Volume 2, Number 1 | Spring 2007

Clinical Report 2 (Japan)< Main text>
Introduction

A Cases in which Goreisan
was effective for Hypoalbuminemic Edema
Masayuki Kashima
Department of Internal Medicine
Kumamoto Red Cross Hospital

Critical conditions like sepsis, multi-organ failure,
major surgeries, chemotherapy etc. are often followed
byhypoalbuminemic

edema.

Western

medicineadministers aldosterone antagonists, loop diuretics, or< Summary >Introduction
Criticala combination of albumin preparations and loop
diuretics to relieve the hypoalbuminemic edema1). Yet,diseasesareoften

followed

byhypoalbuminemic edema. Relief of hypoalbuminemic

sometime

isrequired

until

thealdosterone

antagonists take effect and their effectiveness may beedema is limited to western medical methods, but

insufficient. Albumin preparations are associated withsolutions of various associated problems like efficacy,

the risk of infection via body fluids and because ofeconomical problems, decrease in renal function,

their extremely high costs, there are many obstacles

variations in electrolytes and the like are often

regarding their use. Again, administration of diuretics

difficult. Here we report our observations indicating

decreasesthat goreisan is effective for the treatment ofdisturbances. A major factor responsible for the

hypoalbuminemic edema.

difficulties

renalfunction

relatingand

tocausestheelectrolyte

treatment

ofhypoalbuminemic edema is, that although there is an

Patient

accumulation of both fluid and saline matter, theA 57-year old man who had been found collapsed in
his home after not eating during the winter time
because of economical poverty, was transported to a
hospital by ambulance . Upon admission, there wascardiopulmonary arrest. There was also complicating
hypothermia, so that he was connected to an artificial
heart lung apparatus. Later, because of persistent low
blood pressure and urine volume, large amounts ofblood transfusion and fluid therapy were administered.
Because a marked degree of hypoalbuminemia andedema was observed following subnutrition andcriticaldisease,weadministeredgoreisanandjuzentaihoto, after which a swift recovery of the edema
was achieved.

volume within the vessels often decreases, so thatadministration of ordinary diuretics does not result in
sufficient diuresis, but may easily lead to decreased
renal function and electrolyte disturbances. Thus, wereport here a case in which the Kampo medicine

goreisan proved to be effective for the treatment of
hypoalbuminemic edema.
[Chief complaint] cardiopulmonary arrest due toaccidental hypothermia, subnutrition, edema[Anamnesis]
The patient had not eaten for almost a month after
he had been forced to leave his employer. On December
21s, 2004 his daughter found him collapsed in his homeand had him transported to a hospital by ambulance.

Discussion
Defining suitable conditions and indications for theuse of goreisan has been difficult. An examination of
the classics reveal that it is used to treat uneven
distribution of water. Hypoalbuminemic edema canalso be considered to be a form of even water
distribution and therefore an indication for goreisan.

Upon admission there was cardiopulmonary arrest.
Administration
ventilation

ofcardiacmanagement,massage,andartificial

cardiopulmonary

resuscitation. Moreover, rectal temperature was 24.5℃,
indicating accidental hypothermia associated withcardiopulmonary arrest, so that he was connected toanartificial

heart

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

lungapparatus

and19

Volume 2, Number 1 | Spring 2007

cardiopulmonary

resuscitation

performed.

Later,

following resuscitation he developed shock due tomarkeddehydration

andhemorrhage

fromshowing no signs of renal dysfunction or electrolyte
anomalies.

theconnection sites for extracorporeal circulation, so thatlarge amounts of transfusion fluid were administeredin the form of 30 units of concentrated erythrocytes
and 30 units of frozen fresh blood preparations in orderto maintain blood pressure and urine volume, as wellas an in-out balance + approximately 5 l/day of fluid
therapy. Due to the development of pleural effusion
and ascites, as well as interstitial edema associatedwiththesubnutrition,amarkeddegreeof

hypoproteinemia developed, upon which we initiatedtreatment with 7.5 g/day of goreisan and 7.5 g/day of

juzentaihoto.
12/24
TP: 3.7 g/dl, Alb: 2.2 g/dl, BUN: 10.4 mg/dl, Cre: 0.66
mg/dl, Na: 143 mEq/l, Cl: 109 mEq/l, K: 4.2 mEq/l, Ca:
8.4 mg/dl
Contrast CT performed on 12/24 (Picture 1) revealed
bilateral pleural effusion and ascites. A plain x-ray
film taken on 12/26 showed the same degree of
pleural effusion (Picture 2). From 2 hours after
starting

theadministrationofgoreisan

andjuzentaihoto a diuretic effect started to set in, leading
to a urine volume of around 4 l/day and a decrease in
the edema (see Figure 1). Plain x-ray films taken on
December 29th showed clearly the disappearance ofthe pleural effusion and the edema too had almostdisappeared. Simultaneously,

urine volume alsodecreased. Since a balance had been achieved
between the amount of tube feeding administered via
a nasogastric tube and the urine volume, thePicture 1

administration of goreisan was discontinued. Even

Contrast CT from 12/24

during the diuresis no electrolyte disturbances orShows a large amount of bilateral pleural effusion andanomalies

soft tissue edema.

ofrenalfunctions

wereobserved.

