2 English references liver tuberculosis
tuberculosis?of the?liver
Hepatic tuberculosis is relatively rare. Due to the lack of specific symptoms and signs, the rate of clinical misdiagnosis and mistreatment is high. Due to the improvement of diagnostic level, reports have increased in recent years. It is reported that 79% ~ 99% of chronic pulmonary tuberculosis and death cases have liver tuberculosis, and 76% ~ 100% of patients with miliary pulmonary tuberculosis were found to be complicated with liver tuberculosis at autopsy. The incidence of liver tuberculosis is mostly in young adults, and the ratio of male to female is about 1: 1.2.
The infection route of liver tuberculosis is mostly blood-borne (via hepatic artery or hepatic vein), and a few can spread directly through lymphatic system or adjacent lesions. The so-called "primary liver tuberculosis" may be that after a small amount of mycobacterium tuberculosis enters the liver, the primary tuberculosis focus outside the liver has been absorbed or fibrosed, and liver tuberculosis occurs when the body's resistance decreases.
Pathology of liver tuberculosis is divided into: ① miliary (small nodule) type: the most common type. Most of them form 0.6 ~ 3.0 mm in hepatic lobule and portal area. Miliary tuberculosis nodule; ② Tuberculoma (large nodule) type: this type is rare, and small miliary nodules fuse to form isolated or proliferative tuberculosis nodules, which can then form abscesses; ③ Intrahepatic bile duct type or tuberculous cholangitis: rare, which may be caused by cheese-like substance breaking human intrahepatic bile duct from portal vein system.
Most liver tuberculosis is slow to develop. Besides fever, the most common clinical manifestations are hepatomegaly, blunt edge and tenderness. Nearly half of them have splenomegaly, and jaundice is rare. A few patients may be accompanied by ascites. Complications: lung abscess, hepatic encephalopathy, gastrointestinal bleeding, etc.
Most liver tuberculosis is a part of systemic miliary tuberculosis, which is called secondary liver tuberculosis. The main manifestations of patients are clinical manifestations caused by extrahepatic pulmonary tuberculosis and intestinal tuberculosis, and generally there are no clinical symptoms of liver disease. After anti-tuberculosis treatment, intrahepatic tuberculosis can be cured, so it is difficult to make a diagnosis of hepatic tuberculosis in clinic. Primary hepatic tuberculosis refers to the reason why tuberculosis involves the liver and becomes all its clinical manifestations, or when hepatic tuberculosis occurs, the tuberculosis focus in other parts has healed by itself or is very hidden and has not been found, and the liver is the only organ where tuberculosis is found. At this time, the patient has systemic manifestations of tuberculosis and/or local manifestations of liver disease, such as fever, chills, night sweats, fatigue, emaciation, nausea, vomiting, abdominal distension, diarrhea, pain and tenderness in the liver area, hepatomegaly, jaundice, etc.
Generally speaking, liver tuberculosis is mainly treated by internal medicine, but liver tuberculoma should be treated by surgery. Prevention and treatment of primary extrahepatic tuberculosis is the key to prevent hepatic tuberculosis.
4 disease name liver tuberculosis
5 English name pulmonary tuberculosis
6 alias liver tuberculosis; Tuberculous lesions of liver
7 classification 1. Hepatobiliary surgery: infectious diseases in hepatobiliary surgery
2. Infectious Diseases Department >; Bacterial infection > Mycobacterium infection >: tuberculosis
3. Gastroenterology >; Hepatobiliary diseases > inflammatory diseases and cirrhosis.
8 ICD number A 18.8
Epidemiology In recent years, due to the development of anti-tuberculosis drugs, tuberculosis has been gradually controlled, and the incidence of liver tuberculosis has been very low, which is extremely rare in clinic. Most patients are young people. According to the statistics of 98 cases of liver tuberculosis in China, 66.3% are under 37 years old, and the ratio of male to female is 1: 1.2. A group of autopsy reports abroad reported that chronic tuberculosis and disseminated miliary tuberculosis complicated with liver tuberculosis were 50% ~ 80% and 100% respectively.
1. source of infection
In patients with open pulmonary tuberculosis, especially cavitary pulmonary tuberculosis, bacteria in sputum are an important source of infection of pulmonary tuberculosis.
