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
•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
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.
(1) The epidemiology of irritable bowel syndrome, Clin Epidemiol. 2014; 6: 71–80. Published online 2014 Feb 4.doi:10.2147/CLEP.S40245, Caroline Canavan, Joe West, and Timothy Card
(2) Think Twice: How the Gut’s « Second Brain » Influences Mood and Well-Being by Adam Hadhazy on February 12, 2010
(3) Treatment of irritable bowel syndrome in China: A review Chun-Yan Li, World J Gastroenterol. 2015 Feb 28; 21(8): 2315–2322. Published online 2015 Feb 28. doi:10.3748/wjg.v21.i8.2315
(4) Electroacupuncture versus Moxibustion for Irritable Bowel Syndrome: A Randomized, Parallel-Controlled Trial, Yin Shi et al., Evid Based Complement Alternat Med. 2015; 2015: 361786. Published online 2015 Jul 30.doi:10.1155/2015/361786
(5) Effectiveness of acupuncture to treat irritable bowel syndrome: A meta-analysis, Guan-Qun Chao and Shuo Zhang, World J Gastroenterol. 2014 Feb 21; 20(7): 1871–1877. doi: 10.3748/wjg.v20.i7.1871
(6) Acupuncture for treatment of irritable bowel syndrome, Eric Manheimer et al., Cochrane Database of Systematic Reviews, 16 May 2012 DOI: 10.1002/14651858.CD005111.pub3
(7) Sham Acupressure Controls Used in Randomized Controlled Trials: A Systematic Review and Critique, Jing-Yu Tan, PLOS One, July 15, 2015, https://doi.org/10.1371/journal.pone.0132989
(8) The gap between results from sham-controlled trials and trials using other controls in acupuncture research-the influence of context, Witt CM et al.,Complement Ther Med. 2013 Apr;21(2):112-4. doi: 10.1016/j.ctim.2012.12.005. Epub 2013 Jan 3.
(9) The Acupuncture Evidence Project: A Comparative Literature Review (Revised Edition). Brisbane: Australian Acupuncture and Chinese Medicine AssociationMcDonald J, Janz S. Ltd; 2017
(10) Comparison of the analgesic effects between electro-acupuncture and moxibustion with visceral hypersensitivity rats in irritable bowel syndrome, Ji-Meng Zhao, et al. World J Gastroenterol. 2017 Apr 28; 23(16): 2928–2939. Published online 2017 Apr 28. doi:10.3748/wjg.v23.i16.2928
(11) Comparison of Electroacupuncture and Moxibustion for Relieving Visceral Hypersensitivity in Rats with Constipation-Predominant Irritable Bowel Syndrome,Ji-Meng Zhao, et al.,Evid Based Complement Alternat Med. 2016; 2016: 9410505. Published online 2016 Sep 22.doi:10.1155/2016/9410505
(12) Electroacupuncture versus Moxibustion for Irritable Bowel Syndrome: A Randomized, Parallel-Controlled Trial Yin Shi et al., Evidence-Based Complementary and Alternative MedicineVolume 2015 (2015), Article ID 361786, 12 pages
(13) Breaks in the wall: increased gaps in the intestinal epithelium of irritable bowel syndrome patients identified by confocal laser endomicroscopy (with videos), Jean-Francois Turcotte et al., Gastrointestinal Endoscopy, April 2013 Volume 77, Issue 4, Pages 624–630 DOI:http://dx.doi.org/10.1016/j.gie.2012.11.006
(14) Acupuncture-moxibustion in treating irritable bowel syndrome: how does it work?Ma XP et al., World J Gastroenterol. 2014 May 28;20(20):6044-54. doi:10.3748/wjg.v20.i20.6044
(15) Electro-acupuncture decreases 5-HT, CGRP and increases NPY in the brain-gut axis in two rat models of Diarrhea-predominant irritable bowel syndrome(d-IBS), Jianhua Sun, et al., BMC Complement Altern Med. 2015; 15: 340.Published online 2015 Sep 29. doi:10.1186/s12906-015-0863-5
(16) Electro-acupuncture attenuates stress-induced defecation in rats with chronic visceral hypersensitivity via serotonergic pathway, Xiao YuTian et al., Brain Research, Volume 1088, Issue 1, 9 May 2006, Pages 101-108 https://doi.org/10.1016/j.brainres.2006.03.014
