Differential Diagnosis of Common Symptoms — Diarrhea and Constipation

Diarrhea

Diarrhea, also known as “loose bowels” or “dysentery,” refers to an increased frequency of bowel movements with loose, thin stools, even as watery as fluid. Clinically, it is essential to differentiate the nature of the pathogenic factor, the location of the disease, and whether it belongs to cold, heat, deficiency, or excess.

• Abdominal pain with borborygmus, clear, thin stools, in severe cases as watery as fluid, accompanied by aversion to cold with fever, headache, generalized aches and pains in the limbs, white or white slimy tongue coating, and a floating, rapid pulse: this is cold-damp diarrhea. It is caused by cold-damp pathogens invading the intestines and stomach, impairing the ascent-descent dynamic and the transmission function, resulting in diarrhea.
• Abdominal pain with immediate diarrhea, urgent and rushing like a water spout, yellowish-brown foul-smelling stools, burning sensation in the anus, vexation and thirst, scanty dark urine, red tongue with yellow slimy coating, and a rapid pulse: this is damp-heat pouring downward diarrhea. It is caused by damp-heat pouring downward into the large intestine, impairing its transmission function.
• Abdominal pain with borborygmus, stools with the foul odor of rotten eggs, pain relieved after defecation, epigastric and abdominal stuffiness and fullness, belching of sour, putrid matter, thick slimy tongue coating, and a rapid pulse: this is food retention diarrhea. It is caused by gluttonous overeating, leading to food obstructing the stomach and intestines, inhibited qi dynamic, and impaired intestinal transmission and transformation.
• Intermittently loose or watery stools, undigested grains in the stool, recurrent episodes, with a marked increase in bowel movement frequency upon even slight intake of greasy or oily foods, poor appetite, distention after eating, mental fatigue and lack of strength, pale tongue, white or white slimy coating, and a vacuous pulse: this is spleen-stomach deficiency diarrhea. It is caused by spleen-stomach deficiency with inability to transport and transform water and grains, leading to impaired intestinal transmission.
• Diarrhea that often occurs just before dawn, with pain around the umbilicus and borborygmus preceding defecation, accompanied by aversion to cold and cold extremities, a preference for warm drinks, pale tongue with white coating, and a deep, thin pulse, commonly seen in the elderly: this is kidney yang deficiency diarrhea, also called “early morning diarrhea” (wu geng xie). It is caused by spleen-kidney yang deficiency with weakened control of the intestinal gateway, leading to impaired intestinal transmission.
• Abdominal pain and diarrhea triggered by emotional stress or nervous tension, usually accompanied by chest and hypochondriac stuffiness and frequent belching, pale red tongue with white coating, and a wiry pulse: this is liver qi invading the spleen diarrhea, a pattern of liver-spleen disharmony. It is caused by liver qi depression transversely assailing the spleen, leading to impaired spleen transportation and disordered qi dynamic.
• Tidal fever, delirium, abdominal fullness, distention and pain, discharge of yellowish-brown foul-smelling fecal water, a deep, forceful, solid pulse, red tongue with yellow slimy coating: this is heat bind with fecal water discharge (re jie pang liu) diarrhea. Excess heat pathogens accumulate in the intestines, the qi dynamic is inhibited, and intestinal transmission is impaired; hence the discharge of yellowish-brown foul-smelling fecal water.
• Borborygmus with diarrhea, epigastric discomfort, nausea and vomiting, fever, dietary irregularities, abdominal pain, white slimy tongue coating, and a wiry pulse: this is epigastric stuffiness pattern (pi zheng) diarrhea. It is caused by an intermingling of cold and heat, leading to impairment of the ascent-descent qi dynamic in the middle burner and deranged intestinal transmission.
• Diarrhea with tenesmus, accompanied by fever, thirst, a desire to drink, red tongue with yellow slimy coating, and a wiry, rapid pulse: this is heat toxin internal accumulation diarrhea. Damp-heat and heat toxin accumulate internally, impairing the ascent-descent qi dynamic of the stomach and intestines; the qi dynamic is inhibited, resulting in diarrhea with tenesmus.
• Chronic, unremitting diarrhea with passage of pus and blood, pale in color, fecal incontinence, slightly cold extremities, abdominal pain that prefers warmth and pressure, pale tongue with white coating, and a deep pulse: this is spleen-kidney yang deficiency diarrhea. Spleen-kidney yang deficiency with internal obstruction of cold-damp leads to weakened control of the intestinal gateway and impaired transmission, resulting in diarrhea with fecal incontinence.
• Diarrhea with completely undigested grains in the stool, cold extremities, aversion to cold with curled-up posture, pale tongue with white coating, and a faint, thin pulse: this is yang deficiency with yin excess diarrhea. Kidney yang deficiency with internally exuberant yin-cold pathogens leads to failure in steaming and ripening water and grains, resulting in diarrhea with completely undigested food.
• Sudden simultaneous vomiting and diarrhea, accompanied by fever and aversion to cold, abdominal pain, restlessness and agitation, thirst with a desire to drink, white tongue coating, and a floating or deep pulse: this is cholera (huo luan) diarrhea. It is caused by external pathogens attacking and damaging the stomach and intestines, with clear yang failing to ascend and turbid yin failing to descend.
• Sudden and severe onset, high fever, headache, restlessness, thirst, severe abdominal pain, discharge of pus and blood stools, mostly purplish-red or bloody-watery, in severe cases progressing to coma and convulsions, deep red tongue with yellow dry coating, and a slippery, rapid pulse: this is epidemic toxin diarrhea. Epidemic toxin attacks and fiercely scorches the intestines, damaging the vessels and collaterals, resulting in the discharge of pus and blood stools, mostly purplish-red or bloody-watery.