2. Transmission routing
Mainly respiratory tract. After the sputum is dried, tuberculosis can float in the air with dust. Patients who cough or sneeze with bacterial droplets pollute the environment and can cause infection. The transmission of tuberculosis through gastrointestinal tract is rare, which is usually caused by eating with patients or drinking unsterilized milk with bacteria. Tuberculosis can not pass through healthy skin, but can invade the human body through skin mucosal wounds.
3. Population susceptibility
People are generally susceptible and tend to increase with age. BCG vaccination has relative immune effect.
4. Popular characteristics
/kloc-in the 0/9th century, tuberculosis spread all over the world, known as the "white plague". Since 1945, a variety of anti-tuberculosis drugs have come out one after another, which has gradually reduced the global tuberculosis epidemic and made human beings feel hope for controlling tuberculosis. However, from the late 1980s to the early 1990s, global tuberculosis increased rapidly. According to the statistics of the World Health Organization, there are currently 65.438+0.7 billion people infected with tuberculosis worldwide, accounting for 65.438+0/3 of the world population. There are 20 million tuberculosis patients, about 9 million new cases and 3 million people die of tuberculosis every year, which has exceeded the sum of AIDS, malaria, diarrhea and tropical diseases. Faced with such a grim situation, the 46th World Health Assembly issued the Global Tuberculosis Emergency Declaration on 1993, calling for quick action to fight the tuberculosis crisis. At present, the epidemic situation of tuberculosis in China is also quite severe. According to 1990 national sampling survey, the prevalence rate of tuberculosis is 523/65438+ million, and it is estimated that there are about1500,000 infectious tuberculosis patients in China. Nearly 230,000 people die of tuberculosis every year. The number of people infected with tuberculosis in China is about 330 million. Among tuberculosis patients, 34.7% are drug-resistant patients, which brings difficulties to treatment. Moreover, the spread of AIDS in China and the massive population movement have brought new problems to tuberculosis control.
10 etiology liver tuberculosis is caused by the spread of various extrahepatic tuberculosis bacteria to the liver. Sometimes because the primary focus outside the liver is small or has healed, the primary focus cannot be found. According to statistics, only 35% patients can find the primary lesion.
Mycobacterium tuberculosis belongs to the genus Mycobacterium of Actinomyces and Mycobacteriaceae, and it is a virulent acid-resistant bacterium. Mainly divided into human, cattle, birds, rats and other types. Human-type bacteria are the main pathogens, and bovine-type bacteria are rarely infected. Mycobacterium tuberculosis is slender and curved, with round ends, no spores or capsules, no flagella, about 1 ~ 5 microns long and 0.2 ~ 0.5 microns wide. In the specimen, it is scattered or piled up or arranged in a chain. Mycobacterium tuberculosis is an aerobic bacterium, which can survive for a long time without reproduction under hypoxia. Under good conditions, it takes about 18 ~ 24 hours for the first generation to propagate, and the lipid component of the bacteria accounts for about 1/4 of its weight, showing acid resistance when dyeing. Mycobacterium tuberculosis has strong resistance to dryness, strong acid and strong alkali, and can exist in the external environment for a long time. It can survive for 20 ~ 30 hours in sputum and 6 ~ 8 months in wet place. However, the resistance to damp heat is very low, and it can kill you if you boil it for 5 minutes or directly expose it to the sun for 2 hours. Ultraviolet disinfection effect is better. Both human-type and bovine-type tuberculosis strains are obligate parasites, with human and bovine as natural storage hosts respectively. These two viruses are equally toxic to humans, monkeys and guinea pigs. Drug resistance of tuberculosis can be formed by the development of congenital drug-resistant bacteria in the flora, or by using an anti-tuberculosis drug alone in the human body. Drug-resistant bacteria will cause difficulties in treatment and affect the curative effect. Long-term exposure of mycobacterium tuberculosis to streptomycin can also lead to dependence, which is called drug dependence, but drug-dependent bacteria are rare in clinic.
Pathogenesis 1 1 The liver is rich in blood supply and lymph, which is the most vulnerable part of systemic disseminated pulmonary tuberculosis. Generally, mycobacterium tuberculosis that enters the human body can reach the liver. However, the liver has a strong ability of regeneration and repair and a rich mononuclear phagocyte system. Bile also inhibits the growth of tuberculosis, so not all tuberculosis invading the liver can form lesions. Only when the immune function of the body is low or a large number of tuberculosis bacteria invade the liver or there are some pathological changes in the liver itself, such as fatty liver, liver fibrosis, cirrhosis or drug damage, liver tuberculosis is more likely to occur.
