bubble_chart Concept

Large purulent bloody stool refers to stool that is white like glue, red like melon pulp, or mixed red and white like fish brain. It is accompanied by symptoms such as abdominal pain, frequent bowel movements, and tenesmus. This is the main clinical manifestation of dysentery.

Dysentery has been extensively discussed in medical texts throughout history, with various names. Suwen . Zhizhenyao Da Lun contains records of "dysentery with pus and blood." The "Treatise on Cold Damage Diseases" includes entries such as "heat-induced dysentery with heaviness" and "diarrhea with purulent bloody stool." Zhubing Yuanhou Lun describes 40 types of conditions, including "red and white dysentery" and "pus and blood dysentery." Jisheng Fang states: "What is now called dysentery was referred to as dysentery in ancient times."

The difference between this condition and diarrhea is that although both involve abdominal pain and increased bowel movements, diarrhea does not include tenesmus, and the stool is not purulent or bloody.

Although dysentery may sometimes present with pure bloody stool, it differs from bloody defecation and perianal abscess in terms of disease cause, mechanism of disease, and symptoms. Bloody defecation involves clear, bright red blood, with blood spurting from the anus like a thread or dripping continuously, but without symptoms such as abdominal pain or tenesmus.

bubble_chart Pattern Analysis

1. Large Intestine Dampness-heat︰The onset is relatively acute, with fever and chills, abdominal pain, diarrhea, frequent bowel movements, initially watery stools, followed by a mixture of pus and blood, scant and sticky, dysentery with difficulty, tenesmus, and burning sensation in the anus, scanty and dark urine. It may be accompanied by nausea, vomiting, or a feeling of gastric stuffiness and chest tightness, with a yellow and greasy tongue coating, and a slippery and rapid pulse. Clinically, there are three scenarios: predominance of dampness, predominance of heat, or equal severity of dampness-heat. During the transition between summer and autumn, heat stagnation and dampness steaming lead to dampness-heat lingering in the intestines, obstructing the stomach, corroding the fat membrane, and injuring the blood vessels, resulting in dysentery with pus and blood. Depression and stagnation of qi movement, along with abnormal conduction in the large intestine, cause abdominal pain, distension, and a mix of clear and turbid substances, leading to frequent bowel movements, difficulty in defecation, tenesmus, and burning sensation in the anus. Large intestine dampness-heat and purulent bloody stools are mostly caused by the obstruction of dampness, heat, and stagnation in the Yangming channel. The presence of heat leads to urgent and difficult defecation with rectal urgency; the presence of dampness results in sticky and foul-smelling stools; and qi stagnation causes the sensation of incomplete defecation and tenesmus. In clinical practice, if heat is more severe than dampness, with stools predominantly red or purely bloody dysentery, it indicates excessive heat damaging the blood aspect, and treatment should focus on clearing heat and removing toxins, using Pulsatilla Decoction with modifications. If white predominates over red, it indicates dampness being more severe than heat, with excessive dampness damaging the qi aspect, and Stomach Poria Decoction with modifications should be used. For equal severity of dampness-heat, with mixed red and white dysentery, treatment should aim at clearing heat and resolving dampness, promoting blood circulation, and regulating qi, as the saying goes: "Regulating qi relieves tenesmus, and promoting blood circulation heals pus in the stools." Treatment should involve clearing heat and resolving dampness, regulating qi, and promoting blood circulation, using Peony Root Decoction.
2. Cold-dampness︰Diarrhea with more white and less red, thin and foul-smelling, or like bean juice. Abdominal pain is continuous, prefers warmth and pressure, tenesmus, poor appetite, chest stuffiness without thirst, clear and pale urine, white and slippery or white and greasy tongue coating, and mostly deep and thin pulse. It belongs to chronic dysentery leading to deficiency, where the yang of the spleen and kidneys is damaged by dysentery, and is prone to slippage and reversal cold of the limbs. The main symptoms are spleen yang deficiency or spleen-kidney yang deficiency. Middle energizer deficiency and cold, impaired digestion and transportation, and inability to properly distribute water and grain lead to thin stools with mucus and bloody coating, dull abdominal pain that prefers warmth and pressure; spleen deficiency with sinking and loss of control results in slippage and incontinence. Treatment should focus on warming the middle to strengthen the spleen, astringing the intestines and checking diarrhea, with Immortal Organ-Nourishing Decoction as the main prescription.
3. Epidemic Toxin Syndrome︰The onset is abrupt, the disease tendency is perilous, with high fever, restlessness, thirst, severe abdominal pain, and the passage of purple pus and blood or bloody, watery stools with an exceptionally foul odor. In severe cases, there may be unconsciousness and convulsive syncope. A few patients may exhibit reversal cold of the limbs, panting, cyanotic lips, and a pale complexion, indicating the critical signs of internal block and external collapse. The tongue texture is deep red, often with yellow and dry coating, and the pulse is surging and rapid or slippery and rapid. The disease is caused by the invasion of epidemic toxin evil, which attacks the intestines and stomach, binding with qi and blood. The epidemic toxin evil is violent in nature and harms people swiftly, hence the abrupt onset and perilous condition. The internal excess of epidemic toxin easily transforms into fire, flooding the exterior and interior, leading to immediate symptoms such as high fever, restlessness, thirst, nausea, and vomiting. The toxic heat invades the heart-nutrient level, and excessive heat generates wind, resulting in unconsciousness, convulsive syncope, and a deep red tongue texture. The characteristic of this syndrome is the abrupt onset with prominent symptoms of blazing qi and nutrient levels. In a few patients, high fever, thirst, unconsciousness, and convulsive syncope may appear before the dysentery with pus and blood, and intestinal symptoms may be absent, making it difficult to distinguish from other warm febrile diseases. The main treatment is clearing heat and removing toxins, using modified Coptis Detoxification Decoction combined with Pulsatilla Decoction. For cases with orifice blockage and unconsciousness, Peaceful Palace Bovine Bezoar Pill is added.
4. Summer Heat Entering the Jueyin︰Fever, polydipsia, bloody diarrhea, or a mix of red and white stools, tenesmus, and even limb spasms, with macules and papules on the body. The tongue texture is purplish crimson with a white frost-like coating, and the urine is scanty and dark red. Summerheat epidemic toxin spreads throughout the triple energizer, invades the Jueyin internally, and shifts its toxin to the large intestine, resulting in bloody diarrhea with a mix of red and white stools and tenesmus. Although there is abdominal pain, it is not as severe as the colicky pain caused by epidemic toxin. Despite the presence of tenesmus and mixed red and white stools, the frequency of bowel movements is not as high as with epidemic toxin. As Yu Shi-yu stated in "Detailed Analysis of Epidemic Diseases": "When epidemic toxin transfers heat to the large intestine, it causes tenesmus and mixed red and white stools, or foul and turbid discharge, or purplish blood. Although it resembles dysentery, it is not actually dysentery." Moreover, when summerheat enters the Jueyin, symptoms such as polydipsia, profuse sweating, splitting headache, and epidemic toxin-induced macules and papules often appear. The primary treatment focuses on clearing summerheat, draining heat, and removing toxins, using modified Plague-Clear Toxin-Vanquishing Decoction.
5. Lower Jiao Deficiency-Cold︰The stool is thin and watery, mixed with white mucus or a small amount of blood. The anus feels obstructed, and despite straining, only a few drops of mucus are expelled. There is dull pain in the abdomen, with a preference for warmth and pressure, reduced appetite, abdominal distension and fullness, fatigue, lack of strength, emaciation, cold limbs, and in severe cases, involuntary discharge. The tongue texture is pale, and the pulse manifestation is deep and thin. Chronic dysentery damages yang, primarily manifesting as spleen yang deficiency or spleen-kidney yang deficiency. Middle energizer deficiency and cold lead to impaired digestion and transportation, resulting in thin stools mixed with mucus and blood, as well as dull pain in the abdomen with a preference for warmth and pressure. Spleen deficiency and sinking cause failure to retain, leading to involuntary discharge. Treatment should focus on warming the middle, strengthening the spleen, astringing the intestines, and checking diarrhea. Immortal Organ-Nourishing Decoction is the main prescription.
