Abstract
Irritable Bowel Syndrome (IBS) is a gastrointestinal (GI) mobility disorder causing recurring upper and lower GI symptoms—bloating, constipation/diarrhea, and varying degrees of abdominal pain. IBS-C refers to constipation, IBS-D refers to diarrhea, IBS-M refers to mixed, and IBS-U refers to unsubtyped. The worldwide incidence of IBS is 10%–20%1,2; Asian and Western populations are similarly affected.
Diagnosis is made by symptoms alone in the absence of “red flags,” such as age of onset older than 50, rectal bleeding, weight loss, family history of inflammatory bowel disease, systemic signs of infection, or colitis. 1 There are no specific tests. It is important to exclude colon cancer, giardiasis, thyroid disorders, carcinoid syndrome, microscopic colitis, bacterial overgrowth, and eosinophilic gastroenteritis. If the patient's history is typical and physical examination, colonoscopy, blood count, erythrocyte sedimentation rate, C-reactive protein, thyroid function testing, and three fecal occult blood examinations yield normal findings, a diagnosis of IBS can be made with confidence. Rome Criteria for diagnosis (Rome IV) include abdominal pain and discomfort lasting on average of 1 day per week in the previous 3 months, associated with at least two of the factors, such as pain and discomfort related to defecation, and alteration in the frequency of defecation or stool consistency. 3
Modern biomedicine treatment involves fiber supplements, laxatives, antidiarrheal medications, antispasmodics (20 mg of hyoscine t.i.d.), tricyclic antidepressants, selective serotonin reuptake inhibiters, pregabalin, gabapentin, alosetron (to relax the colon), eluxadoline (to reduce diarrhea), rifaximin (to decrease bacterial growth in the colon), lubiprostone (to reduce constipation), and enteric-coated peppermint oil (to ease bloating and pain). Iberogast,® an herbal extract, has been found to be significantly better than placebo. 4
IBS in Chinese Medicine
Emotional factors are central to the pathology of IBS-like symptoms in Chinese Medicine (CM). Anger, frustration, resentment, and worry cause the Qi of the Chong Mai (Penetrating Vessel) Extra Meridian to rebel and rise. The Extra Meridians hold a position between the Kidney-Dan Tian center and the Principal Meridians, and each of the Extra Meridians has connections to multiple Principal Meridians. Hence, their use simplifies the treatment when multiple Principal Meridians are involved, as is the case in IBS. For a comprehensive discussion on use of these meridians, consult “Extra Meridians—a Simple Practical Approach” (in a previous issue of this journal). 5
When Rebellious Qi rises in Chong Mai from below upwards (from the foot upwards), it causes cold feet and a warm head; this involves the Liver producing Stagnation of Liver Qi. The cardinal symptom of Liver Qi Stagnation is abdominal bloating. Stagnant Liver Qi can also produce a “lump in the throat” sensation, premenstrual tension, and distension of the breasts, as well as causing constipation directly through the Large Intestine or indirectly through the Stomach involving the Stomach–Large Intestine axis (Yang–Ming axis). The effect on the Stomach can also produce retention of food, causing nausea, vomiting, regurgitation, belching, and foul breath. When the Liver Qi invades the Spleen, this produces loose motions and tiredness. These symptoms can also be produced by the emotional factors acting directly on the Liver without involving the Chong Mai. In that case, the pulse will be wiry only in the Liver position. In the Chong Mai, when the Rebellious Qi rises, it produces a firm pulse (beating straight up and down) in all positions.
Treatment is primarily directed to the Chong Mai. Extra Meridians are treated, using the Opening Point, Coupled Point, Entry Point (where the Meridian enters the surface), and Exit Point (where the meridian leaves the surface). For the Chong Mai, these points are:
SP 4—the Opening Point PC 6—the Coupled Point ST 30—the Entry Point KI 21—the Exit Point.
The practitioner reduces SP 4 (right) and PC 6 (left) in women. In men, the sides are reversed. One reinforces ST 30 and reduces KI 21 bilaterally. The author also reduces KI 16, which is situated in the Chong Mai; this has beneficial effects on all IBS symptoms. If this is not sufficient, one can use the points shown in Table 1.
Irritable Bowel Syndrome: Signs, Symptoms & Point Combinations
The treatment is given twice per week; 16 treatments constitute a course. After that, the treatment is repeated once per month for ∼2 years to avoid recurrences. A success rate of 90+% can be expected. In chronic cases, acupuncture often needs support. The Chinese herbal preparation Xiao Yao San—Free and Easy Wanderer powder—(used under the care of a qualified Chinese herbalist) often helps to reduce recurrences in such cases.
Cognitive–behavioral therapy 6 and relaxation therapy 7 are used to address the fundamental emotional factors.
Auricular points can be used. The main points are Abdomen, Constipation, Shen Men, Stomach, Point Zero, Small Intestine, Large Intestine, Rectum, and Rectum E. Supplementary points include Pancreas, Occiput, San Jiao, and Sympathetic Autonomic Point. One chooses points according to tenderness.
The following points can be used in all cases of IBS irrespective of the Disharmony patterns for symptom relief:
In all cases—KI 16 Acute abdominal pain—ST 34, ST 36, LI 4, and ST 25 Nausea and vomiting—PC 6 and ST 36 Diarrhea—ST 25, CV 6, CV 3, ST 36, ST 37, SP 4, and SP6 Constipation—ST 25, TE 6, ST 36, and CV 12 Abdominal distension—GB 25, LR 13, GB 26, CV 12, PC 6, ST 36, SP 6, and LR 3.
All points are reduced.
