rmayroz: November 28, 2019, 1:38am
I apologize for this very lengthy case. It is quite complex. I left out what I could. I would really appreciate some
guidance. Thank you in advance!
43 yr old, slim, tall, attractive woman presenting with chronic diarrhoea up to 30 times/day, for over a year. Cause
unknown.
She has lost about 20 kg in weight (45 pounds), with a lot of medical intervention and effort she managed to gain
5-6 kg back (13 pounds).
She was tested for coeliac, parasites, allergies, all negative. Currently scheduled for capsule endoscopy to
investigate structural changes in GIT.
Diarrhoea started 1 year ago suddenly. At first she thought it was gastro-enteritis, but it never stopped. She has not
had any normal stools during this last year.
First BM of day is explosive and gassy with completely undigested food. By end of day only mucus is passed.
Occasionally when she urinates, stools will come out as well without warning. Mostly, there is cramping pain
before a BM.
She wakes up from pain most nights and needs to have a BM (up to 5/night).
Stools are smelly septic .
St is always noisy.
She has a tumor and haematoma at L4/5 vertebrae. Pain is constant and radiates laterally into hips and pelvis. BM
trigger the nerves and exacerbates the pelvic pain.
Appetite is good and she has a healthy vegetarian diet. The more she eats though, the more BM she gets.
Medical history:
Age 17 Traveled in Turkey and had bad case of parasites and things went downhill since.
Age 19 rare cancerous tumor in tail of pancreas that grew fast to 30 cm (12 inch), ruptured, she vomited blood and
tumor was removed, haemorrhaged badly afterwards from severed artery during surgery.
Had multiple malignant tumors removed from other sites:
tonsils
inside L cheek
Fallopian tubes, cancer spread to part of colon.
L ovary, ovary removed
Tumor on R big toe
Tumor L4/5 as mentioned above
3 skin melanomas removed
meningioma in brain (may be benign?)
Other surgeries/conditions:
GB removed (had 100 s of small stones)
Splenectomy
Tonsillectomy
hysterectomy
multiple sinus polyps -> drainage
LR: L lobe atrophied, R lobe has blocked portal vein24/01/2024, 12:06Chronic diarrhoea up to 30 times/day and complex presentation – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/chronic-diarrhoea-up-to-30-times-day-and-complex-presentation/759/print2/6
Long QT syndrome: HR would go from 240 bpm to 40 in one beat, has pace maker now.
Neuropathic pain entire body, constant
Suffers from Bld disorders:
uterine haematoma (hence hysterectomy),
multiple Bld clots and 7 DVT s, had surgery
Vasculitis in all veins
Before hysterectomy she had heavy and very clotted menstrual bleeding for 8-10/days every 2 weeks.
4 pregnancies, had gestational diabetes with all. One baby died from long QT syndrome very shortly after birth.
Haemorrhaged with all births.
eyes dry, red, irritated all the time
never thirsty
Always cold
Moods: suppresses a lot, irritable when triggered. Diagnosed with complex PTSD and seeing psych regularly.
Teeth & gums good!!!
Medication: antidepressant, Valium, beta blocker, Tamazepam, Lyrica
T: puffy & swollen, red sides, teeth mx and thich white C
P: thin
Abd: thin dry, slightly discolored skin (mild bld stasis from def appearance), tender everywhere
SA AM thoughts:
Bright eyes +7, SJ xs
Thin dry skin, hair, nails, sinuses, eyes +9: LU/ Li xs. I suspect it is more LI although there is mucus and constant
diarrhoea (and thick white T/C). There do not appear to be great resources bodily or financially available.
Tumors, cysts and Bld clots +10, KI xs
Constant pain: Ki xs
Symmetry +8, fleshy heels : Ki xs
Always cold: UB xs,
Diarrhoea: not sure if ST xs (goes through all the time ) or LI xs because too dry internal environment to hold onto
nutrition
Forceful, assertive speech, irritability: GB xs (but then it could be an appropriate reaction ).
