Constipation (Ban B)

Difficult and/or infrequent defecation.

Includes conditions where stool is hard and dry, or where stool quality is normal and there is a desire to defecate
but evacuation is difficult and requires significant straining; may also manifest with sluggish or incomplete bowel
movements.
Constipation primarily involves impairment of the Large Intestines ability to transport and guide turbidity
downwards. However, dysfunction of the Spleen, Stomach, Lung, Liver, and Kidney can also lead to constipation.

Relevant Biomedical Diseases

-Habitual constipation, -Intestinal tumor
-Atonic constipation -Perianal perforation and infection (fissure or fistula)
-Spastic constipation -Hemorrhoids
-Intestinal neurosis -Side-effect of medication
-Irritable Bowel Syndrome -Chronic laxative use
-Bowel obstruction

TCM Etiology and Pathology

Essentially comes down to two things:
Lack of water to float the boat = body fluid, Blood, or Yin vacuity. Wu Ju Tong, in his book Differentiation of
Warm Diseases, says: When fluids are deficient there is not enough water to make the boat move. [often
following a warm pathogen disease]
Lack of force to move the boat = Qi or Yang Qi vacuity.

Accumulated Heat consuming body fluids in the stomach and intestines (pathology) caused by:
1. Diet: excessive consumption of alcohol, spicy foods
2. Pungent and hot drugs/herbs
3. Constitutional yang excess
4. Febrile diseases -> Heat shifting downward to the intestines
5. Qi stag. -> Heat in ST and LI

Qi stagnation (pathology) caused by:

1. Emotional stress (sorrow, sadness, pensiveness, depression, anger) -> deficiency or stagnation of Qi
2. Physical inactivity -> stagnation of Qi in the intestines
3. Failure of Lung Qi to descend

Deficiency of Qi, Blood, Yin and Essence (pathology) caused by:

1. Childbirth and loss of blood
2, Overwork
3. Aging
4. Chronic illness (constipation with medium stool)

Yang vacuity with Cold stagnation (pathology) caused by:

1. Excessive consumption of raw and cold food
2. Bitter and cold drugs/herbs
3.Constitutional yang vacuity
4.Aging
5.Chronic illness -> impaired flow of body fluids in intestines due to cold stagnation (via qi stagnation)
6.Direct attack of pathogenic Cold
Pathogenesis
-Heat in the Stomach channel of foot Yangming -> intestinal Heat (the Large Intestine channel of hand Yangming is functionally
related to the Stomach within the Six channel schema)

-Stagnation of Qi -> Qi is stuck, so cannot move; also causes impairment of body fluids due to depressive Heat or Fire

-Spleen Qi vacuity -> not enough Qi to move

-Blood, Yin, Essence vacuity -> insufficient body fluids to moisten LI -> dryness and difficult passage of stool

-Kidney Yang vacuity -> Cold congeals Yang Qi leading to poor fluid distribution and difficulty in LIs ability to transmit stool

Identification of Types of Constipation

-Dry, hard stool, infrequent and difficult defecation, accompanied by a red face, fever, bad breath, mouth sores, dark scanty urine,
dry yellow tongue coating, and a forceful slippery pulse = Heat

-No significant alteration in the quality of stool (though it can be hard if Qi stagnation has generated Heat), stool sometimes can
be thinner than normal, incomplete or sluggish defecation, belching, distention in the chest and hypochondrium, distending
abdominal pain, a thin greasy, coating and a wiry pulse = Qi stagnation

-Normal desire for defecation, ineffective straining to force bowel movements, possible strain at first followed by loose stools,
great effort and prolonged time required for defecation, stools generally not dry or hard, a pale complexion, fatigue, spontaneous
sweating and shortness of breath, thin tongue coating, vacuous pulse = Qi vacuity

-Dry pebble-like stool that is difficult to evacuate, pale complexion, palpitations, dizziness, a pale tongue, and a thin or choppy
pulse = Blood vacuity

-Dry pebble-like stool that is difficult to evacuate, malar flush, dizziness, vertigo, thirst with desire for sips of water, night sweats,
palpitations, soreness and weakness of the lower back and knees, emaciation, red tongue with little or no coat, fine and rapid pulse
= Yin vacuity

-Stools generally neither dry or hard, difficult and sluggish defecation requiring great effort, cold limbs and/or general cold
intolerance, copious clear urine, a moist white tongue coating, and a deep, slow pulse = Yang vacuity

Clinical Tips for Treating Constipation

Constipation itself is not a critical disorder; its clinical significance is closely related to its complications. Constipation can
be a cost of auto-intoxication via resorption of toxins that remain in the intestines. Symptoms of auto intoxication include
dizziness, headache, loss of appetite, irritability, insomnia, acne, and dry, cracking or peeling skin. Chronic constipation can
also lead to stubborn perianal disorders that do not respond well to treatment, including hemorrhoids, perianal fissures and
fistulas, and perianal abscesses. Finally, it is possible for constipation to provoke a medical crisis; for example
cerebrovascular accident due to hemorrhage and myocardial infarction may be induced by forcing and straining during
defecation.

Discontinue bitter and cold herbs that drain downwards once the therapeutic effect has been achieved. The most common
method for treating constipation is draining Heat and unblocking intestinal obstruction. This strategy incorporates herbs that
are extremely bitter and Cold and thus has a tendency to injure the Spleen/Stomach. Hence the need to discontinue this
strategy once a therapeutic effect has been achieved.