Evidence for Acupuncture
Two Cochrane reviews showed that acupuncture was not more effective than placebo for addressing IBS.8,9 This has not been the experience of the current author. There is nothing called IBS in CM. When a diagnosis of a Disharmony is made—such as Spleen Deficiency or Liver Stagnation—and the patient is treated accordingly, the response to acupuncture is very good. In a study of 29 patients who had IBS, acupuncture treatment produced significant reduction of almost all symptoms. 10 A similar result was shown in another study involving 10 patients. 11 The major drawback of these studies was the small number of patients.
Symptoms of IBS correlate well with disorders of the autonomic nervous system; and acupuncture is known to influence autonomic function. 12 Results, examined symptom by symptom, in a study involving 520 patients with constipation, showed that acupuncture was effective in 80% of the patients. 13
Acupuncture has been used successfully to treat infantile diarrhea. 14 CV 12 has been found to inhibit colonic transit, stimulating the sympathetic efferent pathways; hence, this point is considered useful for treating diarrhea. 15 CV 12 also reduces abdominal pain. 16 It has been demonstrated that electrical stimulation at ST 36 and PC 6 increases the threshold of rectal sensations caused by rectal distension in patients with IBS. 17 Stimulatory effects of acupuncture at ST 36 can be useful for patients with IBS-C, 18 while the inhibitory effects of acupuncture at CV 12 can be beneficial for patients with IBS-D.19,20
Chao and Zhang studied 6 placebo-controlled clinical trials and came to the conclusion that acupuncture produced considerable symptomatic relief of IBS but not to the extent that acupuncture can be recommended as a first-line treatment. 21 A study by MacPherson et al. involving 233 patients with IBS showed a 49% success in an acupuncture-treated group, compared to a 33% success rate in a control group. The benefit persisted at 6, 9, and 12 months. 22
It is expected that acupuncture will play a prominent role in the treatment of IBS and other functional GI disorders and that this development will bring down related health care costs significantly.
Case
A 49-year-old woman had constipation alternating with diarrhea, abdominal distension, pain, gastroesophageal reflux, and substernal pain for more than 10 years. Her tongue color was normal, with redder sides, and her pulse was firm and slightly wiry on the left side.
This patient's bloating and constipation were caused by Liver Qi Stagnation, which invaded the Spleen, causing diarrhea. Her gastroesophageal reflux could have resulted from Liver Qi Stagnation invading the Stomach or from Rebellious Qi of the Chong Mai. The latter diagnosis was preferred because her pulse was firm in all positions (beating straight up and down) and was only slightly wiry. Her red tongue sides indicated Liver Excess.
She was treated, using SP 4, PC 6, and KI 21 (all reduced), and ST 30 (reinforced) to stimulate the Chong Mai. KI 16 was reduced. This combination of points reduced most of her symptoms. Other points used were LR 13 to harmonize the Liver and Spleen, ST 25 and SP 15 to treat diarrhea and constipation, and GB 34 and LR 3 to promote a smooth flow of Qi and calm her abdominal pain, all by the reduction method. CV 12, ST 36, and SP 6 were reinforced to tonify her Spleen.
After 8 weeks of treatment (twice weekly), this patient's symptom relief was nearly total. Acupuncture was then continued on a monthly basis. There is a problem period for recurrence when a patient is weaned from acupuncture; thus, a focus on causative factors is necessary. The foremost is anger, which includes frustration, irritation, and resentment. It is not easy to address these factors, but, if this is not done, the patient's symptoms will return. Worry and sadness also affect the Liver. Dietary advice regarding reduced consumption of red meat, spices, greasy foods, and alcohol is essential. All of these factors were addressed in this patient. Herbs, such as dandelion (Taraxacum officinale) tea and milk thistle (Silybum marianum) support the Liver and will help reduce recurrences. The patient was advised about the use of these herbs.
References
Saito YA, Schoenfeld P, Locke GR 3rd. The epidemiology of irritable bowel syndrome in North America: A systemic review. Am J Gastroenterol. 2002;97(8):1910–1915.
Miwa H. Prevalence of irritable bowel syndrome in Japan: Internet survey using Rome III criteria. Patients Prefer Adherence. 2008;2(2):143–147.
Lacy BE, Patel NK. Rome criteria and a diagnostic approach to irritable bowel syndrome. J Clin Med. 2017;6(11):E99.
Madisch A, Holtmann G, Plein K, Hotz J. Treatment of irritable bowel syndrome with herbal preparations: Results of a double-blind, randomized, placebo-controlled, multi-centre trial. Aliment Pharmacol Ther. 2004;19(3):271–279.
Sudhakaran P. Extra meridians—a simple practical approach. Med Acupunct. 2013;25(5):336–342.
Heymann-Monnikes I, Arnold R, Florin I, Herda C, Melfsen S, Monnikes H. The combination of medical treatment plus multicomponent behavioural therapy is superior to medical treatment alone in the therapy of irritable bowel syndrome. Am J Gastroenterol. 2000;905(4):981–994.
van der Veek PP, van Rood YR, Masclee AA. Clinical trial: Short and long-term benefit of relaxation training for irritable bowel syndrome. Aliment Pharmacol Ther. 2007;26(6):943–952.
Lim B, Manheimer E, Lao L, Ziea E, Wisniewski J, Liu J, Berman B. Acupuncture for treatment of irritable bowel syndrome. Cochrane Database Syst Rev. 2006;4:CD005111.
Manheimer E, Cheng K, Wieland LS, et al. Acupuncture for treatment of irritable bowel syndrome. Cochrane Database Syst Rev. 2012;5:CD005111.
Anastasi JK, McMahon DJ, Kim GH. Symptom management for irritable bowel syndrome: A pilot randomized controlled trial of acupuncture/moxibustion. Gastroenterol Nurs. 2009;32(4):243–255.
Reynolds JA, Bland JM, MacPherson H. Acupuncture for irritable bowel syndrome—an exploratory randomised controlled trial. Acupunct Med. 2008;26(1):8–16.
