【Case 05】Ulcerative Colitis (Remission Phase)

📋 Basic Information

• Medical Record No.: SS-2025-NK-005

• Patient: Mr. Tanaka, Japanese, Male, 42 years old, International Trade Specialist

• Treatment Duration: 12 weeks

Diagnostic Information

• Chief Complaint: Recurrent mucoid bloody stool and abdominal pain for 5 years, symptom fluctuation in recent 1 month.

• History of Present Illness: The patient was diagnosed with ulcerative colitis 5 years ago, involving rectum and sigmoid colon, with long-term mesalazine maintenance and 2-3 acute attacks per year. One month ago, symptoms worsened after improper diet, with 3-4 daily bowel movements, mucoid bloody stool, left lower abdominal pain and tenesmus. External colonoscopy showed chronic persistent ulcerative colitis (mild activity), Mayo endoscopic score 2.

• Western Diagnosis: Ulcerative colitis (chronic persistent, mild activity)

• TCM Diagnosis: Dysentery (Large intestine damp-heat with spleen deficiency damp excess)

💊 Comprehensive Treatment Plan

• Manual Therapy: Abdominal Tuina, twice weekly

• Acupuncture: 3 times weekly

• Topical TCM Therapy: Baitouweng Decoction retention enema, nightly

• Physical Therapy: Medium-frequency electrotherapy, once daily

• Rehabilitation Training: Bowel rhythm training

• Herbal Formula: Modified Shenling Baizhu Powder + Xianglian Pill, 1 dose/day orally for 12 weeks

📊 Quantitative Comparison

✅ Efficacy Evaluation