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Writer's pictureRichard Lai

#75: Stomach Heat Case Study




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Understanding Stomach Heat in Acupuncture: A Case Study from Study Acupuncture with Me

Hey everyone, Dr. Richard Lai here from Study Acupuncture with Me. I'm excited to bring you another insightful episode, and this time, we're diving deep into the concept of Stomach Heat. If you've been following my podcast, you'll know that our last episode featured a detailed case presentation from my recent trip to Boston. Today, I want to break down that case, explore the symptoms, and discuss the appropriate point prescriptions for treating Stomach Heat.

Understanding the Patient’s Symptoms

The patient that I've been working with has a bunch of symptoms that we've been working through - i've known him for YEARS since I was a student, so what I presented to you was a BUNCH of his symptoms that he's had throughout the YEARS. He lost his sense of taste during the peak of COVID, which only partially returned. He also experienced a reduced sense of smell. He also had some complaints of upper stomach pain, which he described as feeling like knots, paired with nausea, headaches, excessive thirst, and bleeding gums. He also described loose stools and a wiry pulse, especially in the middle position. When examining his tongue, I noticed a red coloration, especially in the middle, with a dry, yellowish coat.

Breaking Down the Symptoms of Stomach Heat

In Traditional Chinese Medicine (TCM), these symptoms collectively point towards an imbalance that needs addressing through acupuncture.

  1. Loss of Taste and Smell: These are primarily associated with the Spleen and the Lung, respectively. Since the spleen opens into the mouth, a loss of taste implies a disruption in spleen function. Similarly, the lung, which opens into the nose, is related to the sense of smell. COVID-19, often characterized as a damp-heat pathogen, can obstruct Chi flow to these organs, leading to the symptoms noted in our patient.

  2. Epigastric Pain and Nausea: The upper stomach pain, or pain in the epigastric region, can indicate a stagnation type pain, often related to spleen and stomach issues.

  3. Headaches, Thirst, and Bleeding Gums: These are indicators of heat in the body, particularly affecting the middle jiao, where the stomach and spleen are located.

  4. Loose Stools: This is often a sign of dampness in the body. If the stools are smelly, it indicates heat.

  5. Wiry Pulse: A wiry pulse is typically associated with liver disharmonies, pain, or phlegm. In this case, it points to an issue in the middle jiao due to the spleen and stomach’s association with this area.

Treatment Approach and Point Prescription

Based on these symptoms, the patient is exhibiting signs of Stomach Heat and possible damp-heat. We must choose acupuncture points strategically to clear this heat and support the body's natural balance.

Point Prescriptions

Here are the five points I most recently implemented for this patient:

  1. Stomach 44: This ying-spring point is fantastic for clearing heat. Located in the web space between your second and third toes, it directly targets heat patterns related to the stomach.

  2. Ren 12: Known as the front mu point of the stomach, Ren 12 is crucial for harmonizing the middle jiao. It’s 4 cun superior to your umbilicus, in the midpoint between the belly button and the sternocostal angle.

  3. Stomach 21: Though it doesn’t hold a special category, Stomach 21 is often combined with Ren 12 to enhance the treatment of the middle jiao. It’s 2 cun lateral to the midline, on the same horizontal plane as Ren 12.

  4. LI 11: The He-Sea point of the Large Intestine, LI 11, is potent for clearing heat. Found halfway between your lateral epicondyle of the humerus and Lung 5, it’s almost always included in heat-clearing prescriptions.

  5. Stomach 34: As the Xi-Cleft point of the stomach, Stomach 34 is effective for acute pain management, making it suitable for the patient’s stomach knots. It’s located 2 cun above the superior border of the patella.

Integrating the Comments from Acupuncture Community

A big shout-out to everyone who commented on the previous episode. Your insights are invaluable! Let's review some key points mentioned:

  • CaraxJulian: Highlighted using points like Ren 4, LI 11, Stomach 36, and Stomach 44 for treating stomach fire. Great point selection!

  • Rathikanarayana4718: Suggested clearing heat in both the spleen and liver, showing it could be spleen and liver fire.

  • MoeHoward: Provided a detailed week-by-week intervention plan, emphasizing reassessment, which is crucial in acupuncture.