Ouyang H, Yin J, Wang Z, Pasricha PJ, Chen JD. Electro acupuncture accelerates gastric emptying in association with changes in vagal activity. Am J Physiol Gastrointest Liver Physiol. 2002;282(2):G390–G396.
Fischer MV. Acupuncture therapy in the outpatients-department of the University Clinic Heidelberg [in German]. Anaesthetist. 1982;31(1):25–32.
Su Z. Acupuncture treatment of infantile diarrhoea: A report of 1050 cases. J Tradit Chin Med. 1992;12(2):120–121.
Tada HH, Fujita MM, Harris M, et al. The neural mechanism of acupuncture induced gastric relaxation in rats. Dig Dis Sci. 2003;481(1):59–68.
Gu Y. Treatment of acute abdomen by electro-acupuncture—a report of 245 cases. J Tradit Chin Med. 1992;12(2):110–113.
Xing J, Larive B, Mekhail N, Soffer E. Transcutaneous electrical acustimulation can reduce visceral perception in patients with the irritable bowel syndrome: A pilot study. Altern Ther Health Med. 2004;10(1):38–42.
Bazzocchi G, Ellis J, Villaneuva-Meyer J, et al. Post prandial colonic transit and motor activity in chronic constipation. Gastroenterology. 1990;98(3):686–693.
Vassallo M, Camilleri M, Phillips SF, Brown ML, Chapman NJ, Thomford GM. Transit through the proximal colon influences stool weight in the irritable bowel syndrome. Gastroenterology. 1992;102(1):102–108.
Camilleri M, Ford MJ. Review article: Colonic sensorimotor physiology in health, and its alteration in constipation and diarrhoeal disorders. Aliment Pharmacol Ther. 1998;12(4):287–302.
Chao GQ, Zang S. Effectiveness of acupuncture to treat irritable bowel syndrome: A meta analysis. World J Gastroenterol. 2014;20(7):1871–1877.
MacPherson H, Tilbrook H, Bland JM, et al. Acupuncture for irritable bowel syndrome: Primary care based pragmatic randomized controlled trial. BMC Gastroenterol. 2012;12:150.
Address correspondence to:
Poovadan Sudhakaran, MBBS, PhD, MastACU, MastTCM
26 Tuckers Road,
Templestowe, 3106
Australia
E-mail:
There is a group of chronic complaints that are treated inadequately by conventional medicine; these conditions were formerly termed “functional somatic syndromes.” Irritable bowel syndrome (IBS) is one of these, together with irritable bladder syndrome, restless legs syndrome, multiple food or chemical intolerances, tension headaches, and several others. 1 These conditions are all common comorbidities of fibromyalgia and chronic fatigue syndrome. Indeed, the similarity and crossover of symptoms is sufficient that it has been proposed—and widely accepted—that these conditions are all manifestations of a single syndrome, “central sensitivity,” with the more-prominent individual features giving the diagnostic name for the individual patient. Thus, although IBS is formally characterized by an altered bowel habit, visceral hypersensitivity, and abdominal pain and bloating, IBS sufferers commonly report other additional features, notably: chronic fatigue; noncardiac chest pain; chronic pelvic pain; premenstrual syndrome; chronic dyspepsia; atypical facial pain; and tension headaches. 2
The altered bowel habit may be predominantly constipation or predominantly diarrhea, but my initial approach is the same for both. I inspect the abdomen, noting any bloating or surgical scars, and palpate for tenderness, particularly tenderness in scars. I insert needles at any tender points, but aim to have up to a dozen needles—including in CV 5 or CV 6 (points traditionally recommended for both abdominal pain and swelling, constipation, and diarrhea)—spread over the lower abdomen even if there is no tenderness. 3 I take care to keep needle tips relatively superficial to ensure that the peritoneum is not penetrated nor any viscera damaged. I have found that gentle manual stimulation, withdrawing needles after 10 minutes or less, is more effective for constipation-based IBS; indeed, strong stimulation can make the problem worse. The opposite is true for diarrhea-based IBS, for which stronger stimulation is usually necessary. I prefer electroacupuncture at 2/100 Hz for 20 minutes. The difference between the response for constipation and diarrhea is probably related to the levels of endogenous opioids that are released (this is discussed below).
Bearing in mind the additional morbidity commonly reported in IBS, it is important to ask about the frequency and severity of these other features of the syndrome. It is also important to add acupuncture points suitable for their treatment, such as trigger points in neck muscles for tension headaches or in the chest wall for atypical chest pain.
For some years now, part of the work-up for patients with chronic pain in my clinic has been to inquire about possible comorbidities. We have discovered that a notable feature of patients with fibromyalgic pain has been a high incidence of associated IBS (84% in a recent audit). Unfortunately, one of the other features of fibromyalgia is hyperalgesia, so needling at multiple points can cause excessive pain. Sufferers with IBS comorbid with fibromyalgia might thus be able to tolerate only a few abdominal needles with minimal stimulation, and attempts to treat other areas may result in worsening symptoms. Nonetheless, patients with IBS and/or fibromyalgia tend to suffer from anxiety and stress, so I use the calming point GV 20 routinely. This is usually appreciated, because reducing a patient's stress response makes the IBS seem less burdensome.
A Cochrane review of 17 randomized controlled trials of acupuncture for IBS reported that acupuncture was significantly more effective than antispasmodic medication but was no better than a “sham” acupuncture control. 4 Other researchers have noted that IBS is highly susceptible to reduction with placebo. In clinical trials of conventional medical therapy for IBS, the placebo response rate was 40%, and in a trial of sham, nonpenetrating needle acupuncture in patients with IBS, the placebo effect was shown to be strongly augmented by a warm patient–practitioner relationship. 5 Thus, needling in an area thought likely to be effective, such as the lower abdomen, by a sympathetic practitioner who can explain the mechanism of action to the patient in credible terms, is more likely to produce increased benefit through enhanced nonspecific effects of needling as well as inducing a true acupuncture response.