Electrolyte supplementation was performed, but ablood examination performed on 12/29 showed TP: 4.9g/dl, Alb: 2.6, BUN: 8.8 mg/dl, Cre: 0.58 mg/dl, Na:
142 mEq/l, Cl: 105 mEq/l, K: 4.4 mEq/l, Ca: 8.1 mg/dl,

20

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 2, Number 1 | Spring 2007

Figure 1 below: Due to the rapid onset of diuresis
starting 1 hour after the administration of goreisan,
the fluid therapy was discontinued. On 12/27 the urine
volume reached a peak of 4,570 ml/day, after which theurine volume gradually decreased. On 12/30 a balance

Picture 2
Plain chest x-ray film from 12/24
Shows a large amount of bilateral pleural effusion

with water administered with tube feeding wasachieved.

<Figure 1>

5000

800

4500

700

4000600
Amount尿量（ｍｌ）
of Urine (ml)

3500
500

3000
2500400

2000

300

1500200
1000
100

500
0
12月24日Dec.
24

12月25日Dec. 25

12月26日Dec. 26

12月27日Dec. 27
Edema浮腫

12月28日Dec. 28

12月29日Dec. 290
12月30日Dec. 30

Urine
尿量volume: 7.5 g/day of goreisan: 7.5 g/day of juzentaihoto

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

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Volume 2, Number 1 | Spring 2007

Discussion
Previously, various reports have been publishedthat

dealtwiththekind of symptoms andpathologies for which goreisan could be used.
Although goreisan has
applications,

thewide actual clinicalprovided

explanations

stillcannot be considered sufficient. Turning one's
attention to classical references pertaining togoreisan , leads first to the Shang Han Lun and Jin
Kui Yao Lue. Both of these classics were written in
the later Han period. An examination of thehistoricalapplications

revealsthat

thedescriptions found in the Shang Han Lun, Jin Kui
Yao Lue and also the [Gedai Hiyou Ho] of the Tangperiod are the basis. Examination of the passages
Picture 4
First day of goreisan administered (12/26)
Bilateral pleural effusionreferring to the indications for goreisan among
these classics shows that cases where there is awater surplus in one area of the body and a water
deficitinanothermaldistributionofpartisindicative

water 2-10) .

Inofcaseaofhypoalbuminemic edema, there is a surplus ofwater outside the blood vessels, but the amount in
the blood vessels decreases, creating a condition
that can be considered to be a form of water
maldistribution. In this patient, goreisan was used
for the purpose of treating the hypoalbuminemic
edema induced maldistribution of water andproduced a marked effect. This suggests, that
hypoalbuminemic edema could be an indication for
the use of goreisan . Moreover, since the treatmentof hypoalbuminemic edema with western medicine
has the above described disadvantages, goreisan
could possibly become the drug of first choice.
Picture 5
Fourth day of goreisan administered (12/29)
Marked improvement in the pleural effusion wasobserved.

22The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 2, Number 1 | Spring 2007

[References]1)

Up to date® online 15.1 “Treatment of5) 本以下之故心下痞與瀉心湯。痞不解其人渇而口燥煩小便不利者五苓散主之。(Shang Han Lun, Line156

refractory edema”
2) 脉浮小便不利微熱消渇者宜利小便発汗五苓散主

Early Yang stage 辨太陽病脉證并治下)之(Jin Gui Yao Lue , Chapter13 Dispersion-6) 脉浮小便不利微熱消渇者與五苓散利小便発汗

Thist, Inhibited Urination, and Strangury）(Shang Han Lun 辨発汗後病脉證并治)3) 渇欲飲水水入則吐者名曰水逆五苓散主之（Jin7) 発 汗 已 脉 浮 煩 渇 者 属 五 苓 散 證 (Shang Han

Gui Yao Lue, Chapter13 Dispersion-Thist,Inhibited Urination, and Strangury）
4) 太陽病発汗後大汗出胃中乾煩躁不得眠欲得飲水
者少少與飲之令胃気和則愈。若脉浮小便不利微
熱 消 渇 者 五 苓 散 主 之 。 (Shang Han Lun,Line71 傷寒論

辨太陽病脉證并治中)

Lun, Line72

辨発汗後病脉證并治)8) 傷寒汗出而渇者宜五苓散。不渇者属茯苓甘草湯。(Shang Han Lun, Line73 辨発汗後病脉證并治)9) 五苓散主天行熱病但狂言煩躁不安精釆言語與人不相主當方。(Wai Tai Bi Yao Vol.3 外台秘要方巻三天行狂言方)The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

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