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Irritable bowel syndrome (IBS)

Irritable bowel syndrome (IBS) describes a collection of symptoms, commonly including chronic abdominal pain, bloating, flatulence and altered bowel habits. It is a functional disorder of the intestines, occurring in the absence of visible structural abnormality.

IBS affects up to 22% of people in the UK and is the most common functional digestive disorder seen by GPs. Women are 2-3 times more likely to develop IBS, and often suffer more symptoms during their periods. The condition often begins in adolescence or early adulthood. Predisposing factors may include a low-fibre diet, emotional stress, use of laxatives or a bout of infectious diarrhoea. It is typically a chronic, recurrent disorder, associated with substantial health, social and economic costs. Pain and impairment from IBS can lead to frequent doctor visits, hospitalizations and workplace absenteeism, and can cause depression.

The cause of IBS is unclear, but it appears that sensory nerves in the bowel are hypersensitive in people with IBS and may overreact when the bowel wall stretches. Intestinal muscles can be hypo- or hyperactive, causing pain, cramping, flatulence, sudden bouts of diarrhea, and/or constipation. The symptoms are usually triggered by stress or eating. Systematic reviews of the research literature suggest that conventional medications are of limited benefit in IBS (Akehurst et al, 2001).

How acupuncture can help
Research has shown that acupuncture treatment may benefit IBS symptoms by:

• Providing pain relief (Pomeranz, 1987).

• Regulating the motility of the digestive tract (Chen et al, 2008).

• Raising the sensory threshold of the gut (Xing et al, 2004). A lowered threshold to bowel pain and distention are hallmarks of IBS.

• Increasing parasympathetic tone (Schneider et al, 2007). Stress activates the sympathetic nervous system, which can stimulate colon spasms, resulting in abdominal discomfort. In people with IBS, the colon can be oversensitive to the smallest amount of conflict or stress. Acupuncture activates the opposing parasympathetic nervous system, which initiates the relaxation or ‘rest and digest’ response.

• Reducing anxiety and depression (Samuels et al, 2008). The distress provoked by IBS symptoms can lead to a vicious cycle of anxiety-pain-anxiety, while the embarrassing nature of the condition can lead to feelings of depression. Acupuncture can alter the brain’s mood chemistry, increases production of serotonin (Han et al, 1986) and endorphins (Han, 2004), helping to combat these negative affective states.
Acupuncture can be safely and effectively combined with Western biomedicine, and other treatments such as relaxation exercises, herbal medicine and psychotherapy. In addition to offering acupuncture and related therapies, acupuncturists will often make suggestions as to dietary and other lifestyle changes that may be helpful in combating IBS symptoms. Working with a supportive therapist can also help people suffering from IBS to change their negative health beliefs and improve their coping mechanisms, which can have a positive influence on both mood and symptoms.

Full details of research studies into traditional acupuncture treatment for depression can be found below.

Research
Conclusion

Chen J, Song GQ, Yin J, Koothan T, Chen JD. Electroacupuncture improves impaired gastric motility and slow waves induced by rectal distension in dogs. Am J Physiol Gastrointest Liver Physiol. 2008 Sep;295(3):G614-20.

Experimental trial of effect of electroacupunture on gastric motility in dogs. Found that electroacupuncture restored impaired gastric motility induced by rectal distention, possibly by enhancing vagal nerve activity, mediated via the opioid pathway. Authors conclude electroacupuncture may have therapeutic potential for functional gastrointestinal disorders.

Renolds JA, Bland JM, MacPherson H. Acupuncture for irritable bowel syndrome an exploratory randomised controlled trial. Acupunct Med 2008 Mar; 26(1):8-16.

Pragmatic randomized controlled trial of acupuncture for IBS involving 30 patients. Compared 10 sessions of acupuncture plus usual GP care with usual GP care alone. At 3 months, a statistically and clinically significant difference between groups of 138 points in favour of acupuncture was observed on the IBS Symptom Severity Score.

Trujillo NP. Acupuncture for the treatment of irritable bowel syndrome. Med Acupunct 2008 Mar 20(1):47-49.

Uncontrolled study in which 149 patients with IBS, which had not responded to standard medical care, were treated with two different acupuncture protocols. Found an overall 80% improvement in both acupuncture groups.

Schneider S, Weiland C, Enck P, Joos S, Streitberger K, Gluth  C, Zipfel S, Herzog W, Neuroendocrinological effects of acupuncture treatment in patients with irritable bowel syndrome. Complement Ther Med. 2007 Dec;15(4):255-63.

Randomized controlled trial of acupuncture for IBS involving 43 patients. Compared acupuncture with sham acupuncture using a non-penetrating needle. Found quality-of-life improved in both groups, while true acupuncture group showed greater improvement relating to parameters measuring activation of the parasympathetic nervous system. Authors conclude real acupuncture, but not sham acupuncture, improved IBS symptoms via its effects on parasympathetic control of gut sensations and functions.

Schneider A, Streitberger K, Joos S. Acupuncture treatment in gastrointestinal diseases: A systematic review. World J Gastroenterol 2007 July 7; 13(25): 3417-3424.