In recent years, it has been found that the incidence of liver tuberculosis in patients infected with human immunodeficiency virus (HIV) has increased significantly, suggesting that cellular immunity plays an important role in the occurrence and development of liver tuberculosis.
1 1. 1 Invasive routes of Mycobacterium tuberculosis The ways in which Mycobacterium tuberculosis invades the liver are:
① Hepatic artery: It is the main way to cause hepatic tuberculosis. Systemic disseminated tuberculosis, or active tuberculosis lesions in any part of the body, due to decreased immunity or some local factors, tuberculosis lesions rupture, and mycobacterium tuberculosis enters the blood circulation and enters the liver through the hepatic artery.
② Portal vein: A few hepatic tuberculosis can be infected through portal vein. Tuberculosis originating from organs or tissues of portal vein system, such as intestinal tuberculosis or mesenteric lymph node tuberculosis, invades the liver through portal vein.
(3) Umbilical vein: Mycobacterium tuberculosis in the focus of fetal placental tuberculosis enters the fetus through umbilical vein, causing congenital liver tuberculosis.
④ Lymphatic system: Lymphatic vessels in the liver communicate directly with the celiac lymph plexus and retroperitoneal lymph nodes, so tuberculosis in the abdominal cavity can enter the liver through lymph to form infection focus.
⑤ Direct dissemination: Tuberculosis in organs and tissues adjacent to the liver can directly invade the liver.
1 1.2 The basic pathological change of pathological type of liver tuberculosis is granuloma. Invasive tuberculosis can develop into different pathological types due to the differences in quantity, location and immune function. Generally can be divided into:
1 millet type: the most common. It is a part of systemic disseminated miliary tuberculosis. The lesion is millet with a size of 2cm, hard, white or gray-white multiple nodules, which are widely distributed throughout the liver. This type of illness is serious, and clinical diagnosis is difficult, and it is often found during autopsy or laparotomy.
② Nodular type: rare. The focus is relatively limited, forming hard, gray-white single or multiple nodules over 2 ~ 3 cm, or even merging into a mass, which looks like a tumor, also known as tuberculoma.
③ Abscess type: white or yellow-white caseous pus is formed by necrosis of the center of tuberculosis focus, which can be single or multiple. Abscess cavities are mostly single-chambered, and multi-chambered is rare.
④ Biliary duct type: Hepatic tuberculosis involves bile duct or abscess breaks into bile duct to form bile duct tuberculosis, which is characterized by thickening, ulcer or stenosis of bile duct wall. This type is rare.
⑤ Hepatic serosa type: The so-called "sugar-coated liver" is formed by miliary tuberculosis focus or capsule hyperplasia and hypertrophy. This is rare.
12 clinical manifestations of liver tuberculosis Most liver tuberculosis have a slow onset. Besides fever, the most common clinical manifestations are hepatomegaly, blunt edge and tenderness. Nearly half of them have splenomegaly, and jaundice is rare. A few patients with liver tuberculosis may be accompanied by ascites.
The main symptoms of liver tuberculosis are fever, loss of appetite, fatigue, pain in the liver area or right upper abdomen and hepatomegaly. Fever is mostly in the afternoon, sometimes accompanied by chills and night sweats; Patients with low fever also have relaxation type, with high fever reaching 39 ~ 4 1℃, and those with fever symptoms account for 9 1.3%. People who suffer from tuberculosis or have a clear history of tuberculosis and have repeated fever for a long time often have the possibility of liver tuberculosis if other reasons are excluded.
Hepatomegaly is the main sign of liver tuberculosis, and more than half of them have tenderness, liver hardness and nodular masses. About 15% patients may have mild jaundice due to the compression of the hepatobiliary duct by nodules, and 10% patients may have ascites.
Complications of hepatic tuberculosis 1. prejudice
Generally, it is mild or moderate, mostly persistent, and a few may fluctuate. Most of them are related to acute fulminant type. The reason is:
(1) Tuberculosis lymph nodes compress extrahepatic bile duct.
(2) Tuberculous granuloma of liver destroys liver parenchyma or breaks into bile duct.
(3) Intrahepatic bile duct obstruction.
