Oksana Nachataia. Non-alcoholic fatty liver disease from the point of view of Traditional Chinese Medicine.

Dear colleagues! Again I would like to return to the discussion of liver diseases from the perspective of Chinese medicine. And for what reason. On the one hand, statistics show that the number of such patients, in particular those suffering from steatosis, is steadily growing.  It’s growing in different countries, with different levels of economic and social well-being, different habits in nutrition and lifestyle. I think that Chinese medicine contains a great resource, at least to systematize the causes of this disease – and this is a big step in the direction of choice of treatment. Many of you practice TCM in this disease and, perhaps, this topic will be interesting for discussion. At least, I increasingly meet such patients in my practice and often observe a stubborn steatohepatitis, which requires more attention. On the other hand, it seems to me that the understanding of the need to adapt the fundamental knowledge of TCM to modern conditions is simply in the air. Many experts come to the conclusion that the work at the junction of not only two medical systems, but also at the junction of several scientific disciplines, just gives that fresh view of the problem, a non-standard solution that brings the necessary result. That is, the perception of TCM as a guide to action, but not a dogmatic form, is becoming increasingly relevant. If earlier Chinese medicine was studied in the classical inviolability of its works, and the direction of the study was directed deep into the past (which is still not lost its relevance), today more and more the correspondences are opened between TCM and modern discoveries of physiology and medicine. Especially it’s actually in the light of the spread of modern “diseases of civilization”, which previously simply did not exist. At times it remains only to be surprised how accurately and precisely the statements of contemporary thinkers and scientists correlate with the ancient postulates of TCM. And liver disease is not an exception. So, for example, the Austrian physiologist Ludwig von Bertalanfy, the creator of the “General Theory of Systems,” described the fundamental distinctive character of physical (non-living) systems and living organisms. In his definition, as is known, “living systems constantly exchange matter with environment to get the necessary energy to resist entropy (to support the inner order) and save the stability in the environment.” Agree that this definition generates the association with the theory of TCM, where the main role to maintain the order in the body belongs specifically to the liver: “the liver smoothly distributes qi over the body,” which is due to, in particular, the coordinated work of the autonomic nervous system. On the other hand, according to the theory of TCM, the liver is responsible for the cyclic processes in the body, that is, the change in the phases of sleep and wakefulness, the menstrual cycle in women, the cyclic processes of digestion, bile secretion and so on. For example, in Chinese medicine, the influence of the liver on biorhythms and on the quality of sleep is enormous, as is the dependence of the health of the liver itself on the regular sleep and wakefulness regime, balanced emotional background, regular nutrition. That is, “the liver loves order.” This is not a secret for modern medicine. Not for nothing is the vector of researches is aimed at revealing of significant lifestyle factors, through which it is possible to slow down the process of development of steatosis and reverse it. In particular, it has been proven that poor sleep quality and / or its lack (sleep deprivation) causes not only cognitive impairment, but is also a predisposing factor for steatosis, diabetes, obesity and cardiovascular disorders. Information on this is widely available (for example, SRI International resource, NCBI and many others), fundamental works on this subject have been released (Phillip L.  Ackerman “Cognitive fatigue” and many others). The theory of Chinese medicine allows to connect other problems, that are specific for today, with an increasing of the number of patients with liver disease. These are such conditions as, for example, “cognitive fatigue”, “emotional burnout”, “chronic stress”, round-the-clock state “arousal” due to distraction of attention from gadgets, phone, online communication, etc. associated with increased information load in all spheres of human life. Other factors, such as frequent “jet lag”, the work online at night, when there are mental and visual load, blurring the boundaries of the working day and days off, especially among freelancers, and other moments that contribute a significant mess in the biorhythms. Not for nothing, the Nobel Prize for Medicine in 2017 was awarded to scientists from the United States for the discovery of molecular biological mechanisms that provide human biorhythms, as well as in animals, plants, that is, all living beings, showing how important this topic is for preserving health. In my opinion, it somehow, probably, echoes with Chinese medicine, where the liver is closely connected with cycles, human biorhythms, as well as with the psycho-emotional sphere. It is the receptacle of the so-called soul “hun”, one of the five components of the emotional-mental status of a person. Briefly, unlike the so-called “Shen” spirit, which is “stored in the heart” and has more to do with the higher manifestations of the human psyche, the soul “hun”, as is known, is responsible for the vital functions of person as a living being inscribed into a single living system of our planet. The relations between “Shen” and “Hun”, as is known to specialists in the field of TCM, are complex and diverse and are described in detail. Therefore, today, in the light of the modern “diseases of civilization”, we can probably speak of problems broader even than “stress”, which damage both the “liver” and the “spleen” in the understanding of TCM theory. Although the concept of “stress” here remains the key, but the amount of stress factors becomes more and more, and sometimes they are difficult to recognize. In Chinese medicine, as you know, they are described in other terms (for example, “long-time seeing”, “unproductive thoughts”, “hard mental work,” “exhaustion of the spirit”), but their essence does not change from this. I would say that these are only very brief and simplistic discussions on the causes of the development of steatosis from the position of TCM. But, from my personal experience with working with patients, I would like to note that the links of the pathogenesis of metabolic and endocrine diseases (for example, the metabolic syndrome) are frequently associated with liver function disorders in Chinese understanding or vice versa, the liver suffers indirectly due these diseases (for example, with hypothyroidism, with type 2 diabetes and so on).

