Dull pain in the ribs

　　The disease of胁痛 is mainly attributed to the liver and gallbladder. Because the liver is located under the ribs, its meridians run along both sides, the gallbladder is attached to the liver, and they have an external and internal relationship, and its meridians also run along both sides. The liver is a strong organ, responsible for excretion, and prefers to be smooth; it is responsible for storing blood, with Yin in nature and Yang in function. If emotional disorders are not relieved, diet is not regular, long-term illness, excessive physical exertion, or external invasion of damp-heat, etc., can affect the liver and gallbladder, leading to qi stasis, blood stasis, damp-heat accumulation, the liver and gallbladder failing in excretion, or liver Yin deficiency, meridians not being nourished, which can cause胁痛. The specific etiology and pathogenesis are described as follows:

　　8. Liver qi depression, if emotional disorders are not relieved, or depression, or sudden anger and qi inversion, can all lead to unsmooth liver qi, liver qi depression, qi flow obstruction, blockage leading to pain, and thus causing胁痛.

　　7. Blood stasis blocking meridians, when qi flows, blood flows, and when qi is stagnant, blood becomes stasis. Liver qi depression can affect blood, and over time, it can lead to poor blood flow and blood stasis, or falls and sprains, unconverted恶 blood, can all lead to blood stasis blocking the ribs and sides, blockage leading to pain, and thus causing胁痛.

　　6. Damp-heat accumulation, external invasion of damp-heat pathogen, attacking the liver and gallbladder, or excessive consumption of rich, sweet, strong, and spicy foods, damaging the spleen and stomach, leading to poor spleen function, dampness production and heat accumulation, both internal and external damp-heat can accumulate in the liver and gallbladder, leading to the liver and gallbladder failing in excretion, qi flow obstruction, blockage leading to pain, and thus causing胁痛.

　　5. Liver Yin deficiency, inherent kidney deficiency, or long-term illness, excessive physical exertion, or overindulgence in sex can all lead to consumption of essence and blood, causing water not to nourish wood, liver Yin deficiency, meridians not being nourished, leading to pain due to lack of nourishment, and thus causing胁痛.

　　In summary, the disease of胁痛 is mainly attributed to the liver and gallbladder, and is also related to the spleen, stomach, and kidney. The pathogenesis transformation is relatively complex, it can change from excess to deficiency, and from deficiency to excess, resulting in a syndrome of both deficiency and excess. It can affect both qi stasis and blood stasis, and blood stasis can block qi, leading to a simultaneous disease of both qi and blood. The basic pathogenesis of胁痛 is qi stasis, blood stasis, and damp-heat accumulation, causing the liver and gallbladder to fail in excretion, leading to pain due to blockage, or due to insufficient liver Yin, meridians not being nourished, leading to pain due to lack of nourishment.

　　The disease of胁痛 can be associated with various Western diseases, such as acute hepatitis, chronic hepatitis, liver cirrhosis, liver parasitic disease, liver cancer, acute cholecystitis, chronic cholecystitis, cholelithiasis, chronic pancreatitis, rib trauma, and intercostal neuralgia, etc. The pain in the ribs and sides is particularly severe at night, and if the painful area resists being pressed, it is often due to blood stasis inside, caused by blocked liver meridians; chest and side distension and pain, mainly in the lower side, worsens with breathing and turning, which is often due to retained phlegm and dampness, blocking the liver meridians; severe pain in the ribs and sides with a heavy feeling and a specific location, with marked tenderness, is often due to damp-heat in the liver and gallbladder, and obstruction of the liver meridians; distension and pain in the ribs and sides, with abdominal stuffiness and loss of appetite, is often due to food accumulation and turbid qi inversion; hidden pain in the ribs and sides, continuous and not stopping, worsens after fatigue, and is more comfortable when pressed.

