Irritable bowel with alternating stools
F, 34 years old. A 34-year-old woman with cramping abdominal pain alternating between diarrhoea and constipation for three years, with normal gastrointestinal workup and a clear relation to periods of stress.
The patient
- Age and sex
- 34 years · F
- Chief complaint
- A 34-year-old woman with cramping abdominal pain alternating between diarrhoea and constipation for three years, with normal gastrointestinal workup and a clear relation to periods of stress.
- Tongue
- Pale body with teeth marks and slightly red edges, thin white coating.
- Pulse
- A wiry (Xian) pulse at the left Guan (關) and a weak one at the right Guan (關).
Symptoms
- Cramping pain relieved after a bowel movement
- Alternation between urgent loose stools and days of constipation
- Abdominal distension increasing through the day
- Morning urgency before leaving home and on days with meetings
- Frequent sighing and a sensation of chest oppression
- Fatigue after eating and reduced appetite in bad spells
Warning signs to rule out
- Blood in the stool, diarrhoea waking her at night, fever or weight loss. → Gastroenterology referral. None of these signs belongs to irritable bowel, however well the rest fits.
- Symptom onset after fifty, or a family history of colon cancer or inflammatory bowel disease. → Screening before assuming a functional picture.
- Anaemia, iron deficiency or raised inflammatory markers. → Medical workup: irritable bowel does not alter blood tests.
Case resolution
Think through the pattern first, then expand the resolution
- Pattern
- Liver-Spleen Disharmony: the Liver overacting on the Spleen (Gan Pi Bu He)
- Meridians involved
- Liver, Spleen, Large Intestine
- Pathogenic factors
- Liver Qi stagnation, Spleen Qi vacuity
The pulse sums up the whole case: wiry (Xian) on the left and weak on the right, Liver excess over Spleen vacuity. Liver Qi, constrained by stress, overflows onto the Center and disorganizes transit, which some days speeds up and others stops. That is why the pain eases after a bowel movement, why symptoms follow the calendar rather than the diet, and why treating the bowel alone fails: the Liver must be released and the Spleen supported at the same time.
Differential diagnosis
Shares: Recurrent diarrhoea, fatigue and distension.
Sets it apart: In Yang vacuity the diarrhoea is at dawn, painless or with dull pain relieved by warmth and pressure, with a cold lower back and a deep pulse. Here the pain is cramping, eases after defecation and follows stress, not the clock.
Shares: Bowel urgency and abdominal pain.
Sets it apart: Damp-Heat gives foul, sticky stools, anal burning, thirst and a yellow greasy coating. Here there are no heat signs and stools alternate rather than being consistently pasty.
Shares: Recurrent abdominal pain and altered bowel habit.
Sets it apart: Inflammatory disease presents with blood in the stool, nocturnal diarrhoea that wakes the patient, fever, weight loss and abnormal blood tests. Irritable bowel does not wake people at night: that fact alone mandates referral.
Treatment
Principle: Soothe the Liver and move its Qi, strengthen the Spleen and regulate intestinal transit.
| Point | Role | Technique |
|---|---|---|
| LV3 | Releases the Liver overflowing onto the Center: the point that treats the cause. | Perpendicular 0.5-0.8 cun, gentle reducing. |
| SP3 | Spleen Yuan-source: it supports the weak side of the imbalance. | Perpendicular 0.5 cun, tonifying. |
| ST25 | Large Intestine Mu: it regulates transit whether it is racing or stalled. | Perpendicular 1-1.5 cun. Contraindicated in pregnancy. |
| ST36 | Reinforces the Center and supports the energy that collapses after meals. | Perpendicular 1-1.5 cun, tonifying. |
| CV6 | Sea of Qi: it eases the distension that builds through the day. | Perpendicular 0.8-1.2 cun. |
| PC6 | Opens the chest and releases the oppression that accompanies the sighing. | Perpendicular 0.5-1 cun. |
Formula: Tong Xie Yao Fang. The specific formula for diarrhoea from the Liver overacting on the Spleen: it eases the pain and stops the urgency. When the emotional component outweighs the intestinal one, Xiao Yao San covers the whole better.
- Frequency
- One session weekly for eight weeks. Improvement is not linear in this pattern: there are bad weeks coinciding with work peaks, and it is worth announcing that before it happens.
Home care
- Eat at fixed times and sitting down, even if little: the Spleen values rhythm more than quantity.
- Five minutes of diaphragmatic breathing before each of the three meals.
- Walk twenty minutes a day; Liver Qi moves with the body.
- Avoid long self-imposed exclusion diets, which in this pattern weaken the Center further.
Progress
- Session 1 · day 0 Four or five pain episodes a week, near-daily morning urgency and constant distension from mid-afternoon. LV3, SP3, ST25 and ST36. Eating seated and at fixed times is prescribed, along with breathing before meals. Morning urgency drops to two days a week; the distension is unchanged.
- Session 3 · week 3 A bad week coinciding with a work deadline: daily cramping pain returns. PC6 is added and Tong Xie Yao Fang is started. The flare is normalized: in this pattern the curve rises and falls with the calendar. The episode lasts four days instead of two weeks, the first real sign of change.
- Session 6 · week 6 One pain episode a week and formed stools five days out of seven. Postprandial fatigue and distension persist. Draining of the Liver is reduced and the Spleen is reinforced with moxa on ST36 and CV6: as the excess subsides the vacuity becomes visible. Post-meal fatigue eases within two weeks and distension appears only in the evening.
- Session 8 · week 8 Three weeks without pain and regular transit, including one high-workload week. Treatment ends, with on-demand sessions during high-pressure periods and continued breathing before meals. She returns only once in six months, for a mild flare resolved in two sessions.
- Discharge
- Treatment ends when she gets through a stress peak without the bowel destabilizing. That is the result that matters, not a good run in a quiet week.
- Watch for relapses
- Job changes, house moves and exam periods. The first warning is morning urgency, before the pain returns.
Health notice. Educational and study content. It describes concepts of Traditional Chinese Medicine and does not replace diagnosis or treatment by a healthcare professional. Needling, medicinal herbs and invasive techniques must be applied by trained professionals. Safety guide.