(17) Does Acupuncture Therapy Alter Activation of Neural Pathway for Pain Perception in Irritable Bowel Syndrome?: A Comparative Study of True and Sham Acupuncture Using Functional Magnetic Resonance Imaging, Winnie CW Chu, J Neurogastroenterol Motil. 2012 Jul; 18(3): 305–316. Published online 2012 Jul 10. doi: 10.5056/jnm.2012.18.3.305
(18) Acupuncture Alleviates Colorectal Hypersensitivity and Correlates with the Regulatory Mechanism of TrpV1 and p-ERK, Shao-Jun Wang et al., Evidence-Based Complementary and Alternative Medicine, Volume 2012 (2012), Article ID 483123, 10 page, http://dx.doi.org/10.1155/2012/483123
(19) Electroacupuncture attenuates visceral hyperalgesia and inhibits the enhanced excitability of colon specific sensory neurons in a rat model of irritable bowel syndrome, G.-y. Xu et al., 24 June 2009, Neurogastroenterology & Motility, DOI: 10.1111/j.1365-2982.2009.01354.x
(20) Electroacupuncture diminishes P2X2 and P2X3 purinergic receptor expression in dorsal root ganglia of rats with visceral hypersensitivity, Zhijun Weng et al., Neural Regen Res. 2013 Mar 25; 8(9): 802–808. doi:10.3969/j.issn.1673-5374.2013.09.004
(21) Electroacupuncture at He-Mu points reduces P2X4 receptor expression in visceral hypersensitivity, Guo X et al., Neural Regen Res. 2013 Aug 5;8(22):2069-77. doi: 10.3969/j.issn.1673-5374.2013.22.006.
(22) Electro-acupuncture decreases 5-HT, CGRP and increases NPY in the brain-gut axis in two rat models of Diarrhea-predominant irritable bowel syndrome(d-IBS), Jianhua Sun. BMC Complement Altern Med. 2015; 15: 340. Published online 2015 Sep 29.doi:10.1186/s12906-015-0863-5
(23) Effect of electro-acupuncture at different acupoints on neuropeptide and somatostatin in rat brain with irritable bowel syndrome, Wen-lian Zhu et al., Chinese Journal of Integrative Medicine, Volume 18, Issue 4, p 288–292, https://doi.org/10.1007/s11655-011-0795-y, Chinese Association of Traditional and Western Medicine,Online ISSN1993-0402
(24) Effects of electroacupuncture at ST25 and BL25 in a Sennae-induced rat model of diarrhoea-predominant irritable bowel syndrome, Xianwei Zhu et al. BMJ Journals, Acupuncture in Medicine 2017;35:216-223, http://aim.bmj.com/content/35/3/216, Published first 15 November 2016.
(25) Effect of Electroacupuncture on Visceral Hyperalgesia, Serotonin and Fos Expression in an Animal Model of Irritable Bowel Syndrome, Justin CY Wu, J Neurogastroenterol Motil 2010; 16(3): 306-314 https://doi.org/10.5056/jnm.2010.16.3.306
(26) Electroacupuncture versus Moxibustion for Irritable Bowel Syndrome: A Randomized, Parallel-Controlled Trial Yin Shi et al., Evidence-Based Complementary and Alternative MedicineVolume 2015 (2015), Article ID 361786, 12 pages http://dx.doi.org/10.1155/2015/361786
(27) Regulatory Mechanism of Electroacupuncture in Irritable Bowel Syndrome: Preventing MC Activation and Decreasing SP VIP Secretion, Huan-Gan Wu et al., Digestive Diseases and Sciences, Volume 53, Issue 6,pp 1644–1651
(28) Comparative effect of electroacupuncture and moxibustion on the expression of substance P and vasoactive intestinal peptide in patients with irritable bowel syndrome. Zhenzhong L et al., J Tradit Chin Med. 2015 Aug;35(4):402-10.
(29) Effect of Electroacupuncture Intervention on Constipation-predominant Irritable Bowel Syndrome and Colonic CGRP and SP Expression in Rats, Zhang YN et al., Zhen Ci Yan Jiu, 2016 Feb;41(1):31-4.
(30) Effect of acupuncture at « Zusanli » (ST 36 and « Taichong » (LR 3) on gastrointestinal hormone levels in rats with diarrhea type irritable bowel syndrome, Liu MR et al. , Zhen Ci Yan Jiu. 2012 Oct;37(5):363-8.
