陰虛水腫病例之中醫會診辨治心得

Clinical Experience in Treating Yin Deficiency Edema or Dehydrated Edema– The Application of Radix Paeoniae Alba and Ass Hide Glue

本病例為一位水腫病患，入院時膠體滲透壓、白蛋白與血鈉皆偏低，經西醫標準處置後，水腫仍無法消除，故會診中醫治療。診察症徵如下：頭面四肢水腫甚，皮膚乾燥脫屑，尿素氮與肌酸酐（BUN/Cre.）比值大於20，舌淡紅質裂胖大，苔薄膩根偏厚邊少苔而乾，脈軟短數，勢來去不穩，雙寸不足，偶脈率不整。診斷為陰虛水腫（脫水性水腫），夾下焦濕熱兼心氣虛，以豬苓湯為主去澤瀉，加生白芍、高麗參、杏仁。病患水腫情況於服藥第二天即有明顯消退，住院期間配合每天狀況加減藥物，病情穩定而於會診後一星期出院。經由古籍啟發與現代研究輔助，在治療此陰虛水腫病例的過程中，單純採用限水及利尿劑治療，效果不佳，此時若能以中醫辨證為主加用白芍並搭配阿膠則效如桴鼓。

"Edema" and "dehydration" seems to be opposite states which cannot exist simultaneously; however, pitting edema is one of the common clinical indicators of dehydrated state, especially in old people affected by dehydration. When the intravascular colloid osmotic pressure decreased, water flow that moves from intravascular to extravascular space leads to intravascular dehydration combines with fluid retention in interstitial space at the same time. We present a case that an edema inpatient with hypotonic, hypo-albuminemia and hyponatremia when admission. After the Western medical treatment, edema is persistent; therefore, her family would like to consult the Chinese Medicine Department in out hospital for further evaluation. The patient presented with whole body edema with skin dryness and desquamation. Her urea nitrogen and creatinine (BUN/Creatinine) ratio was greater than 20. The tongue diagnosis showed pink fissured enlarged tongue and a thin-slimy root-thick dry fur. The pulse diagnosis revealed a rapid but soft pulse with unstable and small amplitude, weak pulse at bilateral cun, and occasionally irregular pattern. The diagnosis was yin deficiency edema originated from dehydration, lower burner damp-heat with heart qi deficiency. The patient was administered a modified formula of “Zhu-Ling-Tang” with Ass Hide Glue to enrich yin, to clear away heat, and to drain off dampness. We also used a large quantity of Radix Paeoniae Alba to dilate the arteriolar sphincter and let blood flow into capillary. This would help the translocation of retained water in interstitial spaces back into vessels, and finally eliminate the excessive water through urination. In addition, we added Korean ginseng to improve heart qi and contraction for the protection of heart from overload. After two days of treatment, the patient’s edema was relieved. During this hospital course, we slightly varied formula based on patient’s conditions. The patient was stabilized and discharged in seven days and regularly followed-up in outpatient department.