  • Sylvia: Proposed an approach focusing on spleen chi deficiency possibly leading to liver yang rising with fire due to yin deficiency. Key points included Stomach 44, LI 4, 11, Liver 2, Gallbladder 20, Liver 3, among others.

  • AC: Suggested damp-heat encumbering the spleen with excellent rationale connecting the symptoms to this diagnosis.

These discussions embody the collaborative spirit we need in TCM. Being open to each other’s viewpoints not only enriches our understanding but ultimately benefits our patients.

Emphasis on Acupuncture Community and Learning

I can't stress enough how important community is for growth in any field, especially in acupuncture. The interactions between Sylvia and AC from different parts of the world during our episode demonstrate the power of shared knowledge and support.


Building a positive, supportive community is why I created my private Facebook group, Study Acupuncture with Me. This space is dedicated to fostering growth, positivity, and collaboration among acupuncturists and acupuncture students. If you haven’t joined yet, I highly encourage you to find us!! https://www.facebook.com/groups/studyacupuncturewithme


Free Download

For those who want to dive deeper into this case, I’ve made all the slides and materials from this podcast episode available as a free PDF - you can download it here!




Final Thoughts

Thank you all for being a part of this journey. Until next time, keep studying, keep collaborating, and as always, God bless and happy studying!


Dr. Richard Lai, DPT, LAc

Study Acupuncture with Me


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TRANSCRIPT

Dr. Richard Lai DPT LAc:

Hey, everyone. Doctor Richard Lai here with study acupuncture with me. Now last episode, we went over a case presentation when I was traveling for work to Boston. And this week, we're gonna go over the details of that case presentation over the symptoms and what we think we should do for this patient in terms of a point prescription. If you didn't get to catch that episode, I can actually watch it with you right here on my trusty little hologram, which shows my YouTube channel here. So let's go down a little bit. Tap here. Alright.


Dr. Richard Lai DPT LAc:

And we'll watch this video together. He lost his sense of well, he has it back more so now. But when he had COVID, during the peak of COVID, he lost his sense of taste. And he says that his sense of smell is also affected. But now he has more so of it. But he says sometimes he doesn't taste the food or it doesn't taste as good as it usually does. He's seeking treatment with me because of his stomach pain. He always says that he has knots in his stomach, that he has stomach pain, especially, like, right in this upper area here.


Dr. Richard Lai DPT LAc:

He is nauseous sometimes as well. He gets headaches. He's thirsty all the time. He chugs water every chance he gets. One weird thing is that his gums bleed a lot whenever he flosses. Whenever he uses the bathroom, he has loose stools. When we take his pulses, his pulse feels wiry like a guitar string, literally plucking a guitar string. It especially feels wiry in the middle position.


Dr. Richard Lai DPT LAc:

And then when we look at his tongue, his tongue is red. Look at the middle of his tongue, tongue more red in the middle. It seems like his tongue coat is dry. There's like a yellowish tinge to it. Okay. Alright. Alright. So what you gotta do Get rid of that.


Dr. Richard Lai DPT LAc:

So now let's put up on the screen some of the comments that you went over, and then we'll go into the rationale behind some of the manifestations. Alright. So first of all, I have to say thank you to everyone that commented. Taking the time to comment means so much to me, you have no idea. So first here we have Cara x Julian saying that it could be stomach fire, ren4, li11, stomach36, and stomach 44. So those are good points actually to use for this. Rathy says for this treatment, clear heat in the spleen and liver, and says that it's liver and spleen fire. Okay.


Dr. Richard Lai DPT LAc:

Moe Howard says liver heat, lung, and large intestine in balance, wind heat. 1st week, oh, nice. They even put actually week by week what they would do as interventions. So 1st week, I would treat LI 4, San Jo 5, lung 7, plus stomach 36, splint 6 and liver 3, and then reassess. I love that. Reassessing after the interventions is so important because you see, did it work? And then you can modify the treatment. If stomach 36 didn't work, if liver 3 didn't work, let's put something in and see if it benefits the patient more. And now Sylvia here, she said, I'm thinking spleen chi deficiency, probably a ganyin or blood deficiency leading to chi stagnation, so by gen chi is meaning liver.