Support Upright Qi to restore normal bowel movements. In the late stages of a Warm-febrile disease, constipation is a
common symptom, caused by decreased food and water intake during the acute stage. Treatment to promote bowel
movements might not be necessary in such a case. Instead, nourish Stomach yin and strengthen Stomach Qi. Once the
Upright Qi recovers and normal food and fluid intake resumes, bowel movements will be restored.
TCM Pattern Differentiations

Heat Accumulating in the Large Intestine and Stomach

Signs: dry stool with difficult, infrequent defecation, dark scanty urine
Symptoms: abdominal distention or pain that increases with pressure, red complexion, sensation of heat, dry mouth, halitosis, or
even ulcerations in the mouth
Tongue: red with a dry yellow coating
Pulse: slippery, rapid
Treatment Principle: Clear Heat, moisten the intestines, and promote bowel movement
Acupuncture Treatment: [ST-25, BL-25, SP-15, TB-6, KI-6] + LI-11, LI-4, ST-44
Herbal Treatment: Ma Zi Ren Wan
[Ma Zi Ren (20g), Da Huang (10g.), Xing Ren (10g.), Bai Shao Yao (10g.), Zhi Shi (10g.), Hou Po (10g.)]

Qi Stagnation
Signs: constipation with a desire for defecation, well-formed stool (not necessarily dry) which is hesitant and difficult to push out
Symptoms: frequent sighting, fullness and distention in the chest and hypochondrium, distention and pain in the abdomen,
irritability
Tongue: thin, greasy coating
Pulse: wiry
Treatment Principle: Course the Liver, regulate Qi,eliminate stagnation
Acupuncture Treatment: [ST-25, BL-25, SP-15, TB-6, KI-6] + CV-12, LV-3, CV-6
Herbal Treatment: Liu Mo Tang (Six Ground-Herbs Decoction) OR Xiao Chai Hu Tang/Da Chai Hu Tang
Liu Mo Tang: [Mu Xiang (10g.), Wu Yao (10g.), Chen Xiang (3g.), Da Huang (10g.), Bing Lang (10g.), Zhi Shi (10g.)]

Qi Vacuity
Signs: difficult defecation despite the need to move the bowels, stools are neither particularly hard nor dry, possible feeling of
fatigue after bowel movement
Symptoms: bright-white or pale complexion, spirit fatigue/listlessness, disinclination to speak, shortness of breath, spontaneous
perspiration
Tongue: pale and tender with a thin white coating
Pulse: weak pulse
Treatment Principle: Boost Qi, promote bowel movement
Acupuncture Treatment: [ST-25, BL-25, SP-15, TB-6, KI-6] + ST-36, SP-6, CV-4, BL-20
Herbal Treatment: Huang Qi Tang Astragalus Decoction)
[Huang Qi (20g.), Huo Ma Ren (15g.), Feng Mi (12g.), Chen Pi (12g.)]

Blood Vacuity
Signs: constipation with small, dry and round stools
Symptoms: pale and sallow complexion, palpitations, amnesia, dizziness, vertigo, blurred vision, tingling of the limbs, pale lips
Tongue: pale
Pulse: fine
Treatment Principle: Nourish Blood, moisten the intestines, promote bowel movement
Acupuncture Treatment: [ST-25, BL-25, SP-15, TB-6, KI-6] + SP-6, ST-36, BL-17, BL-20, CV-4
Herbal Treatment: Run Chang Wan (Moisten the Intestines Pill) OR Ba Zhen Tang
[Sheng Di Huang (20g.), Dang Gui (15g.), Tao Ren (10g.), Huo Ma Ren (10g.), Zhi Ke (6g.)]
Yin Vacuity
Signs: constipation with dry, hard stool
Symptoms: malar flush, dizziness, vertigo, thirst with desire for sips of water, night sweats, palpitations, soreness and weakness of
the lower back and knees, emaciation
Tongue: red with little or no coat
Pulse: fine and rapid
Treatment Principle: Nourish yin, supplement the Kidney, moisten the intestines, promote bowel movement
Acupuncture Treatment: [ST-25, BL-25, SP-15, TB-6, KI-6] + SP-6, KI-3
Herbal Treatment: Zeng Ye Tang (Increasing Fluids Decoction)
[Xuan Shen (30g.), Sheng Di Huang (24g.), Mai Men Dong (24g.)]

Kidney Yang Vacuity

Signs: difficult defecation, dry or moist (well-formed) stools, profuse clear urine
Symptoms: abdominal coldness and pain, preference for warmth and aversion to cold, cold limbs, soreness and coldness of the
lower back, bright-white or bluish complexion
Tongue: pale with a white coat
Pulse: deep, slow
Treatment Principle: Warm the yang, supplement the Kidney, and promote bowel movement
Acupuncture Treatment: [ST-25, BL-25, SP-15, TB-6, KI-6] + CV-8, CV-6 + moxa
Herbal Treatment: Ji Chuan Jian (Float the Boat Decoction) OR Zhen Wu Tang (True Warrior Decoction)
[Rou Cong Rong (12g.), Dang Gui (10g.), Huai Niu Xi (10g.), Ze Xie (5g.),, Zhi Ke (3g.), Sheng Ma (5g.)]
can add Tu Si Zi

Acupuncture for Constipation

Primary Points: ST-25, BL-25, SP-15, TB-6, KI-6
Supplementary Points:
Heat in LI and ST: LI-11, LI-4, ST-44, ST-36
Qi Stagnation: CV-12, LV-3, CV-6, PC-6, CV-10
Qi vacuity: ST-36, SP-6, CV-4, BL-20
Blood vacuity: SP-6, ST-36, BL-17, BL-20, CV-4
Yin vacuity: SP-6, KI-3, LU-7
Yang vacuity: CV-8, GV-4, BL-23, CV-6 + moxa

Auricular: ST, LI

Abdominal Massage