④ Toxic hepatocyte injury, fatty liver, etc. Specific to a patient may be caused by several factors.
Chronic disseminated tuberculosis and terminal tuberculosis are accompanied by liver tuberculosis, and 80% of them have jaundice, indicating that jaundice indicates serious illness.
2. Hepatomegaly
The vast majority of patients with liver tuberculosis have hepatomegaly (76% ~ 95%), especially 2 ~ 6 cm below the ribs (42%). The surface of the liver is mostly medium hardness, generally smooth, and a few have obvious nodules. There may be tenderness in the liver, and sometimes tuberculosis involves the capsule of the liver, resulting in a fricative sound. If the liver has tuberculosis abscess, liver pain and tenderness are more obvious; When an abscess ruptures, severe abdominal pain, shock and peritonitis usually occur. The causes of hepatomegaly include tuberculous liver abscess, tuberculoma, tuberculous granuloma, nonspecific reactive hepatitis, fatty liver and amyloidosis.
3. Spleen enlargement
About half of the cases of liver tuberculosis have obvious swelling, mostly 0.5 ~ 9 cm under the ribs or on the umbilicus. Spleen enlargement associated with hepatic tuberculosis usually suggests splenic tuberculosis. It is mainly due to the infiltration of tuberculosis granuloma and the proliferation of reticular cells in spleen marrow. Spleen enlargement is often accompanied by hypersplenism, and the three tangible components of blood are reduced to varying degrees.
4. Ascites and abdominal masses
Mainly tuberculous peritonitis and lymph node tuberculosis.
In addition, liver tuberculosis can also be complicated with lung abscess, hepatic encephalopathy and gastrointestinal bleeding.
14 Laboratory examination 14. 1 The total number of white blood cells in hemogram is normal or low, and splenomegaly can be manifested as a decrease in whole blood. A small number of patients with liver tuberculosis can be aggravated and even have leukemia-like reactions. More than 80% of patients have anemia, and the erythrocyte sedimentation rate is often accelerated.
14.2 liver function test about half of the cases of liver tuberculosis have liver function damage, ALT, ALP and bilirubin are increased, albumin can be decreased, and globulin can be increased. In patients with jaundice, A/G ratio reversed and alkaline phosphatase increased.
14.3 serum anti-PPD)IgG antibody positive results can assist in the diagnosis of liver tuberculosis.
14.4 skin test including OT (old tuberculin) or PPD (purified protein derivative) skin test, continuous observation 12h, positive cases can be used as a reference for diagnosis of liver tuberculosis.
14.5 liver biopsy is of great value in the diagnosis of diffuse or miliary lesions.
14.6 bacteriological examination showed that the acid-fast staining of liver tissue sections obtained by puncture or operation was used to find mycobacterium tuberculosis, and the bacterial positive rate of miliary lesions could reach 60%.
14.7 polymerase chain reaction (PCR) for amplification of mycobacterium tuberculosis DNA in vitro: PCR technology has been used for diagnosis of tuberculosis. It is not only used to detect Mycobacterium tuberculosis DNA in body fluids and excreta, but also used to detect Mycobacterium tuberculosis DNA in biopsy pathological specimens. This technique is still under development and is expected to improve the diagnostic level of liver tuberculosis.
15 auxiliary examination 15. 1 X-ray abdominal plain film may find intrahepatic calcification. It is reported that 48.7% of patients with liver tuberculosis have intrahepatic calcification. In some cases of liver tuberculosis, the right diaphragm is elevated and the movement is weakened.
15.2 b-ultrasound can find hepatomegaly and large lesions in the liver, and can also be guided by it for lesion puncture examination.
15.3 CT scan can find intrahepatic lesions.
15.4 Abdominal examination can find yellow-white punctate or flaky lesions on the liver surface, and puncture the lesions under direct vision for further pathological and bacteriological examination.
15.5 Explore some difficult cases of liver tuberculosis by laparotomy, and make a definite diagnosis by surgery if necessary.
The clinical manifestations of 16 in the diagnosis of hepatic tuberculosis are lack of specificity, and the diagnosis is difficult. The cause of fever in young adults is unknown, accompanied by swelling and pain in the liver area or upper abdomen, liver function damage and anemia, so this disease should be suspected. White blood cells can be reduced or normal, and erythrocyte sedimentation rate will increase faster. Toxin tests can be positive, but severe cases can be negative. Nearly half of the patients can be diagnosed by liver biopsy. If necessary, exploratory laparotomy or early application of anti-tuberculosis drugs can be used for experimental treatment.