Dr. Richard Lai DPT LAc:

Rise of yang and fire and fire in wei maybe also with a yin deficiency and being attacked by gen, so wei meaning like the stomach and then gan again meaning liver. I would first clear the fire and harmonize the gan yang, meaning liver yang, and allow proper chi flow, then tonify pi and gan, so tonifying spleen and liver. Sylvia would use stomach 44, li4 and 11, f 2, gallbladder 20, liver 3, PC 6, spleen 6, e36, meaning stomach 36, ren 12, bladder 20. Also could use liver 8, spleen 10, bladder 18, if GAN deficiency. Hope I use the right words as English is not my first language. Sorry, by F2, I meant liver 2. F is in Portuguese. So that's awesome, Sylvia.


Dr. Richard Lai DPT LAc:

Thank you so much. Not even speaking the native language, you took the time to comment and you did excellent. Great job. And then here we have AC and Sylvia interacting with each other. So AC says, my wild guess, damp heat encumbering the spleen. Currently, heat is predominant, and it cuts off because I wanted the whole graphic to show, but here's the rest of it. Rationale, sense of taste and to a point smell is associated with the spleen. COVID often being a damp heat pathogen obstructing the flow of chi to the upper part of the body, therefore impairing the sense of taste and smell.


Dr. Richard Lai DPT LAc:

Stomach pain and knots in the epigastrium is explained by dampness obstructing the flow of chi leading to pain and knots in the epigastric area. Yes. Nausea, dampness leading to chi counterflow leading to nausea. Unquenchable thirst, now this one's tricky. Either it's due to more heat being predominant or what I've seen more often is dampness obstructing the free flow of fluids to the mouth, giving rise to thirst that is unquenchable. Loose stools is explained by a sign of dampness and if smelly, then it's heat. Bleeding gums, if the blood is bright red, heat in the spleen leading to erratic blood. If the gums are pale and there's only slight bleeding, then this is bleeding due to spleen g deficiency, since the spleen is not able to hold blood due to dampness.


Dr. Richard Lai DPT LAc:

You're very good AC. Wiry pulse, this is explained as a wiry pulse is more often than not a sign of dampness as well. Red tongue with slightly yellow dryish coating. Here we see damp heat. Dryness is either again a sign of heat or the impaired fluid distribution. Now, one symptom is totally not clear for me, the headaches. Here, I would need more information. For me, I'm seeing the headaches, and this is Richard talking.


Dr. Richard Lai DPT LAc:

I'm seeing the headaches because of the heat. Back to AC, here, I would need more information. Is it because of liver involvement, damp heat impairing free flow to the chi, or directly result dampenstall headaches with a feeling like being wrapped in a wet cloth. My treatment method, clear, damp heat, tonify spleen, help the clear yong of the spleen to ascend, and AC uses spleen 9, li 11, stomach 36, spleen 6, li 4, li 20, and ren 12. And these points, great points. To clear dampete, tonify the spleen chi, move chi as well, and also for the knots in the epigastric pain. So this actually opens my mind, now this is Richard talking, this actually opens my mind a lot actually because of the connection with the liver, the wiry pulse, and dampness. Now, Sylvia responds, loved it, always learned in this channel, but I have some questions.


Dr. Richard Lai DPT LAc:

I'm still a student studying for my exams next month. Unquenchable thirst means it does not go away easily. Right. Isn't that because of heat? Dampness wouldn't be like thirst but not wanting to drink. Very interesting, your explanation. AC responds, yes. Actually thinking about it, the unquenchable thirst is more of a sign of heat. Overall, I am also thinking that this case is more pronounced in terms of heat than the dampness.


Dr. Richard Lai DPT LAc:

Usually thirst to dampness is pronounced but the patient will not drink. I was wrong about that, sorry. The pulse, I often see this misinterpreted. A wiry pulse can of course be a sign of liver chi stagnation and pain, totally true, but it is often a sign of phlegm dampness. The wiryness comes from the impaired flow of chi. Hope that helps. And Sylvia responds, Interesting. It helped for sure.


Dr. Richard Lai DPT LAc:

All right. And so after reading those comments, I absolutely love the camaraderie that I'm seeing. I love to see a beautiful moment like that, especially in the modern world, in this technological world where basically you saw 2 people from different parts of the world. They're interacting online together and learning together and teaching each other and supporting each other. I mean, like, that's literally what this is all about. Life is about building each other up instead of tearing each other down. And I've been in a lot of different acupuncture Facebook groups and honestly, even some in person get togethers with other acupuncturists. And there are some acupuncturists, not just acupuncturists, but other health care workers as well in other industries.


