CHAPTER 6 Autoimmune hepatitis

Contents

1. Western medical aetiology and pathology 107

2. Diagnosis by Western medicine 108

3. Chinese medical aetiology and pathology 108

4. General treatment principle 109

Differentiation and treatment 109

1 Liver Yin deficiency 109

2 Extreme Heat due to Liver and Kidney Yin deficiency 110

3 Deficiency of both Liver Yin and Spleen Qi 110

4 Yin deficiency and Blood stasis 111

5. Appendix and complications 112

Primary biliary cirrhosis 112

Differentiation and treatment 112

1 Yang-type jaundice 112

2 Liver and Kidney Yin deficiency with Cold-Dampness 113

Case studies 113

6. Analysis of the cases 118

7. Lifestyle prescriptions and health issues 121

Autoimmune hepatitis (AIH) occurs when the liver is attacked by rogue immune cells that mistake it for foreign tissue or pathogen, causing inflammation. Its alternative name is lupoid hepatitis.

1 Western medical aetiology and pathology

The function of the immune system is to protect the body from viruses, bacteria and other living organisms. Normally, the immune system does not damage the body’s own cells. However, certain viral infections such as hepatitis B or toxins that change the antigenicity of the liver’s cytomembrane may cause the immune system mistakenly to attack liver cells. In addition, a genetic factor may predispose some people to have AIH.

T cells play a central role in the immunopathogenesis of AIH. CD4⁺ T cells are thought to be critical for this disease to develop. Increasing evidence has shown that CD8⁺ T and γδ T cells also play a significant role. HLA genotypes to AIH, as well as the clonal expansion of a limited number of T-cell receptors, suggest that the presentation of a self-antigen or a molecular mimic may be responsible for the initiation of the immune response. Given the association of AIH with viral hepatitis, it is thought that the loss of tolerance begins with an infection of hepatocytes and subsequent cytolysis by CD8⁺ T cells. The presentation of self-antigens or molecular mimics leads to activation and clonal expansion of T cells; this process may be increased by impaired regulatory T cells and a defect in apoptosis. Ultimately T cells initiate B-cell production of autoantibodies, proinflammatory cytokines, and finally hepatocyte cytotoxicity.

2 Diagnosis by Western medicine

Laboratory blood tests and liver biopsy may give a clear diagnosis.

(1) Blood tests

A routine blood test for liver enzymes can help reveal a pattern typical of hepatitis, such as alanine aminotransferase (ALT), aspartate aminotransferase (AST) and the albumin/globulin (A/G) ratio. However, further tests, especially for autoantibodies, are needed to diagnose AIH. In AIH, the immune system makes antinuclear antibodies (ANA), antibodies against smooth muscle cells (SMA), or liver and kidney microsomes (anti-LKM).

AIH is subdivided into three groups. Type 1 AIH is associated with antibodies to nuclear and/or smooth muscle autoantigens. Type 2 AIH is characterized by antibodies to liver and kidney microsomal antigen. In Type 3, a substantial number of patients with AIH produce antibodies to a cytosolic soluble liver antigen alone or in combination with ANA and/or SMA.

(2) Liver biopsy

If blood tests are inconclusive, a liver tissue biopsy is necessary.

3 Chinese medical aetiology and pathology

Chinese medicine does not specifically name AIH. However, the symptoms of AIH belong to the categories of Fa Re , fever; Huang Dan , jaundice; Xie Tong , hypochondrial pain; Zheng Jie , abdominal mass; Shui Zhong , oedema; and Bi Zheng , joint pain.