It has been proposed that IBS results from a change in neural processing between the gut and the brain, mediated by the autonomic nervous system (ANS), that alters gut motility, secretion, and visceral sensation. It has been shown that acupuncture modulates the ANS both directly at segmental and central levels and via endocrine regulation. Thus acupuncture should act beneficially in patients with IBS. 6 A commonly used palliative treatment for the pain and diarrhea of IBS is an opiate, while an effective general IBS treatment is a serotonin-boosting antidepressant, often amitriptyline, which has a synergistic effect with acupuncture. 7 There are both opioid and 5-hydroxytryptamine receptors in the gut, and acupuncture is known to boost endogenous opioid and serotonin levels, thus, again suggesting a possible mechanism of action for acupuncture to affect IBS.
Reference
Wessely S, Nimnuan C, Sharpe M. Functional somatic syndromes: One or many? Lancet. 1999;354(9182):936–939.
Burbige EJ. Irritable bowel syndrome: Diagnostic approaches in clinical practice. Clin Exp Gastroenterol. 2010;3:127–137.
Campbell A. Acupuncture treatment of gastrointestinal disorders. Acupunct Med. 1992;10(2):70–71.
Manheimer E, Cheng K, Wieland LS, et al. Acupuncture for treatment of irritable bowel syndrome. Cochrane Database Syst Rev. 2012;5:CD005111.
Joos S. Acupuncture for gastrointestinal conditions. In: Filshie J, White A, Cummings M, eds. Medical Acupuncture: A Western Scientific Approach, 2nd ed. Edinburgh: Elsevier; 2016:368–375.
Stener-Victorin E. Acupuncture and the autonomic nervous system. In: Filshie J, White A, Cummings M, eds. Medical Acupuncture: A Western Scientific Approach, 2nd ed. Edinburgh: Elsevier; 2016:86–98.
Fais RS, Reis GM, Silveira JW, et al. Amitriptyline prolongs the antihyperalgesic effect of 2- or 100-Hz electro-acupuncture on a rat model of post incision pain. Eur J Pain. 2012;16(5):666–675.
Address correspondence to:
Simon Hayhoe, MSc, MBBS, MRCA
Pain Management Department
University Hospital
Turner Road
Colchester CO4 5JL
United Kingdom
E-mail:
Irritable bowel syndrome (IBS) is a chronic functional disorder of the gastrointestinal (GI) system, classified as predominantly diarrhea (IBS-D), constipation (IBS-C), or both (IBS-M). IBS is diagnosed according to clinical criteria. These include recurrent abdominal pain, at least 1 day per week in the last 3 months, with two or more of the following: the episode is related to defecation, a change in frequency, and/or a change in the appearance of the stool. 1
Functional GI disorders are related with gut–brain interactions. These disorders are characterized by motility disturbances, visceral hypersensitivity, altered mucosal and immune function, altered gut microbiota, and altered central nervous system processing. 2 The gut–brain axis, or enteric nervous system (ENS), influences gut motility, based mainly on serotonergic and cholinergic innervations. 3 Serotonin is involved in both intestinal motility and mood regulation. This could indicate that changes in ENS neurotransmission are involved in the comorbidity of IBS with depressive and anxiety disorders. 4
IBS causes significant impairment of quality of life and has no universally accepted treatment. Pharmacologic treatment includes prokinetics and antispasmodics for IBS-C; and opioid agonists, anticholinergics, and serotonin 5-hydroxytryptamine (5-HT) antagonists for IBS-D, which provide only limited symptomatic relief. It is important to include integrative medicine with lifestyle adjustments and complementary practices. Systematic reviews suggest that various complementary and alternative medicine modalities, including acupuncture, may benefit patients who have IBS. 4
Acupuncture for IBS targets serotonergic, cholinergic, and glutamatergic pathways; can lower blood cortisol levels related to stress; and can increase the concentration of endogenous opioids to reduce pain perception. 4 Acupuncture is believed to alter visceral sensation and motility by stimulating the somatic nervous system and the vagus nerve in patients with IBS. 5 Acupuncture can reduce visceral hypersensitivity, as shown by an animal study with electroacupuncture (EA) at both ST 25 and ST 37. 6 Another animal study with EA at ST 25 and CV 12 showed a visceral analgesic effect. 7 In addition, acupuncture relieved thalamic pain in patients with advanced and central signaling pathways involving 5-HT. 8 Finally, in another study, decreased activated voxel values were observed in the anterior cingulate cortex, right insular cortex, and prefrontal cortex brain regions of an EA group. 9
A meta-analysis of 6 randomized controlled trials (RCTs) suggested that acupuncture reduced abdominal pain and distension, the sensation of incomplete defecation, times of defecation per day, and the state of patients' stools. 5 An RCT compared the effects of EA and moxibustion therapies for patients with IBS-C. Both EA and moxibustion could reduce symptoms significantly, and EA was more effective than moxibustion. Both treatments were performed on bilateral ST 25 and ST 37. Greater reductions of abdominal distension, defecation frequency, and difficulty with defecation, as well as stool features were observed in an EA group; there was also a reduction of depression and anxiety. 9
Another recent meta-analysis included 33 trials. There were no reported side-effects of acupuncture, and the effect of acupuncture on IBS-D was better than some drugs. The most commonly used acupoints included ST 25, ST 37, ST 36, SP 6, GV 20, and Yin Tang (EX-HN 3). The researchers also concluded that sham acupuncture might have a curative effect. 8 Another study had also shown that acupuncture was not, or was only slightly, superior to sham acupuncture. 10 Further studies are necessary to demonstrate the effect of acupuncture on IBS.
