Acupuncture Therapeutics for IBD
Abstract
Irritable Bowel Disease, also abbreviated as IBD, is a chronic condition plaguing over 3 million adults in the US alone (Centers for Disease Control and Prevention [CDC], 2022) . Those with this disease suffer from chronic inflammation of their gastrointestinal tract, resulting in abdominal pain, chronic diarrhea, bloody stools, fatigue, weight loss and experience a lesser quality of life (Walfish & Companioni, 2023). Acupuncture and other Traditional Chinese Medicine modalities have shown through many studies to outperform conventional medicines, limited harmful side effects and improve overall quality of life in patients with IBD. It is important to share this research and provide quality care and relief with our patients suffering from IBD.
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What is IBD?
Irritable Bowel Disease, or IBD, is a chronic inflammatory condition of the GI tract that affects over 3 million people in the US and this number is growing, according to the CDC (CDC, 2022). According to Chen et al.(2020), they “reported that 32.9% of patients with CD eventually become disabled by the disease. Between 5 and 15% of UC patients required colectomy, and 80% of CD patients need at least one operation in their lifetime, which markedly affects quality of life” (p.1) People with IBD not only suffer with chronic and inflammatory bowel symptoms and GI flare ups, but also experience a seriously affected quality of life. Zhou et al. (2021) found that IBD is not only associated with depression, but that incidences of psychiatric disorders are also significantly higher for IBD patients when compared to the general public (p.1). This sheds light on the complexity of IBD and the need for treatments that truly assist patients dealing with this ailment.
IBD includes both Ulcerative Colitis and Crohn Disease. The immune system harnesses cell mediated responses to different threats that enter the body, however with IBD, the imbalance in intestinal flora inappropriately trigger immune reactions causing more harm and internal destruction rather than generating a healthy defense. These inflammatory culprits include cytokines, interleukins, tumor necrosis factor to name a few and when these start to respond unnecessarily, they wreak havoc on our mucosal membranes, resulting in ulcerations throughout the GI tract, bloody stool and intense abdominal pain. The exact cause of IBD is unknown, and symptoms can begin showing up in ages as early as 14 to 24 in young adults. Recent research shows that gut microbial disparity plays a role in the pathogenesis of IBD and so changes in how these microbiota are metabolized may effect immune 06/04/24 2 responses, epithelial dysfunction, and increase mucosa permeability thereby making gut microbiota balance key in treating IBD (Song et al., 2019, p 1134). Those who have family members with IBD are more likely to develop the autoimmune disease. Alongside correlating signs and symptoms, IBD is usually diagnosed through medical tests and scans such as stool cultures, sigmoidoscopy with biopsy, CT scans, Barium x-rays MRE, colonoscopy, or endoscopy (Walfish & Companioni, 2023).
What is Ulcerative Colitis?
A component of IBD, Ulcerative Colitis is limited to the large intestines or colon. Rectal bleeding is present; however, the patient will not suffer from fistulas or perianal lesions. Ulcerative Colitis affects the mucosa and submucosa layers of the colon and unlike Crohn disease, the mucosal membrane will most likely not show skip lesions as the inflammation is more uniform across the mucosa as opposed to skipping around the colon in patches, known as “cobblestone”. In severe cases, Ulcerative Colitis can cause damage all the way down to the muscle layer, resulting in paralysis in segment of colon. Also, colitis will not typically develop epithelial granulomas (Walfish & Companioni, 2023).
What is Crohn Disease?
Crohn Disease is a subcategory of IBD and is also known as Regional Enteritis or Granulomatous Ileitis. Unlike Ulcerative Colitis, this digestive disorder most often affects the small intestine and can affect the entire GI tract and is therefore not limited to the colon and will not always present with rectal bleeding. Crohn disease is a chronic transmural inflammatory bowel disease and can cause mucosal lesions and ulcers throughout the bowels to create it’s characteristic cobblestone appearance in the bowels. Because this disease affects the entire GI tract as the disease and inflammation progresses, the bowel walls can thicken creating hypertrophy or fibrosis of bowel structures and even lead to abscesses or fistulas that affect adjacent structures, such as the bladder, or psoas muscle (Walfish & Companioni, 2023).
Conventional Treatments?
Conventional treatment for IBD involves symptoms management. These include, dietary advice, anti-diarrhea medications, anti-inflammatory medicines, Sulphasalzaine (SASP) and 5-aminosalicycle acid (5-ASA), steroids, biologics and immunosuppressive agents and surgery in some cases. Not only can these treatment options prove expensive and economically burdensome, but also cause adverse side effects. Side effects can be serious including, severe stomach pain, jaundice, vomiting, dizziness, severe fatigue, headache and rash, just to name a few. (Ji et al., 2013, p. 1).
How Can Chinese Medicine Help?
