Xu, male, 27 years old, first consultation on August 29, 1989. Upper abdominal pain for 18 years, worsening over the past 2 years. The patient has experienced abdominal distension and fullness since the age of 9, after eating too many dumplings, accompanied by diarrhea, which was treated and stopped. Since then, the abdomen has often been distended, with acid regurgitation, reduced appetite, recurrent hematemesis and bloody stool. He underwent surgery for upper gastrointestinal bleeding, but the stomach pain recurred post-surgery. Despite using both Chinese and Western medicines, the effect was not significant, leading to this consultation.
Current diagnosis: Pain not only when fasting but also immediately after eating, sometimes even after drinking watermelon juice. More severely, drinking water or tea causes a dull pain in the chest. When lying on the back, the upper abdomen feels distended, as if something is blocking it, and bowel movements are weak. Complexion is shallow yellow, spirit is listless. Tongue texture is slightly pale, tongue body is large, coating is thin white, slightly yellow and slippery, with tooth marks on the edges. Right pulse is floating and wiry, guan pulse is deficient and large, left pulse is deep and wiry. Diagnosed as abdominal pain due to spleen and stomach qi deficiency. Prescribed Cinnamon Twig minus Cinnamon plus Poria and White Atractylodes Decoction:
Prepared Liquorice Root 15g, Peony Root 50g, White Atractylodes Rhizome 50g, Poria 50g, Chinese Date 30g, Fresh Ginger Rhizome 50g
After 3 doses, the pain was significantly reduced, appetite improved, and distension greatly alleviated. Continued with 3 more doses of the same prescription, and the pain stopped, distension disappeared. To consolidate the effect, continued with 10 more doses, and the pain has not recurred.