6. Yin Deficiency︰Diarrhea with red and white sticky discharge, tenesmus, abdominal pain lingering, afternoon tidal fever, or fever worse at night, emaciation and lack of strength, restlessness and unquenchable thirst, a sensation of hunger in the chest, bloating after eating. The tongue is dry and red with scant coating, or shows peeling coating, and the pulse is thin and rapid. This is due to prolonged dysentery damaging yin, with yin deficiency with internal heat as the main manifestation. Although there are symptoms resembling deficiency-cold such as lingering abdominal pain, diarrhea with red and white sticky discharge, and tenesmus, prolonged dysentery damages yin fluids and depletes nutrient-blood, often manifesting as afternoon tidal fever or fever worse at night, heart vexation and dry mouth, occasional retching, a dry red tongue with scant coating or peeling coating, and a thin rapid pulse, which differ from deficiency-cold patterns. Although it is a deficiency pattern, warming and tonifying should not be used. The treatment should focus on nourishing yin, clearing heat, and resolving turbidity, modified Zhuche Wan.
7. Intermittent Onset and Cessation︰The onset is slow, and the course of the disease is prolonged, with intermittent episodes. During an attack, there is discharge of sticky and foul stool, more red than white, resembling jam, or purely dark purple and foul-smelling blood. There is {|###|}grade I abdominal pain{|###|} and {|###|}tenesmus{|###|}. During remission, there is often discomfort from {|###|}abdominal distension and fullness{|###|} or {|###|}dull pain{|###|}, poor appetite, severe {|###|}constipation{|###|}, or alternating {|###|}constipation and diarrhea{|###|}. Over time, the {|###|}complexion becomes shallow yellow{|###|}, with {|###|}mental fatigue{|###|} and physical exhaustion, emaciation, a pale tongue with greasy coating, and a mostly thin and weak pulse. The characteristic of this condition is its recurrent and protracted nature, difficult to cure. Chishui Xuanzhu states: "Those with {|###|}recurrent dysentery{|###|} recover and relapse, with intermittent episodes persisting for months or years, unable to be eradicated." During an attack, the stool is sticky and loose, or mixed with dark purple blood, resembling jam in color, and emits a foul odor, accompanied by {|###|}grade I abdominal pain{|###|} and {|###|}tenesmus{|###|}. The {|###|}mechanism of disease{|###|} generally involves lingering pathogens due to deficiency, a complex interplay of deficiency and excess, depletion of {|###|}healthy qi{|###|} due to prolonged pathogen retention, and persistent {|###|}pathogenic qi{|###|} due to weakened {|###|}healthy qi{|###|}, eventually leading to dual deficiency of qi and blood. For treatment, during the attack stage, the focus is on {|###|}clearing heat and resolving dampness{|###|}, using modified Pulsatilla Decoction. The single herb Brucea javanica (Yadanzi) has some efficacy for this condition. During remission, the focus is on {|###|}tonifying the spleen and replenishing qi{|###|}, using modified Cyperus, Amomum and Six Gentlemen Decoction.
8. Inability to Ingest Food︰Diarrhea with pus and blood, inability to eat, nausea and vomiting, gastric stuffiness and chest tightness, emaciation, mental fatigue, yellow and greasy tongue coating, and soggy and rapid pulse. Closed-mouth dysentery is a symptom during the course of dysentery, characterized by diarrhea with refusal to eat or vomiting that prevents eating. The rest is not significantly different from other pattern types. Diarrhea with refusal to eat indicates severe damage to the spleen and stomach, leading to the absence of a source for the generation and transformation of qi and blood, and the gradual decline of healthy qi, resulting in serious consequences. Therefore, many physicians have classified it as a separate condition. The causes of closed-mouth dysentery are varied, as stated in the Treatise on Febrile Diseases: "It may arise from dampness-heat in the spleen, obstructing the appetite; or from mistakenly taking purgatives, harming stomach qi; or from stopping and astringing too early, leaving pathogens in the middle burner; or from deficiency-cold of the spleen and stomach, with damp pathogens invading; or from blockage of qi movement and obstruction of pathogenic heat; or from foul accumulation in the lower burner with malign qi steaming upward; or from the liver wood element being restricted and overacting on the spleen and stomach; or from retained food failing to digest, or stagnant water retention—all of these can cause closed-mouth dysentery." Treatment should involve pattern identification to determine the disease cause, adapting flexibly without rigid adherence to a single method. Generally, for early-stage closed-mouth dysentery with heat obstructing the appetite, the treatment should focus on clearing heat, harmonizing the stomach, and descending turbidity, using Modified Closed-Mouth Opening Powder. For prolonged closed-mouth dysentery with stomach qi deficiency, the treatment should focus on replenishing qi and nourishing yin, using Modified Six Gentlemen Decoction.

Large purulent bloody stool, with diverse clinical manifestations, in addition to the aforementioned pattern types, there are also Shaoyin diarrhea with pus and blood in cold-damage disease and Jueyin diarrhea with pus and blood in cold-damage disease, etc. Both Shaoyin and Jueyin belong to the category of the three yin. The essence of Shaoyin disease is heart and kidney yang deficiency, although there is thirst and dysuria, it is still due to pudendal coldness internally, with damp dysentery scorching and leading to diarrhea with pus and blood, hence there is often uncontrollable slippage, while tenesmus and abdominal pain with distension are not very obvious. Treatment uses Peach Blossom Decoction to warm the middle and astringe the intestines to stop dysentery. The characteristic of Jueyin disease is the alternation of cold and heat, the struggle of yin-yang interlocking, with depressed heat rushing to the large intestine, injuring the blood collaterals and leading to diarrhea with pus and blood. Jueyin governs the liver, and liver disease often involves qi stagnation, hence there is often hypochondriac distension and fullness, abdominal pain with distension, treatment uses Pulsatilla Decoction to clear heat and remove toxins.

bubble_chart Documentation

1. Zhangshi Yitong-The Large and Small Intestine Gates: "A type of yin-deficient dysentery strictly prohibits the use of purgative medications. Whenever there is discharge of five-colored, thick and sticky pus and blood, incessant diarrhea, fever with thirst, acute pain below the navel worsening at night, aversion to food, or passage of fresh blood, it belongs to yin deficiency. Urgent treatment should focus on clearing heat and preserving yin, such as with Zhuche Pill. ... After dysentery, if there is constipation, tenesmus, frequent urge to defecate without success, or slight white pus, this is due to qi deficiency and sinking. Caution must be taken not to use purgatives; simply raising the yang will naturally cause the yin to descend, such as with Middle-Tonifying Qi-Replenishing Decoction plus Saposhnikovia Root... One should understand that what the Neijing describes as warm blood and feverish body is the fundamental syndrome of yin deficiency, while this condition also involves external pathogens. Reviewing the discussions of dysentery by earlier scholars, white froth was attributed to deficiency-cold, while pus and blood were attributed to damp-heat. It was not until Liu Wansu that the notion of mixed red and white dysentery emerged—could it be that both cold and heat are extreme in the intestines and stomach, jointly causing dysentery? Zhu Danxi followed this view, proposing that red dysentery originates from the small intestine and white dysentery from the large intestine, both due to damp-heat. Once this theory took hold, later generations universally regarded dysentery as a heat syndrome, recklessly using bitter-cold purgatives, causing harm that persists to this day... How could they know that bright purple, thick blood indeed indicates heat, whereas dark, dilute, or agate-colored blood results from yang deficiency failing to control yin? Without warming and regulating the qi, the blood cannot be cleared. Regulating qi is like refining gold in a furnace—the swiftest method."