Overall Efficacy of Acupuncture & Moxibustion Much research has been done to provide evidence of acupuncture’s therapeutic strength in treating IBD, showing Traditional Chinese Medicine (TCM) intervention can effectively Treating Inflammation 06/04/24 3 control bowel inflammation and regulation of the body’s physiological reactions (Ji et al., 2013, p. 1). Specifically in a large randomized control trial with a participation pool of 220 patients, researchers observed electroacupuncture and moxibustion treatment in patients with ulcerative colitis versus conventional oral SASP treatment. They found the overall efficacy of the treatment group (acupuncture and moxibustion group) was 84.5%, which was significantly better than the control group (SASP) which showed a 68.2% clinical effectiveness rate (Ji et al., 2013, p. 4). Furthermore, in a 2004 study a group of 51 patients with Crohn Disease were divided into two groups, where one group received acupuncture and moxibustion and the other received sham acupuncture. After 4 weeks of treatment, the Crohn Disease Activity Index (CDAI) of the patients receiving acupuncture and moxibustion decreased dramatically compared to the sham acupuncture group (Ji et al., 2013, p. 4). Another study observing patients with ulcerative colitis found that after 5 weeks of acupuncture and moxibustion treatments vs sham acupuncture, the patients receiving true TCM reported significantly lower Colitis Activity Index (CAI) than the CAI of the control group (Ji et al., 2013, p. 5). Researchers Ji et al. (2013) concluded in their meta analysis of evidence based research an overall efficacy of acupuncture and moxibustion treatments to be greater and yield more significant results than western medicine specifically in comparison to conventional oral SASP for the treatment of IBD (Ji et al., 2013, p. 6).
Treating Inflammation
The vagus nerve innervates most of the GI tract and plays a crucial role in homeostasis and sending anti inflammatory signals to the body (Song et al. 2019, p. 1131). Researches Song et al. (2019) explain that the vagus nerve does this by inhibiting, via different pathways, tumor necrosis factor, and other pro-inflammatory cytokines while also releasing cortisol by the adrenal glands (p.1131). They noted that recent studies evaluating the stimulation of the vagus nerve found those suffering from chronic inflammation conditions had reduced cytokine and tumor necrosis factor numbers throughout the body (p.1131). These results help to illustrate how the vagus nerve may rebalance the release of inflammatory responses in the body and ease patients inflammation. Song et al. (2019) share that in a recent study that combined vagus nerve stimulation with electroacupuncture to treat rats with ulcerative colitis, they measured a decrease in pro inflammatory cytokines post treatment and improve specific inflammation that caused damaging ulcers in mucosal bowels (p.1132). The combination of vagus nerve stimulation and acupuncture may provide inflammation relief for those diagnosed with IBD.
Balancing Microbiota and Strengthen Gut Barrier
As mentioned above, a possible pathogenesis to IBD is the imbalance in gut microbiota, leading to overactive immune response flare ups, epithelial dysfunction and mucosa permeability. Acupuncture influences the gut microbiota, thereby creating a cascading therapeutic effect. One study found that moxibustion on ST25 and Ren 6 rebalanced gut microbiota, specifically, “increasing Bifidobacterium and Lactobacillus and decreasing Escherichia coli and Bacteroids fragilis” (Song, et al., 2019, p. 1134). Once these bacterial microbiota were rebalanced, inflammation factors were suppressed, including tumor necrosis factor and IL 12 expression (P. 1134). Song et al. (2019) highlighted a study that used acupuncture at acupoints ST2, ST21 and ST36 and found the treatment to partially reversed dysfunctional gut microbiota metabolites such a dimethylamine, which is a bacteria often responsible for stomach inflammation (p. 1134).
Along with acupuncture’s rebalancing effects on microbiota in the gut, recent studies have also shown its advantageous effects at restoring gut barrier. Authors, Song et al. (2019), found that acupuncture at ST36 displayed supportive effects in “decreasing local intestinal inflammation, reducing barrier breakdown, alleviating permeability in the distal ileum and maintaining expression of tight junction protein zonula occludens-1 (ZO-1)” (p. 1135). Additionally, another study observing Crohn disease revealed acupuncture paired with moxibustion worked better than mesalamine in reducing intestinal inflammation and improving epithelial barrier repair by increasing gut protein ZO-1 and claudin-1. (Song, et al., 2019, p. 1134). When these epithelial components of the innate immune responses function abnormally, then IBD symptoms and flare ups occur, so strengthening and repairing the gut barrier is essential in treating IBD and initiating systemic health, which can effectively to be through TCM.
Abdominal Pain
Most people with IBD experience intense abdominal pain. Conventional treatment for abdominal pain includes the use of narcotics, which can have addictive and adverse effects, such as constipation and nausea, which add the IBD list of symptoms, even with providing pain relief. Acupuncture has proven to be affordable with safe, analgesic properties. Many studies have shown receiving acupuncture post surgery delayed the use of opioids (Song et al., 2019, p. 1136). Also, Song et al. (2019) note that well over 1000 randomized control trials have sustained the effectiveness of acupuncture when treating chronic pain such as back, neck, knee, shoulder pain, headache and osteoarthritis (p. 1136). This evidence helps to inform acupuncture’s appropriate application for IBD patients experiencing painful flare ups.