According to Traditional Chinese Medicine (TCM), the four main emotions that aggravate IBS are (1) fear (Kidney), (2) anger (Liver), (3) anxiety (Heart), and (4) worry (Spleen). Treatment is based on TCM diagnosis. Some key points can be used in most cases: BL 20 (Shu point of the Spleen); LR13 (Mu point of the Spleen); SP 6 and ST 36 (Ho points of the Large Intestine); ST 37 and CV 12 (Mu points of the Stomach); CV 6 and ST 25 (Mu points of the Large Intestine); LI 4 (Yuan-Source point of the Large Intestine); LR 3 (Yuan-Source point of the Liver); and Ex-HN 3. 11 CV 12 is the energy center in Deficient Spleen and can be used for reinforcing or for moxibustion. 12
In Stagnant Liver Qi, symptoms are aggravated by depression, frustration, and anger; TE 6 and PC 6 can be added for nausea, and GB 27 and GB 28 can be added for colon pain. In Deficient Spleen Qi and Yang, abdominal distension is worse with tiredness or worry; BL 20, BL 25, and BL 27 can be added, in addition to CV 9 and SP 9 for watery stools and GV 20 and BL 49 for worry. 12
In Stagnant Liver Qi and Deficient Spleen Qi, in which abdominal and epigastric distension worsens with worry and anger, BL 18, BL 20, and BL 25 can be added. If the Kidney and Heart are involved, abdominal distension becomes worse with fear and anxiety; CV 4, SP 4, PC 6, and CV 14, can be added, alternated with BL 20, BL 25, BL 44, and BL 52. In retention of food, symptoms are associated with excessive or irregular eating patterns; CV 10, LI 10, and PC 6 can be used, or ST 44 and LI 4 for Heat, such as constipation, can be used. 12
References
Simren M, Palsson OS, Whitehead WE. Update on Rome IV criteria for colorectal disorders: Implications for clinical practice. Curr Gastroenterol Rep. 2017;19(4):15.
Drossman DA. Functional gastrointestinal disorders: History, pathophysiology, clinical features and Rome IV. Gastroenterology. 2016;150(6):1262.e2–1279.e2.
Gershon MD. Nerves, reflexes, and the enteric nervous system: Pathogenesis of the irritable bowel syndrome. J Clin Gastroenterol. 2005;39(5[suppl3]):S184–S193.
Grundmann O, Yoon SL. Complementary and alternative medicines in irritable bowel syndrome: An integrative view. World J Gastroenterol. 2014;20(2):346–362.
Chao GQ, Zhang S. Effectiveness of acupuncture to treat irritable bowel syndrome: A meta-analysis. World J Gastroenterol. 2014;20(7):1871–1877.
Liu HR, Wang XM, Zhou EH, Shi Y, Li N, Yuan LS, Wu HG. Acupuncture at both ST25 and ST37 improves the pain threshold of chronic visceral hypersensitivity rats. Neurochem Res. 2009;34(11):1914–1918.
Zhu X, Liu Z, Qin Y, Niu W, Wang Q, Li L, Zhou J. Analgesic effects of electroacupuncture at ST25 and CV12 in a rat model of post inflammatory irritable bowel syndrome visceral pain. Acupunct Med. 2018;36(4):240–246.
Zhu L, Ma Y, Ye S, Shu Z. Acupuncture for diarrhea-predominant irritable bowel syndrome: A network meta-analysis. Evid Based Complement Alternat Med. 2018;2018:2890465.
Zhao JM, Lu JH, Yin XJ, et al. Comparison of electroacupuncture and mild-warm moxibustion on brain–gut function in patients with constipation-predominant irritable bowel syndrome: A randomized controlled trial. Chin J Integr Med. 2018;24(5):328–335.
Lowe C, Aiken A, Day AG, Depew W, Vanner SJ. Sham acupuncture is as efficacious as true acupuncture for the treatment of IBS: A randomized placebo controlled trial. Neurogastroenterol Motil. 2017;29(7):1–9.
Wang LG, Pai HJ. [Tratado Contenporâneo de Acupuntura e Moxibustão]. Ed. CEIMEC, 2005. Translated from A Complement Work of Present Acupuncture & Moxibustion: Clinical Acupuncture and Moxibustion, Tianjin Science & Technology Translation & Publishing Corporation, 1996.
Ross J. Acupuncture Point Combinations: The Key to Clinical Success, 1st ed. Edinburgh & New York: Churchill Livingstone; 1995.
Yolanda Maria Garcia, MD, PhD
and Priscilla Alessandra Fiorelli, MD
Medical School of São Paulo University—Brazil
São Paulo, Brazil
Address correspondence to:
