrrhizae Radix Et Rhizoma in the prescription cooperate with each other to give full play to the effect of invigorating qi and fortifying the spleen.

Clinically, Sijunzi Decoction is usually used to tonify the spleen and boost qi. As the representative prescription of tonifying the spleen and boosting qi, Sijunzi Decoction has functions of improving the immunity and adjusting the functions of stomach and intestines. The effects of Sijunzi Decoction may be through its polysaccharide components to regulate the flora in the intestinal tract and stimulate the local intestinal immunity to affect the systemic immunity[12]. Besides, Sijunzi Decoction also has the functions of promoting metabolism, delaying aging, and fighting tumors. In Sijunzi Decoction, Codonopsis Radix can reduce blood sugar and blood lipids in mice, Atractylodis Macrocephalae Rhizoma polysaccharides, Poria polysaccharides can reduce blood sugar, Atractylodis Macrocephalae Rhizoma extract, Poria skin triterpenes reduce blood lipids, Glycyrrhizae Radix Et Rhizoma total flavonoids reduce blood sugar and blood lipids. These four medicinal materials that make up Sijunzi Decoction have hypoglycemic and lipid-lowering activities[13]. Dioscoreae Rhizoma is neutral in nature and sweet in taste, and has functions of fortifying the spleen and stopping diarrhea. It can help Atractylodis Macrocephalae Rhizoma and Poria to fortify the spleen and dispel the dampness, accordingly to realize normal function of spleen qi. Amomi Fructus can weaken the spleen and adjust the qi movement in the whole body. Amomi Fructus is a common drug for moving qi. However, in this prescription, it has strong function of tonifying qi. It can tonify qi through moving qi, and will not cause qi stagnation. In addition, Platycodonis Radix in the prescription has functions of releasing long qi. In this prescription, it can transport the medicinal materials to move upward, to realize the functions of fortifying the spleen and boosting qi, and tonifying and replenishing lung qi. Together, the whole prescription realizes transportation and transformation of the spleen qi, absorption and transportation functions of spleen and stomach get restored, the stagnant dampness turbidity gets resolved and obstructed qi gets moving again, so it can make up the loss of middle energizer. Pungent and warm Citri Reticulatae Pericarpium can fortify the spleen, regulate qi, and dry the dampness. Citri Reticulatae Pericarpium can regulate stagnant qi of lung, spleen, and stomach. Mutual combination of the above medicinal materials realizes tonifying the spleen qi, invigorating the lung qi, makes upward and downward movement of qi orderly, water metabolism harmonized, dampness and turbidity removed, and accordingly stopping the diarrhea. With degradation of the transportation and transformation function of the spleen, the phlegm-dampness gradually accumulates. Over time, stubborn phlegm is formed, and the phlegm is condensed in the intestines. Therefore, in terms of treatment, it is necessary to strengthen the phlegm-removing, and the prescription should follow the disease changes. What’s more, the stubborn phlegm is mainly related to strange, long-term and difficult diseases, properly warming and resolving phlegm may achieve unexpected therapeutic effect. In this prescription, Magnoliae Officinalis Cortex has functions of drying the dampness and eliminating the phlegm. If the spleen yang is weak and deficient, transportation and transformation of water and food will be weak. For a long term, the spleen and stomach will be damaged, then influencing the kidney. Weak kidney will fail to warm the spleen-earth, accordingly forming the syndrome of deficiency of both spleen and kidney. At this time, the symptoms of diabetes are no longer obvious, and loose stools or even watery stools, fatigue, mental fatigue, fear of cold, dull complexion, abdominal distension, anorexia and other systemic weakness may become the main manifestations[13]. Later, the patient suffered from occasional abdominal distension. Clinically, it often uses Magnoliae Officinalis Cortex to treat abdominal distension caused from dampness obstructing the middle energizer spleen and stomach, and stagnation of spleen and stomach qi. Magnoliae Officinalis Cortex contains Magnolol, and its anti-diarrheal mechanism may be related to inhibiting the calcium ion transport process of epithelial cells by controlling the opening and closing of calcium-activated potassium ion channels, gene expression, and affecting receptor-operated calcium ion channels[14]. As stated inTreatiseonThreeDiabeticSyndromesprepared by famous TCM physician Liu Wansu in Jin and Yuan dynasties, internal heat has a great influence on diabetes, and it is believed that the pathogenesis of diabetes is yin deficiency and dryness heat. InSynopsisofPrescriptionsoftheGoldenChamber, there is also the idea that excessive heat in the stomach will consume and damage body fluids, and also the idea of "nutrient qi deficiency will lead to generation of dryness heat inside". In the prescription, Bambusae Caulis In Taenias has functions of clearing heat and resolving phlegm, and Scutellariae Radix has functions of clearing heat and drying dampness. Because of their special physiological characteristics, the elderly also have their own unique places in drug use. In the treatment of geriatric diseases, emphasis should be placed on tonifying and replenishing. The elderly have weak viscera functions, imbalance of yin and yang, and consumption of essence and blood. Deficiency tonifying should be proper and gradual. Drastic tonifying will lead to abnormal exuberance or abnormal debilitation. For example, most qi tonifying medicinals are sweet, if excessive use, it will lead to slimy stagnation, and result in many problems such as chest separation and oppression[15]. Compared with the young, the spleen and stomach functions of the elderly are degraded, and the elderly often lose their appetite. Thus, at this time, tonifying qi should prevent stagnation. In the prescription, Amomi Fructus, Citri Reticulatae Pericarpium, Aucklandiae Radix and other qi-regulating drugs were added, but the dosage was small to achieve smooth qi movement. The physiological function of the elderly is reduced, and the detoxification ability is lower than that of the young people, so the prescription dosage is largely different from that of the young adults[16]. The elderly are often sickly, the spleen and stomach functions are damaged, and they cannot tolerate pungent, dry, bitter and cold foods. Combined with this feature, even if it is neutral supplementation, it should follow the principle of small dosage. Large doses of drugs may increase the burden on the spleen and stomach, making the spleen and stomach unable to transport and transform normally. In this prescription, there was no large dose drug. As stated inIntroductiontoMedicine, for any external pathogen, avoid sweating and vomiting, but harmonize with small dose of drugs, which suggests that for the elderly, small dose and neutral drugs should be used clinically. When removing the pathogens, it is required to take care. In summary, all drugs of this prescription are small dose neutral drugs.

4 Thinking and prospects

Professor Zhou Lingyun is good at tonifying qi, fortifying the spleen, and dispelling dampness in the treatment of diabetes with diarrhea. She is also good at using modified Sijunzi Decoction. Diabetes with diarrhea is often not a simple condition, often complicated and persistent for a long time. As stated inClassicofDifficultIssues, improper diet and fatigue will damage the spleen. Greater yin leads to weak and deficient spleen qi. Water and food will not be transported and transformed normally. Then, symptoms such as fatigue, abdominal distension, poor appetite, weight loss, muscle atrophy, diarrhea and loose stools will appear. Deficient spleen easily leads to abnormal transportation of spleen. Retained water becomes dampness. Therefore, the overall principle is boosting qi, fortifying the spleen, and dispelling dampness. On the basis of grasping the core pathogenesis, combined with the unique physiological and pathological characteristics of the elderly due to aging, which are different from other age groups, and the specific analysis of specific problems, it is recommended to adjust the prescription according to people and local conditions. For the drug use, it should follow the principle of treatment with both elimination and reinforcement. The reinforcement should not be excessive, while elimination should not be violent. As regards the dose, small dose should be followed. Only through careful application of large dose, may it be able to cure long-term incurable diseases.