Constipation

Constipation refers to difficult, obstructed defecation with prolonged intervals between bowel movements, often occurring only once every several days. It is caused by impaired intestinal transmission and transformation. Clinically, it is essential to differentiate the zang-fu organs involved and whether the condition belongs to cold, heat, deficiency, or excess.

• Constipation with scanty dark urine, flushed face, fever, abdominal fullness, distention and pain, vexation, dry mouth, red tongue with yellow dry coating, and a slippery, forceful pulse: this is excess heat constipation. Excess heat pathogens bind in the stomach and intestines, the fu qi is obstructed, hence constipation.
• Constipation accompanied by frequent belching, chest and hypochondriac stuffiness and fullness, poor appetite, abdominal distention, thin slimy tongue coating, and a wiry pulse: this is liver qi depression and stagnation constipation. Liver qi depression transversely assails the spleen, transportation function is impaired, and transmission loses its proper function, resulting in constipation.
• Constipation or difficulty in defecation, requiring straining at the toilet, post-defecation fatigue, or sweating and shortness of breath, pale complexion, pale tongue, thin white coating, and a vacuous pulse: this is qi deficiency constipation. Middle qi deficiency weakens the propulsive force; the large intestine lacks the strength to transmit, resulting in constipation.
• Constipation or dry, difficult stool, accompanied by lusterless complexion, palpitations, dizziness, dry mouth with a preference for drinking, red tongue with scant coating, and a thin, rapid pulse: this is blood deficiency constipation. Depletion of body fluids and blood leads to the intestines losing their moistening and nourishment, impairing transmission and resulting in constipation.
• Constipation with abdominal fullness and pain, accompanied by slightly cold extremities, aversion to cold, soreness and coldness of the lower back and knees, clear, copious urine, a preference for warmth, pale tongue with white coating, and a deep, forceful pulse: this is cold excess constipation. It is caused by cold excess pathogens binding in the stomach and intestines, impairing intestinal transmission, with fu qi obstructed.
• Constipation, or dry, thin, small stools, or stool like sheep's droppings, accompanied by dry mouth and lips, a preference for drinking, red tongue with scant coating, and a thin pulse: this is intestinal dryness constipation. It is caused by yin deficiency with damage to body fluids, resulting in depletion of intestinal fluids and impaired intestinal transmission, hence constipation.