Yolanda Maria Garcia, MD, PhD
Medical School of São Paulo University—Brazil
R. Teodoro Sampaio, 352 cj 57.
São Paulo–SP 05406-000
Brazil
E-mail:
Irritable bowel syndrome is a chronic and complex functional gastrointestinal disorder affecting ∼5%–20% of the general population worldwide. 1 The condition is characterized by recurrent abdominal pain and discomfort—with alterations in the frequency or consistency of stools—that present as diarrhea or constipation in the absence of detectable organic pathology. 2 In addition to these distressing physical symptoms, there is a high incidence of psychiatric disorders among IBS sufferers. 1 Although the exact cause is unknown, a few contributing factors—hypersensitivity to certain foods or drinks, emotional distress, wrong diet, or heavy cigarette smoking— exacerbate the symptoms. The pathogenesis of IBS includes gut microbiota disproportions, visceral hypersensitivity via activation of the intestinal mucosal immunity, dietary intolerance, increased intestinal permeability, imbalanced serotonin levels, dysregulated gut–brain axis, and altered gut motility. 3
IBS has four subtypes—(1) IBS-D (diarrhea-predominant); (2) IBS-C (constipation-predominant); (3) IBS-M (mixed), and (4) unspecified IBS (IBS-U)—according to the Rome III diagnostic criteria. 4 This complexity and diversity of IBS presentation is a challenge when choosing treatments for IBS. In spite of the availability of many pharmacologic formulations, the symptoms of IBS are not addressed adequately. Due to the complex pathophysiology of the disease—which involves both environmental and psychosocial factors—a single pharmacologic agent targeting a particular receptor might not address the problem completely. Therefore, there is a need for exploration of other systems of medicine that adopt holistic approaches. Traditional Chinese Medicine (TCM) is one such valuable option. Numerous clinical trials have shown that TCM therapies alone, or combined with pharmacologic interventions, produced improved treatment outcomes in patients with IBS.5,6
Acupuncture is one of the principal therapies in TCM. Acupuncture works according to the concept of Qi (the life force). Qi circulates along the meridians (energy channels) and manifests in the form of two opposing forces: (1) Yin (the passive, feminine, and sustaining principle of the Universe); and (2) Yang (the active, masculine, and creative principle of the Universe). In acupuncture, fine needles are inserted at specific acupoints along a meridian to revert any imbalances between the opposing forces and the interrupted flow of Qi, which are attributed to be the causes of diseases in the body. There is an evidence base available on the efficacy of acupuncture for reducing pain, 7 regulating gut motility, raising the sensory threshold of the gut, 8 balancing the autonomic nervous system 9 and reducing psychologic distress, which serve as our objectives for treatment of IBS.
Case
A 23-year-old woman came with a history of recurrent abdominal pain and cramping that was associated with nausea, flatulence, and diarrhea with mucus coming from her rectum (3–6 times a day for 3–4 days per week). She had had these symptoms for the past 2 years. She had an acute worsening of the pain just prior to defecation and defecation was followed by a sensation of incomplete evacuation. Her pain was exacerbated by intake of food, resulting in “heartburn” and bloating. She also complained of fatigue, anxiety, and insomnia, which disturbed her daily routine. Her stool consistency matched type 6 on the Bristol Stool Scale. She also had a worsening of her symptoms with emotional distress. She was diagnosed with IBS-D after excluding other probable diagnoses with thyroid-function tests, colon sigmoidoscopy, and barium radiographs.
As part of a TCM examination, her pulse was examined and a detailed case history was taken. It was concluded that she had Stagnation in the Liver (LR) meridian and Deficiency in the Spleen (SP) and Stomach (ST) meridians. Hence, through Ko (the Destructive Cycle), the energy from the Liver meridian had to be drained into the Spleen (SP) and Stomach (ST) meridians to achieve the abovementioned treatment objectives. The following points were selected (needling details are shown in Table 1): ST 36; ST 25; ST 42; CV 6; CV 12; SP 6; SP 8; PC 6; LR 13; LI 4; LI 11; and GB 34. De Qi was achieved following needling. Each acupuncture session was for 30 minutes, 4 times per week, for 5 weeks. Warming moxibustion—at ST 25 bilaterally with a small moxibustion cone placed on the needle's head—was given for 15 minutes, 3 times per week for 5 weeks.
Selected Points, with Needling Details for Management of IBS in Case Study
IBS, irritable bowel syndrome; S., serial number of points mentioned.
Lifestyle modifications, such as regular moderate physical activity, dietary regulations, sleep hygiene, and stress reduction, were also advised. The patient's symptoms were assessed on a visual analog scale (VAS) before the starting the treatment and after completion of the last acupuncture session. Her symptom scores were reduced substantially after 5 weeks of intervention, as shown in Table 2.
Subjective Reduction of Patient's Symptoms Graded on a 10-Point VAS
VAS, visual analogue scale
References
Reynolds JA, Bland JM, Macpherson H. Acupuncture for irritable bowel syndrome—an exploratory randomised controlled trial. Acupunct Med. 2008;26(1):8–16.
Li C-Y, Li S-C. Treatment of irritable bowel syndrome in China: A review. World J Gastroenterol. 2015;21(8):2315–2322.
Rahman MM, Mahadeva S, Ghoshal UC. Epidemiological and clinical perspectives on irritable bowel syndrome in India, Bangladesh and Malaysia: A review. World J Gastroenterol. 2017;23(37):6788–6801.
Longstreth GF, Thompson WG, Chey WD, Houghton LA, Mearin F, Spiller RC. Functional bowel disorders. Gastroenterology. 2006;130(5):1480–1491.
Chao GQ, Zhang S. Effectiveness of acupuncture to treat irritable bowel syndrome: A meta-analysis. World J Gastroenterol. 2014;20(7):1871–1877.
Zhang S, Wang H, Li Z. A multi-center randomized controlled trial on treatment of diarrhea-predominant irritable bowel syndrome by Chinese Medicine syndrome-differentiation therapy [in Chinese]. Zhongguo Zhong Xi Yi Jie He Za Zhi. 2010;30(1):9–12.
Collins J, Rico JC, Trudnowski RJ. Acupuncture and pain. AANA J. 1976;44(1):62–64.
Lembo AJ, Conboy L, Kelley JM, et al. A treatment trial of acupuncture in IBS patients. Am J Gastroenterol. 2009;104(6):1489–1497.
Haker E, Egekvist H, Bjerring P. Effect of sensory stimulation (acupuncture) on sympathetic and parasympathetic activities in healthy subjects. J Auton Nerv Syst. 2000;79(1):52–59.