Regulating Bowel Function
Many patients diagnosed with IBD experience bouts of diarrhea and abnormal small intestine and large intestine motility. Acupuncture effectively ameliorates these symptoms. Song, et al. (2019) list a study that used acupoint PC 6 and ST36 to help to cease chronic diarrhea and another study found that regular acupuncture received 3 times a week for a period of 4 weeks helped to improve diarrhea and abdominal pain (p. 1135). One study that provided the same amount of treatments, observed the effects of moxibustion on ST 25 and ST 36, but for a duration of 6 weeks, had demonstrated an improvement in participants quality of life and stool form in over 100 patients with diarrhea as their chief complaint (Song et al., 2019, p. 1135). These examples illustrate acupuncture’s effectiveness at regulating stool and diarrhea symptoms, but TCM can also address gut motility malfunctions as well.
Research has investigated acupuncture’s effects on GI motility, which has proven to be beneficial and helpful. It is important to note that these recent studies have not researched GI motility malfunctions in connection with IBD specifically, but those with chronic irritable bowel disease do suffer with intestinal movement impairments. Song et al. (2019) noted a study that found using electroacupuncture at PC6 and ST36 in animals reduced nausea, vomiting, and stimulated gastric emptying (p. 1135). It was also noted that the use of ST36 increased motility in the small intestines while ST 25 inhibited jejunal motility (Song, et al., 2019, p. 1136). These studies provide evidence that TCM can successfully regulate bowel movements and address gut motility issues and symptoms that play such a big part of IBD.
Improving Quality of Life
According to Song et al. (2019) the incidence of depression or anxiety in patients with IBD is almost 30% higher than that of the general public, making it a necessary component of IBD to address. Acupuncture treatments have been effective at mimicking anti-depressants behavior and their ability to diminish the severity of symptoms with patients suffering from depression and anxiety (p. 1136). An acupuncture study aimed at treating anxiety and depression-like behavior in IBD induced rats found that acupuncture points SP6 and ST36 receiving electroacupuncture (EA) for 30 min daily for 14 days, diminished anxiety and depression in colitis test subjects (Zhou et al., 2020, p.1). In this study, electroacupuncture at these two acupoints reversed weight loss, low daily food intake and addressed colon length in rats with induced IBD. EA therapy also increased the amount of time spent in shared spaces post EA treatments, suggesting that EA could improve overall anxiety and depression like behavior (Zhou et al., 2020, p. 7). Short chain fatty acids (SCFAs) producing bacteria were all increased after electroacupuncture therapy as well, suggesting this may be why EA treatments improved anxiety and depression in IBD patients, because these SCFAs beyond impacting metabolism, immunity and tight gut junctions, also may “influence neuropsychiatric disorders and improve psychological functioning” (Zhou et al., 2020, p. 15).
Summary
Traditional Chinese Medicine is effective, safe and an affordable option for treating Irritable Bowel Disease. Acupuncture and moxibustion has proven capable and even successful in treating severe abdominal pain, anxiety, depression, diarrhea and influencing the internal structures of the GI tract. This is beneficial research that will help many patients whom are looking for 06/04/24 6 alternative healing modalities, to better understand the value of acupuncture. These studies will also strengthen the health practitioner’s toolbox when a patient with IBD walks into their practice, knowing that they can help their patients in a real way.
References
Center for Disease Control Prevention (2022, April 13). Prevalence of IBD. https://www.cdc.gov/ibd/data and- statistics/prevalence.html
Chen, P., Zhou, G., Lin, J., Zeng, Z., Chen, M., & Zhang, S., (2020). Serum biomarkers for inflammatory bowel disease, 7, 1-17, doi10.3389/fmed.2020.00123
Ji, J., Lu, Y., Liu, H., Feng, H., Zhang, F., Wu, L., Cui, Y., & Wu, H. (2013). Acupuncture and moxibustion for inflammatory bowel diseases: A systematic review and meta-analysis of randomized controlled trials, 2013, 1-11. doi: 10.1155/2013/158352
Song, G., Fiochhi, C., & Achkar, J-P. (2019) Acupuncture in inflammatory bowel disease, 2019, 25, 1129-1139. doi 10.1093/ibd/izy371
Walfish, A & Companioni, R-A-C. (2023). Crohn Disease. Retrieved from https://www.merckmanuals.com /professional/gastrointestinal disorders/inflammatory-bowel disease-ibd/crohn-disease
Walfish, A & Companioni, R-A-C. (2023). Overview of inflammatory bowel disease - gastrointestinal disorders. Retrieve from https://www.merckmanuals.com /professional/gastrointestinal disorders/inflammatory-bowel disease-ibd/overview-of inflammatory-bowel-disease
Walfish, A & Companioni, R-A-C. (2023). Ulcerative Colitis. Retrieved from https://www.merckmanuals.com /professional/gastrointestinal disorders/inflammatory-bowel disease-ibd/ulcerative-colitis
Zhou, F., Jiang, H., Kong, N., Lin, J., Zhang, F., Mai, T., Cao, Z., & Xu, M. (2022). Electroacupuncture attenuated anxiety and depression-like behavior via inhibition of hippocampal inflammatory response and metabolic disorders in tnbs induced ibd rats, 2022, 1-19. doi 10.1155/2022/8295580
