1. TCVM Approach to Megacolon and Megaesophagus

2. “ Mega- ” Introduction If normal directional motion is inhibited in a tubular organIf normal directional motion is inhibited in a tubular organ A type of Qi DeficiencyA type of Qi Deficiency May be a congenital disharmonyMay be a congenital disharmony Yang Jing Deficiency if associated with other signs of Yang DeficiencyYang Jing Deficiency if associated with other signs of Yang Deficiency Yin Jing Deficiency if associated with other signs of Yin DeficiencyYin Jing Deficiency if associated with other signs of Yin Deficiency

3. “ Mega- ” Introduction “ Directional ” or propulsive Qi Deficiency“ Directional ” or propulsive Qi Deficiency May be acquiredMay be acquired Exogenous Pernicious influencesExogenous Pernicious influences E.g. distemper virus, trauma, toxins, poor quality foods for that species or individual constitutionE.g. distemper virus, trauma, toxins, poor quality foods for that species or individual constitution Endogenous Pernicious influencesEndogenous Pernicious influences E.g. hypothyroidism, systemic lupus erythematosus, hypoadrenocorticism, myasthenia gravisE.g. hypothyroidism, systemic lupus erythematosus, hypoadrenocorticism, myasthenia gravis Remember that “ sthenia ” means “ full ” or “ excess ”Remember that “ sthenia ” means “ full ” or “ excess ” “ asthenia ” means “ empty ” or “ weak ” or “ deficient ”“ asthenia ” means “ empty ” or “ weak ” or “ deficient ”

4. “ Mega- ” Introduction “ Directional ” Qi Deficiency“ Directional ” Qi Deficiency May be associated with concurrent Blood or Yin DeficiencyMay be associated with concurrent Blood or Yin Deficiency Subsequent Dryness fails to lubricate either ingesta or fecesSubsequent Dryness fails to lubricate either ingesta or feces Megaesophagus swallowing inhibitedMegaesophagus swallowing inhibited Regurgitate dry ingestaRegurgitate dry ingesta Megacolon defecation inhibitedMegacolon defecation inhibited “ Cannot float the boat in a dry river ”“ Cannot float the boat in a dry river ”

5. Megaesophagus and Megacolon: Types of Wei Syndromes? Wei means “ withered ” in Chinese to describe the withering of musclesWei means “ withered ” in Chinese to describe the withering of muscles Classical Wei or Atrophy Syndrome is a condition characterized by a weakness of the four limbs, progressively leading to atrophy, a limp state of muscles and tendons, an inability to walk properly and eventually paralysisClassical Wei or Atrophy Syndrome is a condition characterized by a weakness of the four limbs, progressively leading to atrophy, a limp state of muscles and tendons, an inability to walk properly and eventually paralysis This weakness generally occurs without painThis weakness generally occurs without pain So are these “ Megas ” localized Wei?So are these “ Megas ” localized Wei?

6. Wei Syndrome Pattern Differentiation Heat in the Lungs injuring Yin fluids- ExcessHeat in the Lungs injuring Yin fluids- Excess Invasion of Damp-Heat- ExcessInvasion of Damp-Heat- Excess Invasion of Cold-Dampness- ExcessInvasion of Cold-Dampness- Excess Stomach and Spleen deficiency- DeficiencyStomach and Spleen deficiency- Deficiency Spleen and Heart collapse- DeficiencySpleen and Heart collapse- Deficiency Liver and Kidney deficiency- DeficiencyLiver and Kidney deficiency- Deficiency Blood Stasis in the channels- Combination of Excess and DeficiencyBlood Stasis in the channels- Combination of Excess and Deficiency