I saw her just once so far and will be seeing her next week again. According to her most health professionals she is
seeing (multiple) are too overwhelmed with big picture and try to deal with current state of malnutrition.
Thank you all in advance for reading and considering this case.
KristinWisgirda #2November 29, 2019, 6:07pm24/01/2024, 12:06Chronic diarrhoea up to 30 times/day and complex presentation – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/chronic-diarrhoea-up-to-30-times-day-and-complex-presentation/759/print3/6
Thanks for sharing the case. This poor lady!
What did you do at the first visit and how did it go?
A couple of tools presented here might help everyone get a clearer picture: Case Study Format
First: formatting your Saam analysis by listing all the channels and then assigning all of the symptoms to the
channels.
For instance:
K excess: multiple tumors/cysts/blood clots +10, constant pain (looks like 10+), symmetry +8, fleshy heels
Formatting it this way, you will see signs and symptoms stack up under some channels and not others.
Second: Stating the biggest/grossest aspects of the presentation. Sounds like pain, tendency to tumors, along with
bms septic/mucus/frequency can be included on the list.
Though the case is complicated, your write up makes me lean heavily toward SI+, especially with all of the pain
before bms, surgeries/tumors. The septic stools with mucus call out for LI+. Even though she is so thin and dry,
LI+ is warranted for this kind of toxic dampness. Septic and mucus both sound like a +10 symptom.
Be absolutely sure you only use 1 channel at a time, so that you can really gauge the results. She will benefit from
clarity more than anything else.
Given her complicated presentation, having taking into account all of the symptoms will help as her case unfolds.
Include channel location and counterbalancers for her hip/pelvic pain and melanoma locations.
Show us your analysis and please let us know how it goes.
rmayroz: November 29, 2019, 8:24pm
Thanks Kristin for your reply.
For her the biggest issue was the constant diarrhoea at this point. I was reluctant to use SI, because I didn t want to
do more clearing and more moving, although from her presentation SI is begging to be tonified.
The first treatment, due to fear of making things worse and due to needing to clarify what was going on (it took me
1,5 hrs to write down the case in a somewhat comprehensible form from all the notes I ve taken,) I did a non Sa am
tx.
I think the mucus is mainly at the end of the day, that was my impression, the rest of the time it was all very loose,
I will seek clarification on this matter from her.
In case there was a lot of mucus throughout, and given she s dry, why would I choose LI over ST?
Thank you again!
michaelmax: December 1, 2019, 12:59am
rmayroz:24/01/2024, 12:06Chronic diarrhoea up to 30 times/day and complex presentation – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/chronic-diarrhoea-up-to-30-times-day-and-complex-presentation/759/print4/6
In case there was a lot of mucus throughout, and given she s dry, why would I choose LI over ST?
HI @rmayroz, thanks for this interesting and challenging case.
Agreed, plenty of reasons to deal with that Kidney excess, but tonifying the SI. But getting the poop under control
first is a good idea.
I would shy away from the tonifying the ST, both because it brings more fluid to the interior (remember ST
presentation is wet inside and dry outside) and because it strongly moves qi downwards. Your patient already has
issues with things moving through the digestive tract too quickly.
Tonifying the LI would help to dry the interior. I suspect that is a good place to start.
If you can get the digestion to settle down, then she ll likely stick with you for working on the KD excess issues
that you ve presented.
Keep us posted on how it goes!
rmayroz: December 1, 2019, 7:56am
Thank you Michael. Yes, of course! I ll tonify Li first and then wait and see.
Will keep you all posted.
KristinWisgirda: December 1, 2019, 4:48pm
michaelmax:
I would shy away from the tonifying the ST, both because it brings more fluid to the interior (remember ST
presentation is wet inside and dry outside)
Writing about Saam it is so easy to transpose counterbalancing pairs! Supplementing Stomach dries the interior
and moistens the exterior. Stomach excess presents as wet outside and dry inside. I reread that statement 3 or more
times to make sure it is correct. Yes! By contrast, Lung excess is dry outside, damp inside. Supplementing Lung
would moisten the interior and dry the exterior. Amen.