Nishitha Jasti, BNYS
and Hemant Bhargav, MD, PhD
Department of Psychiatry
Integrated Centre for Yoga
National Institute of Mental Health and Neuro Sciences (NIMHANS)
Bangalore, India
Address correspondence to:
Nishitha Jasti
Department of Psychiatry
NIMHANS Integrated Centre for Yoga
NIMHANS, Bangalore 560029
India
E-mail:
Irritable bowel syndrome (IBS) is the most common functional gastrointestinal (GI) disorder encountered by doctors; yet, patients are generally dissatisfied with available treatments and are willing to undergo novel or even risky treatments to obtain relief. 1 While patients use a number of strategies to confront the wide array of IBS symptoms with varying success, existing research indicates that acupuncture results are statistically significant and that it is clinically effective for managing symptoms, 2 especially compared with the relative inefficacy of standard drug therapies. 3 A cursory internet search revealed a wealth of generally positive information regarding the effects of acupuncture on IBS, and medical acupuncturists are uniquely poised to provide lasting relief for patients who present with symptoms that remain unresolved.
While exploring acupuncture treatments for IBS, I first look for those points with empirical functions that affect digestion generally, and the intestines specifically. Here, I define empirical points as those used to improve the affected organs without regard for the Traditional East Asian Medicine (TEAM) diagnosis and that will form the basis of an effective acupuncture strategy. Common points of this kind include ST 25 (Front Mu Point of the Large Intestine), ST 37 (Lower Sea Point of the Large Intestine), CV 9, LI 4 (Yuan-Source of the Large Intestine Channel), and LI 11 (He-Sea point of the Large Intestine Channel). Collectively, these points regulate the Intestines, regulate the Spleen and Stomach, regulate the Qi of the abdomen, resolve Stagnation, and dispel Accumulation. These points are indicated for diarrhea, constipation, borborygmus, abdominal pain, abdominal swelling, and many other digestive symptoms. This list is by no means comprehensive, and other points may be substituted or added.
Having found the important empirical points, I then look at TEAM-related diagnoses, specific diagnostic traits, and treatments for particular types of IBS. Possibly the most commonly described pattern for IBS is Liver–Spleen Disharmony, which primarily includes symptoms that are induced or worsened by stress. The patient might also have cold hands and feet, frequent irritability and emotional lability, depression, excessive abdominal bloating, excessive belching, and/or diarrhea alternating with constipation. For this condition, points such as LR 3, PC 6, GB 34, and LR 13 will be added to the empirical points. Biomedical correlates to this pattern might include changes in GI motility and secretions, gut mucosal problems, and even increased visceral perception. 4
Another common diagnosis for IBS could be Damp–Heat in the Intestines. Symptoms indicative of Damp–Heat include foul-smelling stools or flatulence, rectal pain during defecation, general rectal irritation, tenesmus or a feeling of incomplete evacuation, a subjective sensation of burning in the abdomen or rectum, marked abdominal pain, abdominal cramping before bowel movements that is relieved by defecation, or increased frequency of bowel movements. Points that correspond to Damp–Heat in the Intestines include SJ 6, ST 44, ST 28, and SP 9.
A third diagnosis might be a relative weakness of the digestive system, or Spleen Qi Deficiency. Typical symptoms indicating Spleen Qi Deficiency include low energy, poor appetite, loose stools with increased fatigue after bowel movements, symptoms that worsen with fatigue, and a pale complexion. Useful points include ST 36, SP 6, PC 7, and CV 6.
It should be noted further that these patterns can occur in tandem and that points from different categories can be used together.
Several important lifestyle modifications are traditionally indicated for the symptom complex that comprises IBS. The first modification involves diet. Although patients typically find themselves aware of the specific foods that cause discomfort, it is also useful to discuss some basic dietary concepts that might seem less obvious. It is possible that certain dietary habits do not immediately cause discomfort and, therefore, escape notice; yet, nonetheless, they do create an environment of symptomatic inevitability. These habits include chronic overeating, eating meals too soon before sleeping, diets predominantly made up of processed foods, excessive amounts of processed sugars, and mixing foods with “extreme flavors” (e.g., chili dogs and soda, or pizza and ice cream). The first recommendation is to change these habits.
A second recommendation is stress management to reduce the symptoms of IBS. This approach has been shown to be effective for reducing IBS symptoms. 5 Techniques such as cognitive–behavioral therapy, relaxation therapies, hypnotherapy, and biofeedback therapy can also be useful.
A typical acupuncture treatment course begins with 1 treatment per week for 4 weeks. If the patient has not obtained relief by this time, it could be useful to increase the treatment frequency to twice weekly for an additional 4 weeks or to continue with treatment once per week.
Case
I recently treated a 43-year-old woman with a predominance of diarrhea occurring several times per day, bloating, abdominal discomfort, and flatulence. Her symptoms were clearly affected by stress, leading to an increase in abdominal pain and discomfort. Her case was complicated by occasional bouts of extreme cramping and pain prior to bowel movements. Upon questioning her, I also learned that, during these times, her bowel movements had a foul smell. She was diagnosed as having Liver–Spleen Disharmony, with Damp–Heat affecting her bowels. Her weekly treatments included ST 25, ST 37, LI 4, CV 9, LR 3, GB 34, and LR 13. On weeks when her Damp–Heat symptoms had been present, LI 11, ST 44, ST 28, and SP 9 were also included. One treatment per week was applied for 6 weeks, whereupon she reported a 60% reduction of her symptoms. Treatment continued for a further 8 weeks, at the end of which, the patient reported most of her symptoms were abated, with occasional bouts of bloating and diarrhea during extremely stressful periods in her life.
References
Drossman DA, Morris CB, Schneck S, et al. International survey of patients with IBS: Symptom features and their severity, health status, treatments, and risk taking to achieve clinical benefit. J Clin Gastroenterol. 2009;43(6):541–550.