7. Relationship Between Pattern and Pathoetiology Wind-Heat causes only Lung-Heat injuring Yin fluidsWind-Heat causes only Lung-Heat injuring Yin fluids External Dampness leads to Damp-Heat or Cold- DampnessExternal Dampness leads to Damp-Heat or Cold- Dampness Irregular Diet causes the patterns of Damp-Heat, Cold-Dampness and Stomach-Spleen deficiencyIrregular Diet causes the patterns of Damp-Heat, Cold-Dampness and Stomach-Spleen deficiency Excessive sex and overwork cause the patterns of Kidney-Liver deficiency and Blood stasis in the channelsExcessive sex and overwork cause the patterns of Kidney-Liver deficiency and Blood stasis in the channels Trauma causes the pattern of Blood stasis in the channelsTrauma causes the pattern of Blood stasis in the channels Shock leads to the pattern of Heart-Spleen collapseShock leads to the pattern of Heart-Spleen collapse

8. “ Mega- ” Primary treatment principles Tonify global and local QiTonify global and local Qi Assist directional Qi FlowAssist directional Qi Flow Increase MoistureIncrease Moisture Tonify YinTonify Yin Increase Body FluidsIncrease Body Fluids Nourish BloodNourish Blood Invigorate BloodInvigorate Blood

9. Megaesophagus: Pattern Differentiation Qi Deficiency or Yang DeficiencyQi Deficiency or Yang Deficiency may be seen with hypothyroidism, systemic lupus erythematosus, hypoadrenocorticism, myasthenia gravis, poor quality foods for that species or individual constitutionmay be seen with hypothyroidism, systemic lupus erythematosus, hypoadrenocorticism, myasthenia gravis, poor quality foods for that species or individual constitution Blood Deficiency +/- Blood StagnationBlood Deficiency +/- Blood Stagnation may be seen with trauma, toxins, poor quality foods for that species or individual constitutionmay be seen with trauma, toxins, poor quality foods for that species or individual constitution Heat PatternsHeat Patterns may be seen with distemper infection or other febrile diseasesmay be seen with distemper infection or other febrile diseases

10. Megaesophagus Treatment Physical assistance with raised feeding station and soft, highly digestible foodsPhysical assistance with raised feeding station and soft, highly digestible foods Suggest slow-cooked foods based upon Bian Zheng (see following lecture)Suggest slow-cooked foods based upon Bian Zheng (see following lecture) Acupuncture based upon global and local PatternsAcupuncture based upon global and local Patterns Herbal Formula based upon global and local PatternsHerbal Formula based upon global and local Patterns

11. Megaesophagus: Qi Deficiency Clinical SignsClinical Signs Fatigue, weight loss, muscle mass loss, decreased/depressed back Shu pointsFatigue, weight loss, muscle mass loss, decreased/depressed back Shu points TongueTongue Pale, moistPale, moist PulsePulse Feeble, especially middle and upper jiaoFeeble, especially middle and upper jiao

12. Megaesophagus: Qi Deficiency Acupuncture: Use electro-AP!!Acupuncture: Use electro-AP!! PC 6 master of the chestPC 6 master of the chest CV 17 front Mu of the upper Sea of QiCV 17 front Mu of the upper Sea of Qi CV 12 front Mu for the Stomach (esophagus “ belongs to ” the Stomach)CV 12 front Mu for the Stomach (esophagus “ belongs to ” the Stomach) BL 13, 14, 15 as local Shu for upper Sea of QiBL 13, 14, 15 as local Shu for upper Sea of Qi LI 4, LIV 3 to move QiLI 4, LIV 3 to move Qi LI 10, ST 36, CV 6 to nourish QiLI 10, ST 36, CV 6 to nourish Qi LI 1, LU 11, ST 45 to clear fullness of the chest in the region of the HeartLI 1, LU 11, ST 45 to clear fullness of the chest in the region of the Heart

13. Megaesophagus: Qi Deficiency Spleen Qi DeficiencySpleen Qi Deficiency Si Jun Zi Tang or Four Gentlemen DecoctionSi Jun Zi Tang or Four Gentlemen Decoction the chief herb Panax ginseng ren shen is sweet, warm and tonifies Spleen Qithe chief herb Panax ginseng ren shen is sweet, warm and tonifies Spleen Qi the deputy herb Atractylodis macrocephalae bai zhu is bitter, warm and strengthens Spleen Qi and dries Dampnessthe deputy herb Atractylodis macrocephalae bai zhu is bitter, warm and strengthens Spleen Qi and dries Dampness