17 differential diagnosis of liver tuberculosis should be differentiated from hepatitis, typhoid fever, malaria, brucellosis, chronic schistosomiasis and leptospirosis.
① Localized hepatic tuberculoma is sometimes difficult to distinguish from liver cancer, while miliary hepatic tuberculosis is sometimes easily confused with diffuse liver cancer. However, the latter is serious, the course of disease develops rapidly and AFP is positive. Combined with the history of chronic liver disease, it can generally be distinguished.
② Liver tuberculosis should be differentiated from amoeba or bacterial liver abscess after abscess formation. Bacterial liver abscess is mostly secondary to biliary tract infection, with severe symptoms of systemic poisoning, chills and high fever, while amebic liver abscess has a history of purulent bloody stool. Abscess is generally large, pus is chocolate-colored, and it is generally not difficult to identify.
③ Cases with jaundice should not be misdiagnosed as viral hepatitis, cirrhosis, leptospirosis and septicemia. Especially when the patient has a history of tuberculosis or his condition worsens after ineffective treatment, he should be alert to the possibility of liver tuberculosis and do relevant examinations.
④ Hepatosplenomegaly, high fever, jaundice, anemia and cachexia should be differentiated from lymphoma, acute leukemia and malignant reticulocytosis, and bone marrow image and lymph node biopsy can be checked.
18 treatment of liver tuberculosis In general, medical treatment is the main treatment for liver tuberculosis, but surgical treatment should be adopted for liver tuberculoma.
18. 1 general treatment: rest properly and strengthen nutrition; Support treatment should be strengthened for the weak and sick.
18.2 the internal medicine medication scheme of liver tuberculosis can refer to tuberculosis, and the course of treatment is appropriately extended. When patients with liver tuberculosis have abnormal liver function such as elevated ALT, it is not only a contraindication for anti-tuberculosis treatment, but also an indication. ALT may fluctuate slightly during the treatment, but it will soon return to normal.
Early use of anti-tuberculosis drugs, commonly used are isoniazid, streptomycin, p-aminosalicylic acid (PAS), rifampicin and ethambutol. The course of treatment of isoniazid is generally 2 years, and streptomycin is 3 ~ 6 months. According to the patient's reaction, PAS can be used for more than half a year. At the same time, nutrition and systemic support treatment should be strengthened.
Anti-tuberculosis chemotherapy should follow the principle of early, combined, appropriate, regular and full-course medication. Methods With disseminated tuberculosis in blood, short-term chemotherapy under the supervision of WHO was adopted. The specific scheme can be 2SRHZ/4R3H3, 2ERHZ/4R2H2, etc. The course of treatment is 6-9 months (S is streptomycin, H is isoniazid, R is rifampicin, Z is pyrazinamide, E is ethambutol, the number before administration represents the number of months, and the number in the lower right corner after administration represents the number of times per week). If high fever occurs in the early stage, prednisone 10mg can be added at the same time as effective anti-tuberculosis drug treatment, three times a day, and the amount will be reduced as soon as the fever subsides. Drug-resistant tuberculosis, especially multidrug-resistant tuberculosis, is the most difficult problem in clinical tuberculosis prevention and treatment. For the control of MDR-TB, the most important measure is prevention. Effective treatment should be carried out as soon as possible for multidrug-resistant pulmonary tuberculosis, and the treatment plan should include at least 4 drugs, and 6 ~ 7 drugs can be added when necessary. It should be determined according to the lesion scope, drug efficacy, drug sensitivity test and previous drug use history, and strive for individualization.
At the same time of active systemic anti-tuberculosis treatment, repeated puncture and aspiration of abscess, flushing abscess cavity with 0.5%SM and injecting INH 50 ~ 100 mg can accelerate abscess healing.
18.3 surgical treatment of patients with huge tuberculous liver abscess, while using effective anti-tuberculosis drugs, surgical drainage or hepatectomy can be considered.
For patients with hepatic tuberculosis confined to one lobe of the liver, if there is no extrahepatic active tuberculosis and the liver function can tolerate surgery, hepatectomy can be performed after a period of anti-tuberculosis drug treatment, and anti-tuberculosis treatment should be continued after operation to prevent tuberculosis from spreading.