Chao GQ, Zhang S. Effectiveness of acupuncture to treat irritable bowel syndrome: A meta-analysis. World J Gastroenterol. 2014;20(7):1871–1877.
Akehurst R, Kaltenthaler E. Treatment of irritable bowel syndrome: A review of randomised controlled trials. Gut. 2001;48(2):272–282.
Konturek PC, Brzozowski T, Konturek SJ. Stress and the gut: Pathophysiology, clinical consequences, diagnostic approach and treatment options. J Physiol Pharmacol. 2011;62(6):591–599.
Kahn S, Chang L. Diagnosis and management of IBS. Nat Rev Gastroenterol Hepatol. 2010;7(10):565–581.
Address correspondence to:
David Allen LAc, DACM
Pacific College of Oriental Medicine, San Diego
7445 Mission Valley Road, #105
San Diego, CA 92108
E-mail:
Irritable bowel syndrome (IBS) is a gastrointestinal issue that causes a number of symptoms including abdominal pain, diarrhea or constipation (or both), bloating, and fatigue. IBS is not life-threatening but its significant effects on quality of life often lead to anxiety and depression. Unfortunately, pharmacologic treatments offer little relief and can have unpleasant side-effects, so treatment generally involves lifestyle changes made by the patient. Lifestyle changes range from dietary (paying special attention to types of foods consumed and cooking styles) to performing more exercise and reducing stress. 1
Fortunately, Chinese Medicine (CM)/acupuncture can help these patients. 2 According to the theory of CM, digestion is key to having good health overall. Digestion is the center of energy production. It is known that food can be used as medicine, but a patient must be able to digest food properly and use it in order to reap its benefits. Otherwise, the patient's general health will suffer. That patient could have indigestion, stomach aches, fatigue, loss of hair luster, or thinner hair, and more.
Studies have shown that acupuncture is effective for treating IBS. 1 In one study, 84% of patients in an acupuncture group had reductions of symptom severity, compared to 63% of patients in a pharmacologic-treatment group. 3 In another study, 63% of patients in an acupuncture group had reductions of symptom severity, compared to 34% of patients in a no-specific-therapy group, and acupuncture as an adjuvant to another CM treatment was significantly better than the other treatment alone. 4
It is known that acupuncture affects the visceral system by stimulating the somatic system and vagus nerve, which partially explains acupuncture's positive effects on digestion. This knowledge helps CM practitioners—who are aware of how acupuncture affects the brain and nervous system—use acupuncture more effectively.
I make my diagnoses using my own pulse diagnosis and biofeedback system. Examining the pulses is how I determine the imbalances that are causing a patient's conditions or symptoms. CM is about finding and treating the causes or roots of conditions, not just treating symptoms. With regard to treat IBS, most—if not all—patients with this condition have a blocked Dai Mai. The Dai Mai is the “belt channel” that connects all of the meridians that flow vertically. When it is blocked, the flow of the vertical channels is impeded. The Dai Mai block is easily felt in the patient's pulses and can be treated by using the Master point (GB 41) and the Coupled point (SJ 5) 5 with GB 26 as an additional point when necessary. Once the Dai Mai is open, I move on with pulse diagnosis to determine other imbalances. Naturally, the Spleen and Stomach are involved along with the Liver and Heart meridians.
Chong Mai is a very effective Extraordinary channel that can be used to address digestive issues. However, a clear choice when treating IBS with acupuncture needs to be stimulation of the central nervous system by using the Dai Mai, Gall Bladder, San Jiao, and/or Kidney channels. A prescription to treat IBS that has pain and constipation as frequent symptoms can be opening the Dai Mai, followed by ST 40, LI 6, LR 3, 14, LU 1, Chong Mai, HT 5, HT 7, ST 36, GV 20, and GV 24. For IBS with diarrhea as the predominant symptom, I might use Dai Mai, ST 22, ST 23, ST 24, ST 25, KI 6, KI 27, ST 36, LI 4, LI 11, TE 10, GV 20, and GV 24. If the patient has alternating constipation and diarrhea, I still open the Dai Mai, then remove the Excess or Stagnation that might be the cause of the pain and constipation. This is often accomplished by treating the Liver, Gall Bladder, and Stomach channels. The next step would be repairing the weak digestion through Chong Mai, SP 8, SP 9, ST 22, ST 23, ST 24, ST 25, Ren 12, ST 36, Du 20, and Du 24.
IBS is a complicated chronic condition that requires multiple acupuncture treatments along with nutrition and exercise recommendations. It is well-known in medical circles that exercise helps eliminate many physical symptoms and emotional conditions, including depression and anxiety. Yet, the beauty of this is that acupuncture and Chinese herbs also address the depression and anxiety that often accompany IBS, thereby, offering patients who have IBS an effective alternative to pharmaceuticals for treatments.
References
Fireman Z, Segal A, Kopelman Y, Sternberg A, Carasso R. Acupuncture treatment for irritable bowel syndrome: A double blinded controlled study. Digestion. 2001;64(2):100–103.
Chao CQ, Zhang S. Effectiveness of acupuncture to treat irritable bowel syndrome: A meta-analysis. World J Gastroenterol. 2014;20(7):1871–1877.
Manheimer E, Cheng K, Wieland LS, Min LS, Shen X, Berman B, Lao L. Acupuncture for the treatment of irritable bowel syndrome. Cochrane Database Syst Rev. 2012;5:CD005111.
Tillisch K. Complementary and alternative medicine for functional gastrointestinal disorders. Gut. 2006;55(5):593–596.
Maciocia G. Foundations of Chinese Medicine: A Comprehensive Text for Acupuncturists and Herbalists, 2nd ed. London: Churchill Livingstone; 2005.
Address correspondence to:
Martha Lucas, PhD, LAc
Lucas Acupuncture
1331 Vine Street
Denver, CO 80206
E-mail: