13 Jan ACUPUNCTURE AND IRRITABLE BOWEL SYNDROME
IBS Patients: What To Expect
Before we dive into why acupuncture and irritable bowel syndrome go together, let’s take a look at what is actually IBS. IBS is considered a chronic, functional disorder of the gastrointestinal system. It presents either as diarrhea predominant (IBS-D), constipation predominant (IBS-C) or both (IBS-M). On a global scale, 5%-30% of a given population is affected by IBS. (1)
IBS is often associated with psychosomatic symptoms. While any condition can be aggravated by emotional triggers like anger, anxiety or worries, the body-mind link can be even more poignant in diseases affecting the abdominal region. It is no longer a secret that the intestines are nothing short of a 2nd brain (2) anatomically located in a region with the highest concentration of nervous tissue after the cerebral counterpart.
IBS patients will report abdominal pain, possibly with a feeling of incomplete bowel movement. Feces may contain mucus discharge. Gastric symptoms also often manifest. Clinicians should note that IBS may also become a cause of chronic fatigue and systemic inflammation. IBS is a diagnosis of exclusion.
•Irregular bowel movements
•Abdominal discomfort without any signs of lesions at the visceral level
•Patients may also present:
•Constipation or diarrhea, or a combination of both
•Relief with bowel movement
In the spirit of the integrative approach to IBS, proposed in the February 2015 article published in the World Journal of Gastroenterology (3), relaxation and dietary adaptations have a place alongside acupuncture in the management of IBS.
Intolerances and food allergies should be ruled out either by appropriate available testing and/or meal journaling.
Acupuncture in the treatment of IBS: Eliminating visceral pain and establishing functional integrity
Randomized controlled trials have shown that acupuncture is effective at treating IBS (4) A meta-analysis published in 2014 in the World Journal of Gastroenterology also concluded to the effectiveness of acupuncture in the treatment of IBS (5)
In 2012, a Cochrane review claimed that ‘’sham-controlled randomized controlled trials have found no benefits of acupuncture relative to a credible sham acupuncture control for IBS symptom severity or IBS-related quality of life’’ It should be taken into account that a credible sham acupuncture control might very well be in fact, an active control.. i.e. another acupuncture treatment wrongly assumed to be inactive. Relative comparison of an intervention to an active control is based on logic defying methodology. Nevertheless, the negative review states an important point: »Among randomized controlled trials that did not use a placebo control, acupuncture was more effective than pharmacological therapy. » (6) (7) (8)
The acupuncture evidence project, published in 2017 by the Australian Acupuncture and Chinese Medicine Association, states there is a potential positive effect of acupuncture for IBS. (9)
Moxibustion in the treatment of IBS
Altough this summary focuses on acupuncture, acupuncturists should bear in mind a possibly important clinical implication outlined in the evidence. Animal models demonstrated that moxibustion can beat electroacupuncture (EA) alone, particularly in cases where diarrhea is predominant over constipation. Temperature specific moxibustion showed superior benefits. Conversely, EA was found to be more effective than moxibustion in the treatment of constipation and visceral sensitivity.(10) (11) (12) Moxibustion is often upgraded to LASER acupuncture in actual, modern clinical settings.
IBS patients may have significant epithelial gaps in their small intestine compared with healthy subjects. Jean-François Turcotte et al. suggest these ‘’breaks in the wall’’ of the intestinal epithelium create alterations of permeability in the human intestine. (13)
⚙️Mechanisms: Acupuncture in the Treatment of IBS
•Regulates intestinal motility. A serotonergic pathway has been demonstrated to act at the level of the motor dysfunction of the colon. (14) (15) (16)
•Promotes behavioral change. Through pain and stress relief (16)
•Regulates visceral hypersensitivity. Explained in part by the modulation of the serotonin pathway at the insula and the modulation of mood in cortical centers, more precisely in the thalamus. (17) Ion channel, TrpV1 expression and ERK1/2 MAPK pathway activation in the peripheral and central nervous system might be involved in the analgesia of abdominal pain. (18) Analgesia at the visceral level may be mediated by endogenous opioids pathways. This was found to be associated with reversal of the elevated excitability of colon dorsal root ganglion neurons and receptors expression. (19) (20) (21)
•Regulates neuroendocrine, immunological functions & the Microbiota-Gut-Brain axis functions. Evidence has put into light the upregulation of neuro-peptide Y (NPY) (22) (23), modulation of serotonin (5-HT..) receptors (15) (24)(25) (26) somatostatin (SS) (23), and downregulations of substance P (SP), vasoactive intestinal peptide (VIP) (27) (28) (29) (30) (31) colonic calcitonin gene-related peptide (CGRP) (15)(32), corticotropin-releasing hormone (CRH) (31) (33) (34), purinergic (P2X) receptors (20) (21) and Fos expression (25) (35)
Biomarkers evidenced in the Acupuncture treatment of IBS
Acupoint specific mechanisms: a budding field of research
The following points are commonly used in acupuncture clinical trials studying the therapeutic effects on IBS.
(Stomach 36) 足三里
Stimulates the colon’s motility, which may also benefit patients with gastroesophageal reflux disease or functional dyspepsia, and those with constipation predominant-IBS. Regulates neuropeptide Y in thalamus and somatostatin in colonic tissues and blood.
(Large Intestine 4) 合谷
Regulates neuropeptide Y in thalamus and somatostatin in colonic tissues.
(Conception Vessel 12) 中脘
Demonstrated in both human and rat models, acupoint CV 12 inhibits the colon’s motility, which may benefit patients with diarrhea predominant-IBS. (37) (23)
💊Acupuncture Beats Drugs
Electroacupuncture and loperamide medication were found equivalent in their effect of reducing bowel movement frequency in IBS patients. In fact, both interventions increased the weekly average of days with normal stools. (38) Paradoxically, loperamide’s side effects may mimic IBS’ symptoms, including constipation. Most common side effects include a general physical weakness, sleepiness, dizziness, gas, headaches, nausea, vomiting, and dry mouth.
Pinaverium and Probiotics
In a trial evaluating the efficacy on diarrhea-predominant IBS patients, the treatment’s total effective rate of the acupuncture group was found to be significantly superior compared to the medication group, which had been given pinaverium combined with a live bifidobacterium probiotic. Score was obviously better in the acupuncture group at week 1 and week 4 of treatment, as well as 3 months after the treatment. In consequence, acupuncture was considered superior to the medication evaluated in the treatment for diarrhea predominant-IBS.(39) Pinaverium’s main side effects may be similar to IBS itself, including stomach pain or fullness, nausea, constipation or diarrhea, heartburn, headache, and dry mouth.
In another study comparing acupuncture to pinaverium alone, acupuncture’s effective rate was also superior to the pharmaceutical treatment. On the follow-up at 3 months the acupuncture treatment also beat the abovementioned drug.(40)
Deanxit and Probiotics
In yet another trial, comparing acupuncture versus a probiotic supplementation combined with medication (Bacillus licheniformis+Deanxit), there was also a lower recurrence of IBS in the electroacupuncture group at the 3 months follow up.(41) Deanxit is a medication that combines flupentixol (an antipsychotic) and melitracen (a tricyclic antidepressant). Deanxit is now banned in several countries due to its potentially serious neurological side effects.
In a study comparing still another drug -trimebutin maleate- to acupuncture, again, acupuncture prevailed. (42) Trimebutin maleate’s side effects may also resemble IBS. These include, but are not limited to, constipation, diarrhea and abdominal pain.
Acupuncture is widely recognized as a safe intervention when delivered by licensed practitioners who meet the standards required for licensed acupuncturists and physicians. In the light of the available data, a meta-analysis allowed for an unequivocal statement: ’’Acupuncture and moxibustion for IBS is better than conventional western medication treatment.’’ (43)
There is evidence to support the use of cognitve behavior therapy in the treatment of IBS. It’s effect was found significantly larger than relaxation therapy alone. Gut-directed hypnotherapy has also been shown to be effective. A 2009 Cochrane review concluded that psychological interventions may be slightly superior to standard care. (44) (45) (46)
Cost-effectiveness of Acupuncture for IBS
While acupuncture may be cost-effective for the severe forms of IBS, the intervention may not be a cost-effective option for all IBS patients as an adjunct to usual care. (47)
✍🏼About the author
Olivier Roy has 15 years of clinical acupuncture experience, deployed in a plurality of diverse contexts: multidisciplinary models, readaptation clinics, hospitals, private clinics. His practice focuses on japanese acupuncture, acupressure, scalp acupuncture, and LASER acupuncture. His private practice is established in Montreal, Canada.
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