The Treatment of Constipation-Predominant Irritable Bowel Syndrome with Acupuncture and Moxibustion: A Case Report (2024)

Abstract

Irritable bowel syndrome (IBS) is one of the most common functional gastrointestinal disorders in North America. The severity and chronic nature of this condition have a significant impact on health-related quality of life. With few effective therapies available, there is a need for integrative approaches to symptom management. This report describes a successful case of using acupuncture and moxibustion to reduce symptoms of constipation-predominant IBS.

Introduction

Irritable bowel syndrome (IBS) is a common gastrointestinal (GI) disorder in which abdominal pain or discomfort is associated with defecation or a change in bowel habit.¹ In addition to GI symptoms of diarrhoea and/or Constipation, bloating, belching and flatulence, patients commonly report non-GI symptoms such as fatigue and anxiety. The prevalence of IBS in North America and Europe is estimated to be 10 to 15 per cent; it occurs more often in women than men and is increasing in countries with developing economies.² According to the Rome III diagnostic criteria for functional GI disorders,¹ which is accepted and used by most allopathic clinicians, a diagnosis of IBS is made if a patient experiences recurrent abdominal pain or discomfort for at least three days per month three months, with the onset of symptoms at least six months prior to the diagnosis. The recurrent abdominal pain or discomfort must be associated with at least two of the following symptoms: improvement with defecation, onset associated with a change in frequency of the stool, and/or onset associated with a change in form or appearance of the stool.¹ IBS is subtyped according to predominant stool patterns as follows: IBS with constipation (IBS-C), IBS with diarrhoea (IBS-D), IBS-Mixed (IBS-M) and unsubtyped IBS (IBS-U).¹

IBS has been associated with an impact on several domains including work, activities, quality of life,³ and healthcare resource utilisation.^4,5,6 Patients with IBS consistently report greater absences from school and work,⁷ limitations in social activities and lifestyle modifications.⁸ Additionally, the direct and indirect costs of IBS are estimated to exceed 20 billion dollars annually in the United States.³

Pathophysiology

The exact pathophysiology of IBS remains unknown. Possible factors that have been proposed are: altered gut motility, enhanced visceral sensitivity, dysregulated brain-gut communication and abnormal serotonin levels in the GI tract, immune activation, alterations in gut microflora, genetic factors and psychosocial distress.⁹ There is no cure for IBS and current treatment focuses on symptom management using anti-diarrhoea medication, anticholinergics, antidepressants, antispasmodics, antibiotics, laxatives, probiotics and fibre supplements. In addition, lifestyle and dietary changes are often recommended, for example exercise, increasing dietary fibre and avoiding specific foods. Foods that have been reported to aggravate IBS symptoms include: caffeinated beverages, alcohol, raw fruits and vegetables, dairy products or certain artificial sweeteners like sorbitol and xylitol.¹⁰ Two drugs have been approved for the treatment of IBS. Alosetron is a selective serotonin 5-HT3 antagonist prescribed for women (clinical studies have not confirmed its benefit in men) by physicians enrolled in a restricted marketing programme; it is intended for severe cases of diarrhoea-predominant IBS that have not responded to other treatment, and works by blocking the action of serotonin in the colon and slowing the movement of the stool through the intestines. Serious adverse reactions have been reported with its use such as ischaemic colitis and severe constipation.¹¹ Lubiprostone is a laxative approved for women with constipation-predominant IBS. It works by increasing the amount of fluid in the intestines to allow the stool to pass through more easily. However, common side-effects include nausea, diarrhoea and abdominal pain.¹²

Research

The efficacy of acupuncture for the treatment of IBS has been studied in a few randomised controlled trials (RCTs).^13,14,15,16 A 2006 meta-analysis reported that the effects of acupuncture are variable, and that it remains inconclusive whether acupuncture is more effective than control or any other interventions; the papers studied were hampered by their sample sizes, power and controls.¹⁷ This case study illustrates a successful case of using acupuncture and moxibustion to treat IBS symptoms.

Case report

A 28-year-old woman with a one-year history of constipation-predominant IBS presented with abdominal pain. Two years previously the patient had experienced an episode of acute gastroenteritis after returning from a trip to South America, which seemed to resolve after three days. However, over the next three months she developed symptoms of abdominal pain and cramping in the lower quadrant, constipation and flatulence. Her physician found no abnormal findings on physical examination or routine blood work, and a lower GI series ruled out other possible conditions. According to Rome III criteria her physician diagnosed her with IBS. Her IBS symptoms persisted for several months with further abdominal pain, constipation and bloating. She experienced only minimal relief from using stool softeners and fibre supplements such as psyllium, and avoiding dairy products, spicy food, coffee and carbonated beverages. She reported no history of any other medical or psychiatric problems in either her or her family, although she reported seeing a therapist occasionally. She was married and worked in a professional administrative position. She exercised occasionally, drank alcohol socially and was a non-smoker. Her only medications were multivitamins and oral contraceptives. She was referred for acupuncture treatment by her gastroenterologist.

During her initial visit, the patient rated her overall abdominal pain score as eight on a scale of one to ten. She reported incomplete bowel movements every three to four days and her stools were hard and difficult to pass. Her stool size was either quite small or very large, and her lower abdominal pain felt better after a bowel movement. Her complexion was clear and pale with dark circles under her eyes, although she reported no sleep problems or fatigue. Her hair was full and thick. She reported that her hands and feet often felt warm and sweaty. Her diet consisted of mostly organic foods - meat, fish, grains, fruits and vegetables - and she avoided white flour products and sweets. She generally drank tea and water.

Upon palpation the acupuncture points Sanyinjiao SP-6 and Yinlingquan SP-9 were tender. Her tongue was pink to red with a thin, white, moist coating, red spots on the tip and sides, and distended and dark sublingual veins (the appointment was a week before her menstrual cycle began). Her pulse was thin and wiry, particularly on the left side in the cun (distal) and guan (middle) positions, and the chi (proximal) positions were slightly weaker on both sides.

IBS is a modern Western diagnosis while traditionally Chinese medicine discussed diseases (bing) such as diarrhoea (xie xie), constipation (bian bi), loose stools (bian tang) and abdominal fullness (fu man). The selection of points for this case was based on traditional texts, clinical experience and related gastrointestinal acupuncture research.¹⁸ The general treatment strategy was to promote the movement of qi, tonify the Spleen and harmonise the qi of the Liver. The patient was treated with acupuncture once per week over two months. She then stopped for a month as she was travelling, and subsequently continued weekly treatment for three more months.

The first four sessions of treatment focused on using the following points to stimulate the qi in the lower abdomen and promote bowel movements:

• Qihai REN-6: to regulate qi in the lower abdomen

• Tianshu ST-25: the front-mu point of the Large Intestine

• Zusanli ST-36: the command point for disorders of the abdomen

• Taichong LIV-3: the yuan-source point of the Liver

• Sanyinjiao SP-6: the meeting point of the three leg yin channels to tonify the Spleen and Kidney and harmonise the Liver

This front treatment was initially alternated with a back treatment using the following points:

• Ganshu BL-18: the back-shu point of the Liver

• Pishu BL-20: the back-shu point of the Spleen

• Dachangshu BL-25: the back-shu point of the Large Intestine

• Shenshu BL-23: the back-shu point of the Kidney

However, the patient expressed discomfort with lying on her abdomen and preferred to be treated supine. All acupuncture was performed with Seirin^® J-type No. 2 (0.18) × 30mm needles, which were inserted until deqi was elicited and retained for 20 to 25 minutes, with no more than 10 needles used per session.