14. Megaesophagus: Qi Deficiency Spleen Qi DeficiencySpleen Qi Deficiency Si Jun Zi TangSi Jun Zi Tang assistant herb Poria cocos fu ling is sweet, bland and leeches out Dampness and mildly Tonifies Spleen Qiassistant herb Poria cocos fu ling is sweet, bland and leeches out Dampness and mildly Tonifies Spleen Qi the envoy Glycyrrhiza uralensis gan cao is warm, sweet and warms and regulates the middle burnerthe envoy Glycyrrhiza uralensis gan cao is warm, sweet and warms and regulates the middle burner modify with Hou Po magnolia bark to promote Qi flow, transform Dampness, relieve food stagnation, direct rebellious Qi downward for a stifling sensation in the chestmodify with Hou Po magnolia bark to promote Qi flow, transform Dampness, relieve food stagnation, direct rebellious Qi downward for a stifling sensation in the chest Or modify with Platycodon jie geng resolve phlegm and guide other herbs to upper burnerOr modify with Platycodon jie geng resolve phlegm and guide other herbs to upper burner

15. Megaesophagus: Blood Deficiency Clinical SignsClinical Signs Dry fur, dry pads, firm, dry stools, decreased firmness in back Shu pointsDry fur, dry pads, firm, dry stools, decreased firmness in back Shu points TongueTongue Pale, dry, may have slight lavender huePale, dry, may have slight lavender hue PulsePulse Weak, thin, especially middle and upper jiaosWeak, thin, especially middle and upper jiaos

16. Megaesophagus: Blood Deficiency Acupuncture: Use electro-AP!!Acupuncture: Use electro-AP!! PC 6 master of the chestPC 6 master of the chest CV 17 front Mu of the upper Sea of QiCV 17 front Mu of the upper Sea of Qi CV 12 front Mu for the Stomach for post-heaven BloodCV 12 front Mu for the Stomach for post-heaven Blood BL 17, 18 to engender BloodBL 17, 18 to engender Blood LI 4, LIV 3 to move Qi with BloodLI 4, LIV 3 to move Qi with Blood SP 10, ST 36 to engender Blood and benefit Spleen and StomachSP 10, ST 36 to engender Blood and benefit Spleen and Stomach LI 1, LU 11, ST 45 to clear fullness of the chest in the region of the HeartLI 1, LU 11, ST 45 to clear fullness of the chest in the region of the Heart

17. Megaesophagus: Blood Deficiency Tao Hong Si Wu Tang Four Substances Decoction with Peach Kernel and SafflowerTao Hong Si Wu Tang Four Substances Decoction with Peach Kernel and Safflower Shu di huang prepared rehmanniaShu di huang prepared rehmannia Dang gui angelica sinensisDang gui angelica sinensis Bai shao yao white peonyBai shao yao white peony Chuan xiong ligusticumChuan xiong ligusticum Tao ren peach kernelTao ren peach kernel Hong hua safflowerHong hua safflower Nourish Blood, promote Blood circulation, removes Blood StasisNourish Blood, promote Blood circulation, removes Blood Stasis

18. Megaesophagus: Blood Stagnation Clinical SignsClinical Signs Pain in chest, front Mu and back Shu points, uncomfortable lying in ventral recumbencyPain in chest, front Mu and back Shu points, uncomfortable lying in ventral recumbency TongueTongue Lavender, usually slightly pale and dryLavender, usually slightly pale and dry PulsePulse Wiry, choppy, commonly thinWiry, choppy, commonly thin

19. Megaesophagus: Blood Stagnation Acupuncture: Use electro-AP!!Acupuncture: Use electro-AP!! LI 4, LIV 3, LIV 14 to move BloodLI 4, LIV 3, LIV 14 to move Blood PC 6 master of the chest, reduce stagnationPC 6 master of the chest, reduce stagnation CV 17 front Mu of the upper Sea of QiCV 17 front Mu of the upper Sea of Qi BL 17, 18, SP 10 to engender and circulate Stagnant BloodBL 17, 18, SP 10 to engender and circulate Stagnant Blood CV 12, GB 21, GV 1 to descend QiCV 12, GB 21, GV 1 to descend Qi LI 1, LU 11, ST 45 to clear fullness of the chest in the region of the HeartLI 1, LU 11, ST 45 to clear fullness of the chest in the region of the Heart

20. Megaesophagus: Blood Stagnation Xue Fu Zhu Yu Tang Remove Stasis from the Mansion of Blood DecoctionXue Fu Zhu Yu Tang Remove Stasis from the Mansion of Blood Decoction Tao ren peach kernelTao ren peach kernel Hong hua safflowerHong hua safflower Dang gui angelica sinensisDang gui angelica sinensis Sheng di huang prepared rehmanniaSheng di huang prepared rehmannia Chuan xiong ligusticumChuan xiong ligusticum Chi shao yao red peonyChi shao yao red peony Chuan niu xi cyathulaChuan niu xi cyathula Jie geng platycodonJie geng platycodon Chai hu bupleurumChai hu bupleurum Zhi ke bitter orangeZhi ke bitter orange Gan cao licoriceGan cao licorice Promotes the circulation of Blood and Qi, removes Blood Stasis, relieves painPromotes the circulation of Blood and Qi, removes Blood Stasis, relieves pain

21. Megacolon: Pattern Differentiation Qi DeficiencyQi Deficiency seen with chronic poor quality foods for felids in general or individual constitutionseen with chronic poor quality foods for felids in general or individual constitution Blood Deficiency +/- Blood StagnationBlood Deficiency +/- Blood Stagnation seen with trauma, poor quality foods for that species or individual constitutionseen with trauma, poor quality foods for that species or individual constitution Heat PatternsHeat Patterns may be seen with chronic Stagnation of Qi or Bloodmay be seen with chronic Stagnation of Qi or Blood Yin DeficiencyYin Deficiency usually a consequence of Chronic Heatusually a consequence of Chronic Heat Mixed Qi and Blood DeficiencyMixed Qi and Blood Deficiency is very commonis very common

22. Megacolon: Primary treatment principles Tonify global and local QiTonify global and local Qi Assist directional Qi FlowAssist directional Qi Flow Tonify Qi of all Bowels (i.e. Stomach System)Tonify Qi of all Bowels (i.e. Stomach System) Increase MoistureIncrease Moisture Tonify YinTonify Yin Increase Body FluidsIncrease Body Fluids Nourish BloodNourish Blood

23. Megacolon: Qi Deficiency Clinical SignsClinical Signs Firm to moderate stools that are difficult to expel, thin, small muscles, easily fatiguedFirm to moderate stools that are difficult to expel, thin, small muscles, easily fatigued TongueTongue Pale, normal to moistPale, normal to moist PulsePulse Weak, deepWeak, deep

24. Megacolon: Qi Deficiency AcupunctureAcupuncture BL 20, 21, ST 36 and CV 12 to nourish the Spleen and StomachBL 20, 21, ST 36 and CV 12 to nourish the Spleen and Stomach ST 37 lower He Sea for Large IntestineST 37 lower He Sea for Large Intestine BL 25, ST 25 back Shu and front Mu for Large IntestineBL 25, ST 25 back Shu and front Mu for Large Intestine TH 6, TH 5 empirical points for moving the Qi of the intestines for constipationTH 6, TH 5 empirical points for moving the Qi of the intestines for constipation