Dr. Richard Lai DPT LAc:

And I'm really sorry to say, but some of them are very egotistical when it comes to the health care world. And I mean, I understand we work hard, we study hard, we're really confident in our skill sets, but it shouldn't come at the expense of diminishing someone else's flame just because maybe they're newer or maybe they haven't seen that diagnosis before because not knowing something is not their fault. If we can build each other up like how AC and Sylvia did and also everyone else who commented, thank you guys for doing that. Thank you for leaving a positive impact. And that's what I'm looking for in the Facebook group that I have that's currently private. It's only for acupuncturists and acupuncture students who want to foster this type of growth, this type of positivity in each other while they're studying for their board exams, while they're getting their foot in the door for their clinic, while they're building their practice. So if you want to join, find my Facebook group. Just search for Study Acupuncture with Me.


Dr. Richard Lai DPT LAc:

It's a private Facebook group. You need my approval to enter. And, honestly, please forgive me because, some of you have emailed me saying, hey. I I I requested access a couple weeks ago, and I didn't get any access yet. Please forgive me. For some reason, Facebook groups don't send me any occasions when someone requests to join. So sometimes there's this stretch of time where I don't look at that and I don't check the whole member request area. So I do apologize for that one, but just send me an email and I promise I'll try to be better.


Dr. Richard Lai DPT LAc:

Shoot me a DM or shoot me an email if you find that it's getting too long, that you've been waiting for too long, and I will prove you right away. Alright. So now let's get into this patient's case and I'll let you know my thoughts on the case. And honestly, based on what you guys have been saying, I'm actually gonna bring a lot of new things back to this patient, and I feel like they're really gonna get a lot of benefit from it because of your help. So thank you guys for that. Now our patient is presenting with what? Our patient is presenting with a chief complaint of pain in the upper stomach area. Now when we talk to each other as clinicians, instead of saying upper stomach area, what we would say is epigastric area. Now in terms of this, he's saying that he's having loose stools or, at the very least, they're not very formed like they usually are.


Dr. Richard Lai DPT LAc:

He's saying that his stomach just feels like it's in knots at times. He says he feels like he has nausea. He has headaches. He's got the bleeding gums. And on top of all that, he has this diminished sense of taste and smell, which started a while ago when he got COVID. It never really came back fully. He also says that he's thirsty all the time. And when we look at his tongue and pulse, his tongue is red with an even redder middle, and the tongue coat is dry, and there's this yellow tinge to the tongue coat.


Dr. Richard Lai DPT LAc:

So it's clear from your comments that this patient's presentation has something to do with the spleen and maybe even the liver. So now, let's go back to the basics about the spleen, the liver, and other organs, and talk about each of these manifestations. So first, let's start with the spleen. So on the screen, I will put all the functions of the spleen from governing the transformation and transportation. Even one of the functions of the spleen is that it's affected by pensiveness. Now what we're gonna focus mostly on is one of the functions, which is that the spleen opens into the mouth. And we know that with the spleen, the element that corresponds with the spleen is earth. The earth element has a lot of other correspondences.


Dr. Richard Lai DPT LAc:

For example, the earth element corresponds with the mouth. And so this actually makes sense for all the other functions of the spleen as well. Because the spleen, we know, it governs transformation and transportation. The mouth is the first step of that process because it prepares the food by chewing it up and then transporting it down to the stomach and the spleen where it can go and be digested, where it can be broken down, transformed, and transported all over the body. And of course, all this happens normally if the spleen is functioning normally. Meaning, if our spleen chi is intact, then our function is gonna be intact as well, meaning the mouth function. The mouth function has to do with taste. So that means our sense of taste is gonna be good.


Dr. Richard Lai DPT LAc:

Also, our ability to chew food is gonna be good too. So if your patient, for example, is saying that they have difficulty chewing food, this could have to do with the health and status of the spleen. So just to recap all of that, the earth element, it corresponds with the spleen organ. The spleen has a lot of functions. One of them is that it opens into the mouth. If we have good spleen chi, then the functions of the mouth is gonna be also good or intact, meaning we'll be able to chew easily and we'll be able to taste our food as well. That means though that a loss of taste, like our patient has in this case, could be related to a spleen chi deficiency or something like that. And that's actually in line with all of your comments.