According to Chinese medicine, the material structure of the Liver belongs to Yin and its function belongs to Yang. When a patient has a Yin deficiency due to a genetic inheritance from their parents, or from an improper diet, or following an illness treated by a medication that damaged Liver Yin, or if the patient is in low spirits, Liver depression will bring Fire that further impairs Liver Yin, and causes prolonged Liver disease. Febrile diseases may also lead to the impairment of Liver Yin. Sometimes, the Liver may not be moistened by Kidney water because of a deficiency of Kidney Yin. Deficiency of Liver Yin makes it impossible not only for the Liver to be nourished but also for Yin to control Yang, so Fire flares up. At the same time, Fire can singe the Blood to cause Blood stasis, which blocks the Liver channel and impedes water flow and bile and blood transportation. The water, bile and blood exude from their regular pathways, causing oedema, ascites, jaundice and bleeding.

4 General treatment principle

The principle of treatment is to eliminate pathogenic Heat from the Blood, remove Blood stasis, and nourish Liver and Kidney Yin.

Differentiation and treatment

1 Liver Yin deficiency

Clinical manifestations

The patient may have no major clinical complaints, but be diagnosed by general physical examination and laboratory tests. The tongue may be red with a white and thin coating. The pulse will be thready and taut.

Treatment principle

Nourish Liver Yin and regulate Blood flow.

Herbal treatment

YI GUAN JIAN variation

Linking Decoction

Sheng Di Huang Rehmanniae Radix 12 g

Mai Men Dong Ophiopogonis Radix 10 g

Gou Qi Zi Lycii Fructus 12 g

Nu Zhen Zi Ligustri lucidi Fructus 12 g

Bai Shao Paeoniae Radix alba 12 g

Chuan Lian Zi Toosendan Fructus 10 g

The herbs above are decocted in water for oral administration.

Acupuncture

BL-18 Ganshu, BL-17 Geshu, SP-6 Sanyinjiao, KI-3 Taixi and LIV-2 Xingjian.

Supplementary treatment

If the patient is not using any medication, but liver enzymes are rising, add Wu Wei Zi Schisandrae Fructus and Chui Pen Cao Sedi Herba, and needle hepatitis point (extra located 0.7 cun distal to the carpal bones between the 4th and 5th metacarpal bone) and Du-20 Baihui; if the patient is thirsty and has a red tongue, add Ku Shen Sophorae flavescentis Radix and Tu Fu Ling Smilacis glabrae Rhizoma, and needle LI-11 Quchi and HE-7 Shenmen; if there is cirrhosis, add Yu Jin Curcumae Radix, Zhi Ke Aurantii Fructus, Dan Shen Salviae miltiorrhizae Radix, Tao Ren Persicae Semen and Hong Hua Carthami Flos, and needle SP-10 Xuehai, LIV-14 Qimen and LIV-13 Zhangmen.

2 Extreme heat due to liver and kidney Yin deficiency

Clinical manifestations

Low-grade fever or tidal fever in the afternoon, a feverish sensation in the palms and soles, thirst, fatigue, night sweats, irritability, insomnia or aching pain in the joints. The tongue is red, small and fissured, or mirror-like. The pulse is taut and thready or rapid.

Treatment principle

Clear pathogenic Heat and remove Toxins, cool the Blood, and nourish Liver and Kidney Yin.

Herbal treatment

LONG DAN XIE GAN TANG variation

Gentiana Longdancao Decoction to Drain the Liver

Long Dan Cao Gentianae Radix 4 g

Zhi Zi Gardeniae Fructus 10 g

Huang Qin Scutellariae Radix 12 g

Chai Hu Bupleuri Radix 6 g

Ze Xie Alismatis Rhizoma 10 g

Dang Gui Angelicae sinensis Radix 10 g

Che Qian Zi Plantaginis Semen 12 g

Gan Cao Glycyrrhizae Radix 3 g

Sheng Di Huang Rehmanniae Radix 12 g

The herbs above are decocted in water for oral administration.

Acupuncture

BL-18 Ganshu, BL-19 Danshu, LI-11 Quchi, SP-10 Xuehai, LIV-2 Xingjian, KI-3 Taixi and SP-6 Sanyinjiao.