　　This disease is characterized by pain in the costal region. The pain may occur on one side or both sides at the same time. The nature of the pain can be distending pain, piercing pain, stabbing pain, hidden pain, mostly repelling pressure, occasionally preferring pressure. It often recurs, and the pain is usually severe at the beginning, and then the hidden pain in the costal region occurs from time to time.Internal and external injury costal pain is caused by the invasion of damp-heat external pathogen into the liver and gallbladder, leading to the liver and gallbladder failing to disperse and communicate, accompanied by cold and heat symptoms, and sudden onset. At the same time, symptoms such as nausea and vomiting, jaundice of the eyes, yellow greasy tongue coating may also occur.. Liver and gallbladder damp-heatSymptoms..

　　If liver depression costal pain is not cured for a long time or the treatment is not proper, the long-standing qi stagnation and blood stasis can transform into blood stasis costal pain; if damp-heat accumulation costal pain is not cured for a long time, the heat syndrome can damage Yin, and transform into liver Yin deficiency costal pain; if the evil invades the vital energy, the long-standing illness leads to deficiency, all the实证 costal pain can transform into the syndrome of both deficiency and excess; and if the虚证 costal pain is due to emotional imbalance, or heavy attack of damp-heat evil, it can also transform into Yin deficiency and qi stagnation, or Yin deficiency and damp-heat syndrome with both deficiency and excess. If neglected or misdiagnosed, long-standing disease can also develop into mass, and even severe cases can transform into鼓胀.

　　Whether it is external or internal injury of costal pain, as long as the treatment is appropriate, the prognosis is generally good. If the treatment is not proper, it may develop into mass and swelling, which is more difficult to treat. Costal pain is all related to the dysfunction of liver's dispersing function. Therefore, a cheerful spirit, stable emotions, smooth qi flow, are of great importance for prevention and treatment. Costal pain belongs to liver Yin deficiency, attention should be paid to rest, combination of work and rest, and eating more light and nutritious foods such as vegetables, fruits, and lean meat. Costal pain belongs to damp-heat accumulation, especially attention should be paid to diet, avoiding alcohol, spicy and sweet foods, and cold and unclean products should also be noted.

　　Costal pain is a type of liver and gallbladder disease characterized by pain in the costal region. Costal pain is a traditional Chinese medicine disease, which is usually diagnosed through observation, listening, inquiring, and touching. Routine laboratory tests such as blood routine, liver function, gallbladder imaging, and ultrasound are also helpful for diagnosis.

　　In addition to routine treatment, patients with costal pain should also pay attention to the following aspects in diet. Patients should eat foods with diuretic effects, as well as foods with anti-inflammatory and antibacterial effects.

　　Costal pain is often related to liver and gallbladder diseases. Emotional depression, liver qi stagnation, overeating of rich and sweet foods, excessive drinking, prolonged illness with physical weakness, worry, fatigue, or falls and traumatic injuries can all lead to costal pain. Its main treatment methods are as follows:

　　辨证要点

　　Key points of differentiation

　　1. Distinguish between external and internal injuries External hypochondriac pain is caused by invasion of damp-heat pathogenic factors by external pathogenic factors, leading to liver and gallbladder failing to unblock and reach, accompanied by cold and heat exterior symptoms, with an acute onset, and may also appear symptoms such as nausea and vomiting, yellowing of the eyes, yellow greasy tongue fur, and liver and gallbladder damp-heat symptoms; internal injury hypochondriac pain is caused by liver depression and Qi stagnation, internal obstruction of blood stasis, or insufficient liver Yin, without exterior symptoms such as aversion to cold and fever, with a slow onset and long course.

　　2. Distinguish between Qi and blood syndromes Generally speaking, Qi stagnation is characterized by distending pain, which is not fixed and may vary in intensity, and the severity of symptoms is often related to emotional changes; blood stasis is characterized by lancinating pain, which is fixed and not easily moved, the pain persists continuously, locally resistant to pressure, worse at night, or there may be masses under the hypochondria.