Dr. Richard Lai DPT LAc:

So congratulations on that. So now let's actually expand on that concept. So I'll put on the screen here a table, and this table is gonna have a couple columns. Column 1, we're gonna put our elements. Column 2, we're gonna put the organs that they correspond with. And in column 3, we're gonna put the sense organ and even the sense that they correspond with as well. And now these organs, they have influence over these senses. And that's actually the reason why I'm putting it in this order.


Dr. Richard Lai DPT LAc:

Because I want you to appreciate this fact that when you get into the details with your patient, when you're talking with your patient about the abnormalities that they're experiencing with their vision, with their taste, with their sense of smell, with their hearing, there's a relationship between the health and the acuity of that sense with the health of the organ that's related to that sense. In other words, the health of, for example, your vision is gonna depend on the health of your liver, which means also that the health of your eyes also depends on the health of your liver. So a healthy liver means good vision, sharp vision, healthy eyes. But if your liver is experiencing, for example, liver blood deficiency, then the eyes are gonna be affected because the eyes correspond with the liver. So you could have dry eyes. You could have poor vision. Now, if we relate this to our case presentation, our patient has a diminished sense of taste and of smell. So like all of you have been saying in the comments, taste has to do with the spleen.


Dr. Richard Lai DPT LAc:

And you are 100% correct. And that's because the earth element, it corresponds with the spleen organ. The spleen organ, it controls the mouth, and therefore has influence over the sense of taste. Now on this table, there's also another organ that has to do with taste, and that is the heart. And that's because the heart has a specific function, which is that it controls the tongue, and therefore, it controls taste there as well. And so differentiating between whether your patient is presenting with something more of a spleen root cause or a heart root cause, that's gonna depend on the other symptoms that the patient is presenting with. Now the other symptom that our patient is presenting with is a diminished sense of smell, which is the sense that corresponds with the lung organ. And so this symptom could be coming from a lung root as well, only though if we see other lung related symptoms, like, for example, a weak voice or a propensity to get sick.


Dr. Richard Lai DPT LAc:

And so now before we talked about how the heart also has to do with the taste, so let's go over some of the functions of the heart here. Now here on the screen, I'll put the function of the heart. One of them is that it opens into the tongue. Now what this means, when it opens into the tongue, it just means that the heart, it controls the tongue. And when I say control, I mean that it controls 4 things in relation to the tongue. The heart controls the color of the tongue. It controls the form of the tongue. It controls the appearance of the tongue, and it controls the sense of taste that's related to the tongue.


Dr. Richard Lai DPT LAc:

And so that means if the heart is functioning normally, then the tongue is gonna be normal in terms of its color, its form, its appearance, and, of course, the ability to taste will be normal as well. So in terms of our patient, though, our patient is presenting with both a diminished sense of taste and smell. So the question is, is it the lung or is it the spleen? Or maybe is it the lung and the spleen? Or is it the lung and the heart? That's also a possibility because the heart also controls taste. But for the other manifestations that the patient's presenting with, like, for example, the pain in the epigastric area, the nausea, the headaches, the bleeding gums, the loose stools, those don't really point to the heart or even actually to the lungs. So most likely, the loss of sense of taste and smell is probably coming from the spleen. And I'll put on the screen a table here, which shows you a connection between the lung and the spleen, because they are both in fact tie in channels. Alright. So now the patient is also presenting with other manifestations like pain in the upper stomach area, which when you and I have a clinical conversation between 2 health care practitioners, we would say that the patient is complaining of pain in their epigastric region.


Dr. Richard Lai DPT LAc:

And then we would also share details of our investigation, like we would ask our patient what kind of pain are they experiencing. And in this case, the patient is saying that they have knots in their stomach. Now, when you take the word knots in the stomach, this word knots, it could be related to a stagnation type pain. When they say knots, that's generally related to stagnation. Now, if you look at the other manifestations that this case is presenting with, like, for example, the headache, the thirstiness, the bleeding, even the red tongue, and also the fact that the patient has a wiry pulse, especially in the middle position. This is actually showing us that the patient has some heat in the middle of the patient. And a really simple way to evaluate your patient's pulse is to relate the front, middle, and rear position to the 3 burners in the body. We have an upper burner.