Supplementary treatment

To treat symptoms and signs of Spleen Qi deficiency, such as fatigue, bilateral oedema in the ankles, with symptoms and signs being worse in the afternoon than in the morning, add Bai Zhu Atractylodis macrocephalae Rhizoma and Fu Ling Poria, and needle ST-36 Zusanli and KI-16 Huangshu to treat symptoms and signs of Blood stasis, such as a dark tongue, add Tao Ren Persicae Semen, Hong Hua Carthami Flos and Dan Shen Salviae miltiorrhizae Radix, and needle BL-17 Geshu, GB-21 Jianjing and BL-40 Weizhong; to treat symptoms and signs of sleeplessness due to Liver Fire, add Long Dan Cao Gentianae Radix, Huang Lian Coptidis Rhizoma and Ze Xie Alismatis Rhizoma, and needle Du-20 Baihui, Yintang (extra), HE-7 Shenmen and LIV-2 Xingjian.

3 Deficiency of both liver Yin and Spleen Qi

Clinical manifestations

Thirst, night sweats, pain or ache in the hypochondrial region, dizziness, blurred vision, lassitude, fatigue, dysphoria with feverish sensation in the chest, palms and soles, anorexia and indigestion. The tongue is red and/or fissured with teeth marks and little coating. The pulse is thready and weak, or thready and rapid.

Treatment principle

Nourish Liver Yin and supplement Spleen Qi.

Herbal treatment

SHENG MAI SAN variation

Generate the Pulse Powder

Dang Shen Codonopsis Radix 12 g

Mai Men Dong Ophiopogonis Radix 12 g

Wu Wei Zi Schisandrae Fructus 10 g

Shan Zhu Yu Corni Fructus 10 g

Sheng Di Huang Rehmanniae Radix 12 g

The herbs above are decocted in water for oral administration.

Acupuncture

BL-18 Ganshu, BL-20 Pishu, BL-23 Shenshu, ST-36 Zusanli, SP-6 Sanyinjiao, KI-3 Taixi and LIV-2 Xingjian.

Supplementary treatment

To treat symptoms and signs of Kidney Yin deficiency, add Nu Zhen Zi Ligustri lucidi Fructus and Xuan Shen Scrophulariae Radix; to treat extreme Heat, add Huang Qin Scutellariae Radix, Ku Shen Sophorae flavescentis Radix and Zhi Zi Gardeniae Fructus, and needle LIV-2 Xingjian, SP-10 Xuehai and LI-11 Quchi.

4 Yin deficiency and blood stasis

Clinical manifestations

Hepatomegaly and splenomegaly, discomfort or distress in the hypochondrium, distension of the abdomen, anorexia, thirst, sallow yellow and jaundiced complexion or spider angiomas on the skin and ‘liver palms’.¹ The tongue is deep red, or crimson and purple. The pulse is taut and thready.

Treatment principle

Nourish Yin, promote Blood circulation, remove Blood stasis and soften hepatosplenomegaly.

Herbal treatment

DA BU YIN WAN and HUA YU TANG variation

Great Tonify the Yin Pill and Removing Blood Stasis Decoction

Dang Gui Angelicae sinensis Radix 12 g

Dan Shen Salviae miltiorrhizae Radix 10 g

Tao Ren Persicae Semen 10 g

Hong Hua Carthami Flos 10 g

Bie Jia Trionycis Carapax 15 g (decoct first for 30 min)

Sheng Di Huang Rehmanniae Radix 10 g

The herbs above are decocted in water for oral administration.

Acupuncture

KI-3 Taixi, BL-23 Shenshu, BL-18 Ganshu, BL-17 Geshu, SP-10 Xuehai and KI-16 Huangshu.

Supplementary treatment

To treat additional symptoms and signs of Heat in the blood, add Shui Niu Jiao Bubali Cornu and Mu Dan Pi Moutan Cortex, and needle LI-11 Quchi and LIV-2 Xingjian; for Qi deficiency, add Bai Zhu Atractylodis macrocephalae Rhizoma and Fu Ling Poria, and needle ST-36 Zusanli and BL-20 Pishu.

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