I agree with Michael that St+ would be too downbearing for this patient.
rmayroz:
In case there was a lot of mucus throughout, and given she s dry, why would I choose LI over ST?
The septic smell says toxic. LI+ is doubly dry but it is also used for toxic situations. Even if there isn t lots of
mucus, the toxicity and looseness are enough to warrant LI+, despite her morphology. I have seen Toby LI+ a super
skinny, super dry woman because she had abscessed teeth and a necrotic jaw after radiation. Losing her teeth was24/01/2024, 12:06Chronic diarrhoea up to 30 times/day and complex presentation – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/chronic-diarrhoea-up-to-30-times-day-and-complex-presentation/759/print5/6
an emergency. Of course, when treatment seems counter to the morphology you have to watch your patient extra
closely and make sure she is able to contact you in the following days.
rmayroz:
The first treatment, due to fear of making things worse and due to needing to clarify what was going on (it took
me 1,5 hrs to write down the case in a somewhat comprehensible form from all the notes I ve taken,) I did a
non Sa am tx.
This was wise as you are learning the system.
The cramping before bm sounds significant. And the history of abdominal/pelvic surgeries and internal
hemorrhaging!!! and the general Kidney excess give weight to SI+. The stasis is so, so significant here. The
moving aspect of SI+ could help regulate her bowels by improving micro and macro circulation in the walls of the
bowels. SI+ also supports LI+ in moving out damp.
rmayroz: December 1, 2019, 10:58pm
Thank you Kristen.
So I guess I”ll start with LI+ and then see what happens before moving on to SI+.
I so appreciate the input!
George_Mandler: December 3, 2019, 1:45pm
KristinWisgirda:
I have seen Toby LI+ a super skinny, super dry woman because she had abscessed teeth and a necrotic jaw after
radiation.
I think I recall Toby stating that for lower jaw issues think LI+. That may be another reason he chose LI+ in his
patient?? I have treated this a couple of times after a patient s dental work and have gotten measurable benefit.
I would like some clarity on this – is it LI for lower teeth/gums and ST for upper?
KristinWisgirda: December 3, 2019, 3:48pm
George_Mandler:
is it LI for lower teeth/gums and ST for upper?24/01/2024, 12:06Chronic diarrhoea up to 30 times/day and complex presentation – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/chronic-diarrhoea-up-to-30-times-day-and-complex-presentation/759/print6/6
Yes. That is classic channel trajectory.
George_Mandler:
That may be another reason he chose LI+ in his patient??
Location being the lower jaw was icing on the cake. Sometimes channel AND quality. But the quality of extreme
damp= toxic abscess + rotting jaw was the primary consideration. I suspect he would have used LI+ for the same
issue in the upper jaw for this case.
George_Mandler: December 3, 2019, 4:31pm
Thanks Kristin – do you know if this is a rock or a gem? Is Toby going by classic trajectory or did his teacher
Sunim use this line of thinking as well?
KristinWisgirda: December 3, 2019, 5:53pm
My notes don t have this as a specific reference from Toby s teacher. The NJ states that the Stomach enters the
upper and LI enters the lower. If it is in the NJ, then is it not a gem?
rmayroz: December 19, 2019, 2:04am
Just a short update for those of you who are wondering
I ve seen this patient only once since writing the case study. In the meanwhile she had to cancel an appointment
due to her entire family being sick. She was diagnosed with another rare cancer of the pancreas and very low Blood
Sugar levels
We did LI+, she felt better and her abdomen felt less irritated.
I was supposed to see her tomorrow, but she cancelled as she had a melanoma cut out and didn t feel like having
another intervention so soon.
I hope I”ll have a chance to see her in 2020, and can give you more encouraging updates.