Hypochondriac pain is a disorder characterized by pain over the unilateral or bilateral sides of the hypochondriac region.

Etiology and Pathogenesis

The liver and gallbladder, exterior-interior related, are located under the hypochondriac region through which their meridians pass, so hypochondriac pain chiefly involves these two organs. The etiology and pathogenesis of hypochondriac pain are: (1) emotional depression leading to the stagnation of liver-qi; (2) long-term stagnation of qi resulting in blood stasis; (3) dysfunction of the spleen causing the retention of dampness-heat; and (4) insufficiency of essence and blood failing to nourish the liver and its meridians. In addition, the dysfunction of the stomach, spleen and kidneys is also related according to the five-elements doctrine.

Syndrome Differentiation and Therapeutic Principles

A. Syndrome differentiation

(a) Differentiation based on qi and blood: A migratory and distending pain is attributed to the stagnation of qi, a localized stabbing pain due to blood stasis and a sustained dull pain to yin-blood deficiency. A severe spasmodic pain associated with bitter taste in the mouth and yellow tongue coating suggests the retention of dampness-heat.

(b) Differentiation between asthenia and sthenia syndromes: Cases due to stagnation of liver-qi, blood stasis and dampness-heat manifest themselves as sthenia-syndrome, and an asthenia syndrome occurs in cases of yin-blood consumption and malnutrition of the liver. Moreover, a case of sthenia-syndrome changing into asthenia-syndrome and coexistence of both may also be seen clinically.

B. Therapeutic principle

Opening the stagnation is the general therapeutic principle for hypochondriac pain. The therapies of regulating qi, clearing heat, eliminating blood stasis and discharging dampness should be employed for sthenia-syndrome, and the therapies of nourishing yin and softening the liver for asthenia-syndrome.

Classification and Treatment

A. Stagnation of liver-qi  

Manifestations: Migratory and distending pain over the hypochondrium varying in degree with emotional changes, distress, frequent sighing, loss of appetite, red tongue with thin coating and wiry and smooth pulse.

Therapeutic principles: Disperse the stagnated liver-qi, and arrest pain.

Prescription: The Modification of Bupleuri Powder for Dispersing the Depressed Liver-Qi

Radix Bupleuri 10 g
Radix Paeoniae Alba 15 g
Rhizoma Cyperi 10 g
Fructus Aurantii 10 g
Pericarpium Citri Reticulatae 10 g
Rhizoma Chuanxiong 6 g
Radix Glycyrrhizae 5 g

Remarks: Add Fructus Toosendan, Rhizoma Corydalis and Radix Curcumae for cases with severe hypochondriac pain. Add Cortex Moutan Radicis, Fructus Gardeniae and Radix et Rhizoma Rhei, and omit Chuanxiong and Citri Reticulatae for those cases with restlessness, bitter taste in the mouth, constipation and yellow urine due to the stagnated-qi changing into fire. Add Fructus Lycii, Radix Polygoni Multiflori, Radix Ophiopogonis and Semen Ziziphi Spinosae, and omit Chuanxiong and Citri Reticulatae for those cases with dull pain, dizziness, mental fatigue, insomnia, red tongue with little coating and wiry and thready pulse due to the stagnated-qi impairing yin. Add Rhizoma Atractylodis Macrocephalae, Semen Coicis, Poria and Radix Ledebouriellae for those cases with increased borborygmus and diarrhea due to liver-qi invading the spleen.

B. Retention of blood stasis

Manifestations: Localized stabbing pain over the hypochondriac region (aggravated at night) or a mass palpable in the hypochondrium, dark purplish tongue with petechiae and uneven pulse.

Therapeutic principles: Eliminate blood stasis, activate blood circulation, and dredge meridians.

Prescription: The Modified Decoction of Inulae

Flos Inulae 10 g
Radix Curcumae 10 g
Semen Persicae 10 g
Fructus Toosendan 10 g
Rhizoma Corydalis 5 g
Radix Angelicae Sinensis 10 g

Remarks: Add Radix et Rhizoma Rhei and Squama Manitis for cases with constipation and predomination of blood stasis. Add Rhizoma Sparganii, Rhizoma Zedoariae and Eupolyphaga seu Steleophaga or Carapax Trionycis Bolus for cases with hypochondriac mass when the bodily physique is not weakened.

C. Retention of dampness-heat in the liver and gall-bladder

Manifestations: Hypochondriac pain, chest oppression, bitter taste in the mouth, dryness of the throat, nausea, vomiting, poor appetite, redness of eyes, yellow-tinged sclera, skin and urine, yellow, greasy tongue coating and wiry, smooth and rapid pulse.

Therapeutic principles: Clear away heat, and discharge dampness.

Prescription: The Modified Decoction of Gentianae for Purging Liver-Fire

Radix Gentianae 10 g
Radix Scutellariae 10 g
Fructus Gardeniae 10 g
Caulis Akebiae 5 g
Semen Plantaginis 10 g
Rhizoma Alismatis 10 g
Fructus Toosendan 10 g
Radix Curcumae 10 g
Rhizoma Pinelliae 10 g

Remarks: Add Cortex Phellodendri and Herba Artemisiae Scopariae for cases with fever and jaundice. Add Herba Lysimachiae, Spora Lygodii and Endothelium Corneum Gigeriae Galli for those cases with colicky pain radiating to the shoulder and back, indicating the presence of gall stone. Add Radix et Rhizoma Rhei, Natrii Sulfas and Fructus Aurantii Immaturus for those cases with constipation, abdominal and epegastric distention. Apply Radix Linderae Pill for those with severe hypochondriac pain and vomiting of ascarid.

D. Insufficiency of liver-yin

Manifestations: Hypochondriac dull pain aggravated by fatigue, dryness of mouth and throat, dizziness, restlessness, red tongue with little coating and thready, wiry and rapid pulse.

Therapeutic principles: Nourish yin, and soften the liver.

Prescription: Yiguan Decoction

Radix Rehmanniae 10 g
Fructus Gardeniae (fried) 10 g
Radix Adenophorae Strictae 15 g
Radix Ophiopogonis 10 g
Radix Angelicae Sinensis 10 g
Fructus Toosendan 10 g
Fructus Lycii 10 g
Semen Ziziphi Spinosae (fried) 10 g
Fructus Ligustri Lucidi 10 g
Heyrba Ecliptae 10 g

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