I would like to share the experience of my teachers, specialists of Tianjin University in the area of ​​Shang Han Lun and in the field of liver diseases and more about the position of Chinese medicine with regard to the treatment of steatosis. The reasons can be divided into several groups, and the diagnosis requires the involvement of both the syndrome approach of “Ba Gang Bian Zheng” and the “six meridians” and, what seems to me the main thing, determining at what level the disease is “qi fen” or “xue fen “. The first group of causes can be associated with a violation of the relationship between the liver and the spleen according to the principle of direct or feedback connections of Wu Xing. Often these conditions are primarily associated with a violation of the spleen function, in particular, its transport function with subsequent stagnation of food, stagnation of qi, stagnation of bile. Either dampness and phlegm block the middle jiao, causing a second time stagnation in the liver itself. Of course, the chronic stress in combination with spleen problems can cause steatosis. All this usually takes place at the level of “qi fen”, and the TCM recipes affecting qi and soothing the liver help quite well. These are, for example, Chai Hu Shu Gan San, Liu Mo Tang, Wen dan tang, Xiang Sha Liu Jun Zi, Li Dan Pai Shi San, their modifications and other recipes of similar action. Such states at the level of “qi fen” are usually rather favorably. Symptoms depend on the prevailing syndrome. Another group of causes that cause not only fatty hepatosis, but also other metabolic and endocrine disorders, refers to cold damages, especially if the patient is living in a cold climate or moving to a colder  climate, especially to the large megacities where seasonal respiratory viral infections are common . That is, these factors are optimally considered from the point of view of the “six meridians” from “Shang Han Lun” concept. It is the opinion of many specialists, that here are quite a few correspondences worthy of a separate large research work. Separately there is a group of the reasons connected with chronic disturbance of biorhythms. But apparently it is not advisable to consider these factors as direct causes of steatosis, rather as factors that generally damage the “zheng qi” and create a predisposition of the organism to any systemic diseases. Significant deterioration in the course of the disease, the emergence of steato-hepatitis with rapid progression, as we know, can be caused by a group of pathogenic factors that are related to “heat and poison”. In this case, the barrier “xue fen” is involved in pathogenesis, new symptoms appear, biochemical indices worsen. These factors can be conditionally divided into “living infectious agents” and “hepatotoxic substances”. The first group includes a variety of hepatitis viruses, some other viruses that can cause a hypertoxic reaction with damage to liver tissue, some types of bacterial and protozoal infection, fungi, parasites. In severe cases, the presence of so-called “Gu Zheng (Gu Syndrome) is possible, that is extreme exhaustion of patient  with the emotional disorders and “incomprehensible symptoms” against the background of a combination of several different infectious agents and weakened immunity. In the academic program of TCM, this syndrome is practically not covered, but modern researchers in the field of TCM work in this direction. The second group, hepatotoxic substances, is actively being investigated, and the new groups of substances are revealed.  These substanses in combination with other causes can lead to hepatosis if they are acting for a long time. These two factors seem to me very important if, for example, a person takes any “researched” and “safe” substances, for example, industrial ingredients that are part of food or pharmaceuticals, but for a long time. And it is combined with other reasons (in my experience it often happens). For example, such a patient often travels with the change of time zones, climate and food, undergoes stress, experiences information loads and so on and so on. All this in a complex apparently causes persistent violations of liver function and progression of steatosis with a gradual transition to hepatitis and cirrhosis. The advantage of Chinese medicine is the generality of the treatment approaches, if the symptoms of the patterns “xue re” and “re du” are clear, when the “xue fen” barrier is already touched. For the treatment, recipes are usually used that not only soothe the liver and move qi, but also cool the blood and remove the poison (liang xue jie du).

As is known, in modern medicine there are no clear schemes for treating steatosis with the help of pharmacotherapy. The causes of this disease are not so precisely defined. There is a lot of disagreement, for example, in terms of standardized lifestyle recommendations, there is no single approach to the diet. It is well known that a large role in terms of a healthy lifestyle is played, for example, by local peculiarities in terms of habitual food products, comfortable climatic living environment for the patient, and its genetic features. Therefore, of course, there cannot be a single recommendation for everyone, both in the diet and in the treatment of ingredients from natural raw materials, in particular, in dosing phytopreparations – all this requires adaptation, personification and further study. As well, direct copying of dietary recommendations from one culture to another does not bring much success. Of course, naturopathic medical systems, in particular, modern herbal medicine have the means that positively influence the liver, in particular, on the safety of hepatocytes, the function of bile secretion. But the knowledge of Chinese medicine remains relevant, I think, precisely because of the systematic and logical approach from the perspective of its theory to liver disease, to understanding the causes, methods of treatment and a rich arsenal of remedies. They include herbal recipes, acupuncture and life recommendations that the patient really able to observe even in rapidly changing modern conditions.