The patient reported that the first four sessions of acupuncture provided pain relief for just two hours, and that her bowel movements remained unchanged. During the second month of treatment, Yanglingquan GB-34 was alternated with Taichong LIV-3 in order to spread and clear stagnant qi in the lower jiao, and the points Yinxi HE-6 and Neiguan P-6 were included in order to calm the spirit when she reported some difficulty with sleeping at night. Indirect pole moxibustion was applied to the points Qihai REN-6, Zhongwan REN-12 and Tianshu ST-25 for several minutes after all the needles were removed in order to stimulate the circulation of qi, warm the channels and promote movement in the lower abdomen After two months of treatment, the patient noted her bowel movements required less straining and difficulty and felt more complete.

For the next month of treatment (after a break of one month) the emphasis was on tonifying the Spleen and Kidney with the yuan-source points Taibai SP-3 and Taixi KID-3; Zhaohai KID-6 was also used to benefit kidney yin and for its classical indication for constipation.¹⁹ Pole moxibustion on the abdominal points Qihai REN-6 and Zhongwan REN-12 was also continued. During this time, the patient was experiencing some nasal congestion and discharge, so Yingxiang LI-20 and Hegu LI-4 were included in order to benefit the nose.

After four months of treatment - 16 acupuncture sessions - the patient was having a bowel movement every other day without discomfort. Her stools were much softer and easier to pass and she was relying less on the stool softeners and psyllium. As her bowel habits became more regular, she still had to avoid certain foods that made her feel bloated (primarily dairy products such as cheese and ice-cream). The patient still continues acupuncture treatment once every three months for maintenance and overall well-being. The long-term maintenance approach includes strengthening the Spleen and Stomach for optimal digestion and nourishing qi and blood.

Discussion

It is estimated that between 11 and 43 per cent of patients with gastrointestinal disorders use complementary/alternative medicine (CAM) therapies, and many consider them beneficial.²⁰ This case report suggests acupuncture and moxibustion may be a treatment option for reducing IBS symptoms such as abdominal pain, cramping and constipation with little to no side effects.

The Western diagnosis of IBS relies on the symptoms of abdominal pain and bowel patterns. Traditional Chinese medicine on the other hand emphasises the importance of a wide spectrum of signs and symptoms presented by the individual patient, and is thus well suited to the treatment of this clinically heterogeneous condition.

Studies in animals have suggested that acupuncture mitigates visceral hyperalgesia,^21,22 inhibits the enhanced of colon-specific sensory neurons,²³ stimulates regulation of gut neuropeptides,^24,25 and decreases hypothalamic corticotropin-releasing hormone levels.²⁶ Electroacupuncture has a stimulatory effect on the contractility of the distal colon, which may be mediated via the cholinergic pathway.²⁷ While animal research has demonstrated the effects of acupuncture on gastric motility and visceral sensation, additional research is needed in clinical studies in humans. One study showed no difference between true acupuncture and a control, but showed both were statistically and clinically superior to usual care;¹⁶ however, this study was nested within a larger study examining the effect of patient-practitioner interaction on IBS treatment, and was powered to detect differences in patient-practitioner interaction rather than improvement in IBS. Fully powered studies need to be conducted to explore the role of acupuncture’s effectiveness in helping patients with the different subtypes of IBS.

Moxibustion is used in clinical practice for a variety of conditions and is traditionally often paired with acupuncture. More rigorous studies are needed to explore the potential of this combined therapy. Herbal medicine, which is often used alongside acupuncture for the treatment of GI disorders, was not utilised in this case; a combined approach would perhaps have furthered healing and the speed of response. Given the current limited treatment options for IBS, this case study shows promise in terms of the benefit of acupuncture and moxibustion as adjunct therapies to conventional treatments and the minimal likelihood of untoward side effects.

Contributor Information

Joyce K Anastasi, Founding Director of the Division of Special Studies in Symptom Management and Independence Foundation Professor at New York University.

Bernadette Capili, Associate Director of the Special Studies in Symptom Management and Assistant Professor at New York University.

References