25. Megacolon: Qi Deficiency Si Jun Zi Tang or Four Gentlemen DecoctionSi Jun Zi Tang or Four Gentlemen Decoction Panax ginseng ren shen is sweet, warm and tonifies Spleen QiPanax ginseng ren shen is sweet, warm and tonifies Spleen Qi Atractylodis macrocephalae bai zhu is bitter, warm and strengthens Spleen Qi and dries DampnessAtractylodis macrocephalae bai zhu is bitter, warm and strengthens Spleen Qi and dries Dampness Poria cocos fu ling is sweet, bland and leeches out Dampness and mildly Tonifies Spleen QiPoria cocos fu ling is sweet, bland and leeches out Dampness and mildly Tonifies Spleen Qi Glycyrrhizae uralensis gan cao is warm, sweet and warms and regulates the middle burnerGlycyrrhizae uralensis gan cao is warm, sweet and warms and regulates the middle burner Modify with Rhubarb da huang as a bitter, cold herb to move the bowels and dispel stasisModify with Rhubarb da huang as a bitter, cold herb to move the bowels and dispel stasis

26. Megacolon: Qi Deficiency Fan Xie Ye (I8001)Fan Xie Ye (I8001) Fan Xie Ye senna leafFan Xie Ye senna leaf Sweet, bitter, coldSweet, bitter, cold Enters the Large Intestine ChannelEnters the Large Intestine Channel Drains downward and guides out stagnationDrains downward and guides out stagnation For constipation due to heat accumulation in the IntestinesFor constipation due to heat accumulation in the Intestines Contains anthraquinone glycosidesContains anthraquinone glycosides Hepatic metabolites stimulate pelvic ganglionHepatic metabolites stimulate pelvic ganglion Purge Large Intestine, resolve food stasisPurge Large Intestine, resolve food stasis

27. Megacolon: Blood Deficiency Clinical SignsClinical Signs Hard, dry stool, dry hair, dry and flakey skinHard, dry stool, dry hair, dry and flakey skin TongueTongue Pale and dryPale and dry PulsePulse Thin, weakThin, weak

28. Megacolon: Blood Deficiency AcupunctureAcupuncture BL 20, 21, ST 36 and CV 12 to nourish post-heaven Blood production via SP/STBL 20, 21, ST 36 and CV 12 to nourish post-heaven Blood production via SP/ST BL 17 and SP 10 to nourish BloodBL 17 and SP 10 to nourish Blood ST 37 lower He Sea for Large IntestineST 37 lower He Sea for Large Intestine BL 25, ST 25 back Shu and front Mu for Large IntestineBL 25, ST 25 back Shu and front Mu for Large Intestine TH 6, TH 5 empirical points for moving the Qi of the intestines for constipationTH 6, TH 5 empirical points for moving the Qi of the intestines for constipation

29. Megacolon: Blood Deficiency Dang Gui Cong Rong (A0250)Dang Gui Cong Rong (A0250) Dang gui angelica sinensisDang gui angelica sinensis Rou cong rong cistancheRou cong rong cistanche Qu mai dianthusQu mai dianthus Shen qu massa fermentataShen qu massa fermentata Fan xie ye senna leafFan xie ye senna leaf Hou po magnoliaHou po magnolia Mu xiang saussureaMu xiang saussurea Xiang fu zi cyperus seedXiang fu zi cyperus seed Zhi ke bitter orangeZhi ke bitter orange Tong cao tetrapanaxTong cao tetrapanax Moisten Large Intestine, resolve impacted Large IntestineMoisten Large Intestine, resolve impacted Large Intestine

30. Megacolon: Dryness due to Heat Clinical SignsClinical Signs Constipation with hard stool difficult to expel, frequent urinationConstipation with hard stool difficult to expel, frequent urination TongueTongue Dry, yellow coatingDry, yellow coating PulsePulse Deep, rapid or floating and choppyDeep, rapid or floating and choppy