Systematic review and meta-analysis of acupuncture for gastrointestinal diseases. In 2 trials of acupuncture for IBS identified as being of high methodological quality, quality-of-life improved remarkably after acupuncture, although there was no difference between real and sham/placebo acupuncture.

Tian XY, Bian ZX, Hu XG, Zhang XJ, Liu L, Zhang H. Electro-acupuncture attenuates stress-induced defecation in rats with chronic visceral hypersensitivity via serotonergic pathway. Brain Res. 2006 May 9;1088(1):101-8.

Experimental study of electroacupuncture for IBS in rats. Found acupuncture decreased sensitivity to mechanically induced rectal pain and reduced stress-induced defecation in rats with experimentally induced IBS.

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 Oct 18;(4):CD005111.

Systematic review and meta-analysis of acupuncture for IBS. Analysed pooled results of 6 trials. Acupuncture treatment and sham acupuncture found to be equally effective. For two studies without a sham control, acupuncture was more effective than control treatment (herbal medicine and psychotherapy) for improvement of symptoms.

Forbes A, Jackson S, Walter C, Quraishi S, Jacyna M, Pitcher M. Acupuncture for irritable bowel syndrome: a blinded placebo-controlled trial. World J Gastroenterol 2005; 11: 4040-4044.

Randomized controlled trial of acupuncture for IBS involving 60 IBS patients. Compared acupuncture with sham acupuncture. Patients in both groups improved, but no real difference was found between the two groups.

Cui KM, Li WM, Gao X, Chung K, Chung JM, Wu GC. Electro-acupuncture relieves chronic visceral hyperalgesia in rats. Neurosci Lett. 2005 Mar 7;376(1):20-3.

Experimental study of electroacupuncture for IBS in rats. Found acupuncture effectively reduced pain induced by mechanical distention of the colon and rectum in rats with experimentally induced IBS.

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 Jan-Feb;10(1):38-42.

Experimental study of electroacupuncture for IBS involving 7 patients. Patients received either real or sham acupuncture while undergoing rectal distention using an inflatable balloon apparatus. Real acupuncture stimulation, but not sham stimulation, significantly increased the threshold of rectal sensation of gas, desire to defecate and pain, as compared to a control period. Authors conclude that acupuncture can reduce rectal sensitivity in IBS patients.

Lu B, Hu Y, Tenner S. A randomised controlled trial of acupuncture for irritable bowel syndrome. Program and abstracts of the 65th Annual Scientific Meeting of the American College of  Gastroenterology; October 16-18, 2000, New York, NY. Poster 268, p.428

Randomized controlled trial of acupuncture for IBS involving 27 patients. Compared acupuncture with relaxation sessions. Found quality-of-life and gastrointestinal symptom scores improved equally in both groups. A significant reduction in abdominal pain was observed in both groups at the end of the trial, however, only in the acupuncture group did pain reduction persist at 4 weeks post trial. Reduced stress perception was also observed in acupuncture group, but not with relaxation.

Samuels N, Gropp C, Singer SR, Oberbaum M. Acupuncture for psychiatric illness: a literature review. Behav Med. 2008 Summer;34(2):55-64.

Literature review of acupuncture for psychiatric illness. Presents research which has found that acupuncture increases central nervous system hormones including ACTH, beta-endorphins, serotonin, and noradrenaline. Concludes that acupuncture can have positive effects on depression and anxiety.

Han JS. Acupuncture and endorphins. Neurosci Lett. 2004 May 6;361(1-3):258-61.

Literature review of studies relating to the release of endorphins by acupuncture.

Pomeranz B. Scientific basis of acupuncture. In: Stux G, Pomeranz B, eds. Acupuncture Textbook and Atlas. Heidelberg: Springer-Verlag; 1987:1-18.

Needle activation of A delta and C afferent nerve fibres in muscle send signals to spinal cord, where dynorphin and enkephalins are released. Afferent pathways continue to midbrain, triggering excitatory and inhibitory mediators in spinal cord. Ensuing release of neurotransmitters serotonin and norepinephrine onto spinal cord leads to pain transmission being inhibited both pre- and postsynaptically in spinothalamic tract. Finally, these signals reach hypothalamus and pituitary, triggering release of adrenocorticotropic hormones and beta-endorphin.

Akehurst R, Kaltenthaler E. Treatment of irritable bowel syndrome: a review of randomised controlled trials. Gut. 2001 Feb;48(2):272-82.

Systematic review of randomised controlled trials examining the clinical effectiveness of medical interventions for IBS. Concludes that ‘the evidence for efficacy of drug therapies is weak’.

Han JS. Electroacupuncture: An alternative to antidepressants for treating affective diseases? Intl J Neurosci 1986;29:79-92.

Review presenting evidence that acupuncture can accelerate synthesis and release of serotonin and noradrenline in the CNS. As well as clinical data indicating that electroacupuncture is effective in treating depressive patients, and at least as effective and with a higher therapeutic index than tricyclic amitriptyline.