Indications for surgical treatment are:
(1) Huge solitary tuberculoma and tuberculous nodule fuse into mass or caseous liver abscess.
(2) Jaundice caused by hepatic portal compression.
(3) Patients with portal hypertension, esophageal variceal bleeding or spleen tuberculosis and hypersplenism.
(4) Patients with massive biliary bleeding.
(5) In the case of unclear diagnosis, patients with malignant diseases cannot be excluded.
19 prognosis Because the liver is rich in mononuclear macrophages and reticular endothelial tissue, it has strong reactivity, strong regeneration and defense ability, and can form a barrier in time, liver tuberculosis often heals itself. However, once patients have active liver tuberculosis such as high fever, chills and hepatomegaly, it is difficult to recover on their own. If special treatment is not given in time, it will generally deteriorate rapidly and die within weeks or months. Anti-tuberculosis drug treatment can be immediate, and even very serious cases of liver tuberculosis can be cured.
The prognosis of liver tuberculosis largely depends on the correct clinical diagnosis, or the diagnosis sooner or later. Even severe cases can be cured if early diagnosis and timely anti-tuberculosis treatment can be carried out. After effective anti-tuberculosis treatment, miliary liver tuberculosis usually recovers within 6 ~ 8 months. Other types of liver tuberculosis may take a little longer to heal. Most deaths are misdiagnosed or diagnosed too late, and the treatment opportunity is lost. If the disease worsens, the prognosis will be poor. Severe liver failure caused by fatty liver can be the cause of death. Jaundice indicates severe liver injury and poor prognosis.
20 Prevention of liver tuberculosis 20. 1 Controlling the source of infection Finding and managing the source of infection is an important link in the prevention and treatment of tuberculosis. Early detection and treatment should be achieved. Therefore, the collective lung health examination should be carried out regularly and the registration management system should be implemented.
20.2 To cut off the route of transmission, first of all, active pulmonary tuberculosis should be cured actively, as soon as possible and thoroughly, so that sputum bacteria can turn negative.
The main methods to manage and treat patients' sputum are to carry out mass health campaigns, widely publicize the knowledge of tuberculosis prevention, develop good health habits and not spit everywhere. The sputum of tuberculosis patients should be spit on paper and burned, or cough in a sputum cup with 2% coal phenol soap or 1% formaldehyde solution (which can be sterilized in about 2 hours), and the contact can be directly exposed to the sun (which can be sterilized in a few hours).
Tableware for patients with active pulmonary tuberculosis should be used alone, and boiled and disinfected regularly to prevent cross infection.
Milk must be pasteurized (56℃×30 minutes) or boiled, and raw milk cannot be drunk.
Strengthen personal hygiene, dry clothes, bedding and other daily necessities frequently, and kill the contaminated mycobacterium tuberculosis.
Strengthen physical exercise and improve the body's disease resistance.
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20.3 BCG vaccination can enhance the body's resistance to tuberculosis, which is beneficial to the prevention of tuberculosis. At present, China stipulates that BCG vaccine should be inoculated after birth, and those who are negative should be vaccinated. When ethnic minorities and border residents enter mainland cities or recruits, they must do tuberculin test, and those who are negative must be vaccinated with BCG.
2 1 related drugs isoniazid, streptomycin, salicylic acid, rifampicin, ethambutol.
Acupoints for the treatment of liver tuberculosis: Pain or dizziness in the outer Shu of the shoulder, and pricking Taiyang Shu Fei and Ganshu if the chest is knotted and the heart is swollen and painful. "Get ready for 1000 yuan": upset and irritable, moxibustion Shu Fei, acupuncture into five points. ...
The weather will broaden the mind, clear away heat and disperse knots. Tianchi point is the intersection of pericardium meridian, triple energizer meridian, gallbladder meridian and liver meridian, which has the functions of widening chest, regulating qi, calming heart and calming nerves. Attending heartache, ...
The function of compound spasm is to improve lung ventilation and relieve asthma. Improve the blood circulation of the liver: by injecting radioactive nuclides into blood vessels, it is found that acupuncture is going on. ...
My head is dull and I can't lie down. Syndrome of cold and heat in Huangdi Neijing Lingshu: acute carbuncle, liver and lung fighting, blood overflowing from mouth and nose, taking Tianfu. Acupuncture Classics A and B: Cough and Breathe Out ...
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