(31) Effect of electro-acupuncture on substance P, its receptor and corticotropin-releasing hormone in rats with irritable bowel syndrome, Xiao-Peng Ma et al., World J Gastroenterol. Nov 7, 2009;15(41): 5211-5217 Published online Nov 7, 2009.doi:10.3748/wjg.15.5211
(32) Effect of Electroacupuncture Intervention on Constipation-predominant Irritable Bowell Syndrome and Colonic CGRP and SP Expression in Rats, Zhang YN et al., Zhen Ci Yan Jiu. 2016 Feb;41(1):31-4.
(33) Electro-acupuncture relieves visceral sensitivity and decreases hypothalamic corticotropin-releasing hormone levels in a rat model of irritable bowel syndrome, Huan-ganWu et al., Neuroscience Letters, Volume 465, Issue 3, 20 November 2009, Pages 235-237, https://doi.org/10.1016/j.neulet.2009.09.018
(34) Effects of electroacupuncture on corticotropin-releasing hormone in rats with chronic visceral hypersensitivity, Hui-Rong Liu et al., World J Gastroenterol. 2015 Jun 21; 21(23): 7181–7190.Published online 2015 Jun 21. doi:10.3748/wjg.v21.i23.7181
(35) Neuropeptides and the Microbiota-Gut-Brain Axis, Neuropeptides and the Microbiota-Gut-Brain Axis, Peter Holzer and Aitak Farzi Adv Exp Med Biol. 2014; 817: 195–219. doi:10.1007/978-1-4939-0897-4_9
(36) Downregulation of the spinal NMDA receptor NR2B subunit during electro-acupuncture relief of chronic visceral hyperalgesia, Hongping Liu et al., The Journal of Physiological Sciences, Volume 67,Issue1, pp 197–206
(37) Acupuncture for functional gastrointestinal disorders, Toku Takahashi, Journal of Gastroenterology, Volume 41, Issue 5, pp 408–417, https://doi.org/10.1007/s00535-006-1773-6
(38) Electroacupuncture for patients with diarrhea-predominant irritable bowel syndrome or functional diarrhea: A randomized controlled trial, Zheng H et al., Medicine (Baltimore). 2016 Jun;95(24):e3884. doi: 10.1097/MD.0000000000003884.
(39) Effects and efficacy observation of acupuncture on serum 5-HT in patients with diarrhea-predominant irritable bowel syndrome, Zhan DW et al., Zhongguo Zhen Jiu. 2014 Feb;34(2):135-8., PMID: 24796047
(40) Comparative observation on therapeutic effects between acupuncture and western medication for diarrhea-predominant irritable bowel syndrome, Li H et al., Zhongguo Zhen Jiu. 2012 Aug;32(8):679-82.
(41) Comparison of the therapeutic effects of electroacupuncture and probiotics combined with deanxit in treating diarrhea-predominant irritable bowel syndrome, Chen YH et al., Zhongguo Zhong Xi Yi Jie He Za Zhi. 2012 May;32(5):594-8.
(42) Comparative study on irritable bowel syndrome treated with acupuncture and western medicine, Shi ZM et al., Zhongguo Zhen Jiu. 2011 Jul;31(7):607-9.
(43) Meta analysis of acupuncture-moxibustion in treatment of irritable bowel syndrome, Pei LX et al., Zhongguo Zhen Jiu. 2012 Oct;32(10):957-60.
(44) Psychological Interventions for Irritable Bowel Syndrome and Inflammatory Bowel Diseases, Sarah Ballou and Laurie Keefer Clin Transl Gastroenterol. 2017 Jan; 8(1): e214. Published online 2017 Jan 19 doi:10.1038/ctg.2016.69
(45) Comparative efficacy of psychological therapies for improving mental health and daily functioning in irritable bowel syndrome: A systematic review and meta-analysis, Kelsey T.Laird et al., Clinical Psychology Review, Volume 51, February 2017, Pages 142-152, https://doi.org/10.1016/j.cpr.2016.11.001
(46) Psychological treatments for the management of irritable bowel syndrome, Cochrane review, Zijdenbos IL, 21 January 2009
(47) Cost-effectiveness of acupuncture for irritable bowel syndrome: findings from an economic evaluation conducted alongside a pragmatic randomised controlled trial in primary care, Eugena Stamuli et al., BMC Gastroenterology 2012 12:149
Cover photo by People photo created by drobotdean – www.freepik.com