　　3. Distinguish between excess and deficiency syndromes. Excess syndromes are usually caused by liver depression and Qi stagnation, blood stasis blocking meridians, and external invasion of damp-heat pathogenic factors, with an acute onset, short course, severe pain that is resistant to pressure, and a strong and forceful pulse; deficiency syndromes are usually caused by insufficient liver Yin, meridians and collaterals failing to be nourished, often triggered by fatigue, with a slow onset, long course, subtle pain, persistent and preferable to pressure, and a weak pulse.

　　Principles of treatment

　　Distinguish between syndromes and treat them according to the syndrome. The treatment of hypochondriac pain focuses on the liver and gallbladder, treating based on deficiency and excess. Excess syndrome is suitable for regulating Qi, activating blood circulation, unblocking meridians, clearing heat, and removing dampness; deficiency syndrome is suitable for nourishing Yin and blood to soften the liver. Clinically, according to the theory of 'Pain indicates blockage, and unblockage indicates no pain', and the basic pathogenesis of liver and gallbladder Qi stagnation and unblockage, appropriate herbs for relieving liver depression and regulating Qi, and promoting bile and unblocking meridians should be added to various syndromes.

　　Liver Qi stagnation

　　Symptoms: Distending and painful hypochondria, wandering pain that is not fixed, severe cases may even involve the chest, shoulders, and back, and pain increases when the mind is not at ease, chest oppression, fond of sighing, relief with belching, reduced appetite, epigastric and abdominal fullness, thin white tongue fur, wiry pulse.

　　Therapeutic Method: Relieve liver depression and regulate Qi.

　　Prescription:Chaihu Huaxue San.

　　In the formula, Chaihu relieves liver depression, Xiangfu, Zhishen, and Chenpi regulate Qi and relieve swelling, Chuanxiong activates blood circulation and promotes Qi flow to unblock meridians, Baishao and Gancao relieve urgency and pain, and the whole formula works to relieve liver depression, regulate Qi, and relieve pain. If Qi stagnation and blood stasis are present, and the pain in the hypochondria is severe, consider adding Yujin, Chuanglianzi, Yanhusuo, Qingpi to enhance the effect of regulating Qi and activating blood circulation to relieve pain; if there are symptoms such as irritability, dry mouth and bitter taste, yellow urine and dry stool, red tongue with yellow fur, wiry and rapid pulse, which are signs of Qi stagnation transforming into fire, consider adding Zhizi, Huangqin, Danshaang, etc., to clear the liver; if accompanied by pain in the hypochondria, intestinal rumbling, and diarrhea, it is a syndrome of liver Qi flowing laterally and spleen failing to transport, consider adding Baizhu, Fuling, Zexie, Yiyiren to invigorate the spleen and stop diarrhea; if accompanied by nausea and vomiting, it is due to disharmony between the liver and stomach, the stomach failing to descend, consider adding Banxia, Chenpi, Huoxiang, Shengjiang, etc., to harmonize the stomach and relieve vomiting.

　　Blood stasis blocking meridians

　　Symptoms: Lancing pain in the hypochondria, the pain is fixed and resistant to pressure, the pain persists continuously, worse at night, or there may be masses under the hypochondria, or the complexion is dark, the tongue is purple and dark, the pulse is deep and wiry.

　　Therapeutic Method: Activate blood circulation and remove blood stasis, regulate Qi and unblock meridians.

　　Prescription:Xuefu Zhuyu Decoction.

　　Fang uses Taoren, Honghua, Danggui, Shengdihuang, Chuanxiong, Chishao to activate blood circulation and remove blood stasis while nourishing blood, Chaihu promotes Qi flow and relieves liver depression, Jiegeng opens lung Qi, Zhishen promotes Qi flow and relieves middle Qi, Niuxi promotes blood circulation and removes blood stasis, and guides blood downward. If blood stasis is severe and there is a clear history of trauma, it should be treated primarily with removing blood stasis, and the formula of Fuyuan Huaxue Tang should be chosen. The formula uses Dahuang, Taoren, Honghua, and Chuanshanjie to activate blood circulation and remove blood stasis, disperse nodules and relieve pain, Danggui to nourish blood and remove blood stasis, Chaihu to relieve liver depression and regulate Qi, Tianhuafen to reduce swelling and resolve phlegm, and Gancao to relieve urgency and pain, harmonizing various herbs. It can also be added with Sanqi powder to be taken separately, to assist in removing blood stasis and promoting new blood.

　　Damp-heat accumulation

　　Symptoms: Swelling and pain in the ribs, marked tenderness and resistance to pressure, or radiation to the shoulder and back, accompanied by chest stuffiness, poor appetite, nausea and vomiting, aversion to greasy food, dry mouth and bitter taste, abdominal distension and oliguria, or jaundice, yellow greasy tongue coating, wiry and slippery pulse.

　　Therapeutic Method: Clear heat and promote diuresis, regulate Qi and open collaterals.

　　Herbal Medicine: Longdan Xiegan Decoction.

　　In the formula, scutellaria baicalensis, gardenia, and scutellaria baicalensis clear the liver and expel fire, bupleurum relieves liver Qi and regulates Qi, cimicifuga, alisma orientale, and plantago asiatica clear heat and promote diuresis, raw rehmannia and angelica sinensis nourish the blood and clear heat to benefit the liver. According to indications, add bupleurum, pinellia ternata, citrus reticulata, and cyclocarya paliurus to relieve liver Qi and harmonize the stomach, regulate Qi and relieve pain. If constipation and abdominal distension are due to heat being more severe than dampness, and intestinal fluid is consumed, add rhubarb and natrium sulfocarbamate to relieve heat and promote defecation to conserve Yin. If there is yellowish conjunctiva, yellow urine, fever, thirst, add herba artemisiae scoparia, phellodendron amurense, and herba lysimachiae to clear heat and eliminate dampness, promote bile excretion and relieve jaundice. If the disease persists for a long time, add notoginseng, curcuma, salvia miltiorrhiza, and the tail of angelica sinensis to activate blood circulation and remove blood stasis. For rib pain caused by damp-heat accumulation, it is necessary to remove evilness early and exhaust it thoroughly to prevent damp-heat from sticking together, leading to heat-toxin, causing difficulties in treatment.

　　Insufficient Liver Yin

　　Symptoms:Hidden pain in the ribs, continuous and persistent, exacerbated by labor, dry mouth and throat, dry eyes, restlessness and heat in the heart, dizziness and blurred vision, red tongue with little coating, wiry and thready pulse.

　　Therapeutic Method: Nourish Yin and soften the liver, assist with Qi-regulating and collaterals.

　　Herbal Medicine: Yiguan Decoction.

　　This formula is a famous recipe for softening the liver. The principle of prescription follows the meaning of Ye's 'The liver is a rigid organ, which cannot be harmonized without soft and moistening'. Based on nourishing Yin and blood to nourish the liver, a little assistance is given to regulate Qi and relieve pain, which is suitable for pain in the ribs due to insufficient liver Yin and unvitalized meridians. In the formula, raw rehmannia and fructus lycii nourish the liver and kidney, platycodon grandiflorus, ophiopogon japonicus, and angelica sinensis nourish Yin and blood to soften the liver, and cyclocarya paliurus relieves liver Qi and relieves pain. If there is dryness in the eyes and blurred vision, add herba senna and fructus ligustri lucidi; for those with severe dizziness and blurred vision, add uncaria tomentosa, gastrodia elata, and chrysanthemum; if there is restlessness and heat in the heart and a bitter taste in the mouth, add gardenia and salvia miltiorrhiza. Liver Yin deficiency leading to rib pain, in addition to long-standing illness, blood loss and other reasons, there are also those caused by excessive use of fragrant and dry Qi-regulating crystals. Generally speaking, Qi stagnation causes swelling and pain, patients suffer from pain and swelling, but seek temporary relief, doctors do not investigate the origin of the disease from deficiency, and are eager to achieve results, resulting in excessive fragrant and dry Qi-regulating and injuring liver Yin, which should be taken as a warning.