Dr. Richard Lai DPT LAc:

We have a middle burner. And then, of course, we have a lower burner. The soon position in our pulse is the front pulse position. If you palpate, you feel something awry in this area of the pulse, then that means there's something awry in the upper jowl area of the body. Now in this case, the patient has a wiry pulse in the middle position. Now, this has to do with the middle jowl. What is in our middle jowl? In our middle jowl is our spleen and our stomach. Our spleen and our stomach is in the middle jowl.


Dr. Richard Lai DPT LAc:

And our patient is presenting with stomach related issues, like, for example, the loose stools, the knots in the stomach. Even they have a diminished sense of taste and smell, which before, we've connected that to the spleen. And so these are all middle jowl related problems. And we can confirm all this through the tongue and the pulse. The tongue presents with a red tongue with an even redder middle. The middle of the tongue, we know that to be the spleen and stomach area. Red, of course, corresponds with heat, so that means there must be some form of heat in the middle jowl. So your pattern could be something like heat in the middle jowl.


Dr. Richard Lai DPT LAc:

The pulse also shows us that because there's a wiry pulse in the middle position and a wiry pulse we know it's indicative of a liver disharmony, of pain, even phlegm. And so because the patient is complaining of epigastric pain, that must be showing us that there's pain or wiryness in the middle position, in the middle jowl of the body. Now, in terms of the tongue again, there's also dry tongue coat. There's also yellowish on the tongue. So those are also all signs of heat. And because the tongue coat is dry, that's actually even showing us that the heat has been there for a long time. It's even causing the body fluids to be dried up. That's why there's dryness on the tongue coat.


Dr. Richard Lai DPT LAc:

So now the question is, what are we gonna do with this patient? So on the screen, I'll put what I've been doing most recently, which is just 5 points, most of them bilateral. For those stomach 34, I have not been doing bilateral, I've been just doing on his left side. So I've been doing stomach 44, which is the ying spring point. We know that ying spring points are really great for heat related patterns. So we're using this point to clear that stomach heat or clear the heat that's in the middle jaw area. This is the point that's located just on the inside of the web space between your second and your third toes. I've also been using ren 12. Ren 12, we know, is the front mu point of the stomach.


Dr. Richard Lai DPT LAc:

Mu means gathering or collecting point. So basically, at this point in the body, this is where there's gonna be a lot of chi that's gathering or collecting from the stomach. That's why it's the front mu point of the stomach. So for that reason, we can treat the stomach directly because of that. And ren twelve is very easy to find on your patient. Basically, between your umbilicus or your belly button and your sternocostal angle is 8 cun. Ren twelve is halfway between that. So 8 divided by 2 is 4.


Dr. Richard Lai DPT LAc:

So it's 4 soon superior to your umbilicus. All it is is a simple halfway point between the umbilicus and the sternocostal angle. The next point we've been using is stomach 21. Now this point doesn't really have a special category, but it is special in that it's on the same horizontal plane as Ren 12. And so it's very commonly combined with Ren 12 to strengthen the function of harmonizing the middle jowl. And with this one, it's stomach 21. And any points after stomach 18 is too soon from midline versus 4 soon, which is basically right in the middle of your abdominal muscle. And then we have li 11 and we have stomach 34.


Dr. Richard Lai DPT LAc:

Li 11 is the Hussey point of the large intestine. And li11 has a very specific function and a strong function, actually, to clear heat in the body. So for most heat patterns, you're gonna find this point in the point prescription. And this one's really easy to find as well. It's located halfway between your lateral epicondyle of your humerus and lung 5. So right in the middle between those 2. And then the last point that we've been using for this patient is stomach 34. Stomach 34 is the Chi cleft point of the stomach.


Dr. Richard Lai DPT LAc:

Chi clef points, we know, are really useful for acute type pains. And since our patient has been having stomach pain, that's why we've been using the Chi clef point of the stomach. Alright. And so that brings us to the end of this episode. If you want a PDF of the slides that you saw in this video, head on over to my website, which is www.studyaccu with me.com forward slash podcast, and you can download the PDF for free there. Alright, everyone. Until next time. God bless, and happy studying.




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