31. Megacolon: Dryness due to Heat Ma Zi Ren Wan Hemp Seed PillMa Zi Ren Wan Hemp Seed Pill Huo ma ren cannabis seedHuo ma ren cannabis seed Xing ren apricot seedXing ren apricot seed Shao yao peonyShao yao peony Zhi shi immature bitter orangeZhi shi immature bitter orange Hou po magnolia cortexHou po magnolia cortex Da huang rhubarbDa huang rhubarb Moisten the Intestines, drains Heat, promotes Qi movement, unblocks the bowelsMoisten the Intestines, drains Heat, promotes Qi movement, unblocks the bowels

32. Megacolon: Yin Deficiency Clinical SignsClinical Signs Constipation, thirstConstipation, thirst TongueTongue Dry, redDry, red PulsePulse Thin and slightly rapid or weak and feebleThin and slightly rapid or weak and feeble Consequence of warm-febrile disease in weak or Yin Deficient patientConsequence of warm-febrile disease in weak or Yin Deficient patient

33. Megacolon: Yin Deficiency AcupunctureAcupuncture BL 25, ST 25 back Shu and front Mu of Large IntestineBL 25, ST 25 back Shu and front Mu of Large Intestine SP 6, KI 3,, CV 4, BL 23 to nourish the YinSP 6, KI 3,, CV 4, BL 23 to nourish the Yin TH 6, ST 37 to unblock the Large IntestineTH 6, ST 37 to unblock the Large Intestine

34. Megacolon: Yin Deficiency Zeng Ye Tang Increase the Fluids DecoctionZeng Ye Tang Increase the Fluids Decoction Xuan shen scrophulariaXuan shen scrophularia Mai men dong ophiopogonMai men dong ophiopogon Sheng di huang fresh rehmanniaSheng di huang fresh rehmannia Generates fluids, moistens dryness and unblocks the bowelsGenerates fluids, moistens dryness and unblocks the bowels

35. Megacolon: Stagnation with Heat Clinical SignsClinical Signs Severe constipation and flatulence, focal distention and abdominal fullness, abdominal pain which increases with pressure, tense and firm abdomenSevere constipation and flatulence, focal distention and abdominal fullness, abdominal pain which increases with pressure, tense and firm abdomen TongueTongue Dry, yellow or dry and dark coatingDry, yellow or dry and dark coating PulsePulse Deep, excessiveDeep, excessive

36. Megacolon: Stagnation with Heat AcupunctureAcupuncture Ren 4 tonifies Yin and fluidsRen 4 tonifies Yin and fluids LI 11 clears Heat in the Large IntestineLI 11 clears Heat in the Large Intestine ST 37 lower He Sea for Large Intestine to harmonize LIST 37 lower He Sea for Large Intestine to harmonize LI ST 44 clears Stomach HeatST 44 clears Stomach Heat LI 2 clears Large Intestine HeatLI 2 clears Large Intestine Heat SP 6, KI 6, Ren 12 promote body fluidsSP 6, KI 6, Ren 12 promote body fluids

37. Megacolon: Stagnation with Heat Da Cheng Qi Tang Major Order the Qi DecoctionDa Cheng Qi Tang Major Order the Qi Decoction Da huang rhubarbDa huang rhubarb Mang xiao mirabilitumMang xiao mirabilitum Zhi shi immature bitter orangeZhi shi immature bitter orange Hou po magnolia cortexHou po magnolia cortex Vigorously purges Heat accumulationVigorously purges Heat accumulation

38. Conclusion Megaesophagus and Megacolon are predominantly types of localized Qi DeficiencyMegaesophagus and Megacolon are predominantly types of localized Qi Deficiency Although heritable (Jing) factors may be involved, Exogenous Pathogens and poor quality foods are root causeAlthough heritable (Jing) factors may be involved, Exogenous Pathogens and poor quality foods are root cause Blood Deficiency with or without Blood Stagnation may be a complicating factorBlood Deficiency with or without Blood Stagnation may be a complicating factor Acupuncture and Herbal formula based upon Pattern Differentiation may improve quality of lifeAcupuncture and Herbal formula based upon Pattern Differentiation may improve quality of life