DIGESTIVE & BOWEL DISORDERS (© JCM Ltd)

CHINESE MEDICINE EFFECTIVE FOR CONSTIPATION
TCM interventions appear to be useful in the management of constipation, according to a systematic review from an Australian group. One hundred and thirty-seven studies met the inclusion criteria, of which 21 were high-quality trials. Eighteen of the trials were of Chinese herbal medicine (CHM) and three were of acupuncture. Significant positive results were found in 15 high-quality studies. CHM was more effective than conventional medicines in eight trials. Of the 10 remaining CHM trials, nine compared the CHM being studied with another CHM and the results were significant in four trials. The effective rate was significantly higher in the intervention group than in the placebo group in the last CHM study. One of the three acupuncture trials compared acupuncture with conventional medicine, one compared it with Senna (Cassia angustifolia) and one with a deeper acupuncture technique. The therapeutic effect in the treatment group was more effective than that in the control group in all three studies. The authors urge that the results should be interpreted cautiously due to heterogeneity in diagnostic procedures, interventions and outcome measures across the studies. (Efficacy of Traditional Chinese Medicine for the Management of Constipation: A Systematic Review. J Altern Complement Med. 2009 Dec 3. [Epub ahead of print]).

ACUPUNCTURE FOR IBS
A sizeable trial investigating the ability of acupuncture to relieve symptoms of irritable bowel syndrome (IBS) has found that both real and sham acupuncture resulted in significant symptom reduction. This US study involved 230 IBS patients. All participants initially underwent a three-week ‘run-in’ period, during which they received placebo acupuncture involving either a warm empathic interaction (‘augmented’ group) or a neutral interaction (‘limited’ group). Patients were then assigned to three weeks of true or sham acupuncture (six treatments). The third arm of the study was a waitlist control group. Although there was no statistically significant difference between acupuncture and sham acupuncture on the IBS Global Improvement Scale (41% versus 32 %), both groups improved significantly compared with the waitlist control group (37% versus 4 %). Eliminating those who responded to sham acupuncture during the run-in period did not change the results. (A treatment trial of acupuncture in IBS patients. Am J Gastroenterol. 2009 Jun;104(6):1489-97).

ACUPUNCTURE FOR IBS
A small randomised, sham/placebo-controlled pilot study assessing the effect of individualised TCM acupuncture and moxibustion (AcuMoxa) treatment on symptom control of IBS patients found that it showed promise as a treatment. Twenty-nine patients with IBS were randomised to either individualised AcuMoxa (treatment group) or sham/placebo AcuMoxa (control group). After four weeks of twice-weekly AcuMoxa treatment, average daily abdominal pain improved significantly, whereas the control group showed minimal reduction. Intestinal gas, bloating and stool consistency composite scores showed a similar pattern of improvement. (Symptom management for irritable bowel syndrome: a pilot randomized controlled trial of acupuncture/moxibustion. Gastroenterol Nurs. 2009 Jul-Aug;32(4):243-55).

ACUPUNCTURE FOR FAECAL INCONTINENCE
Italian researchers have carried out a pilot study to investigate the effect of acupuncture on faecal incontinence. Fifteen female patients, median age 60 years, received one acupuncture treatment per week for a ten-week period. Before treatment and at regular intervals after acupuncture sessions, anal continence was assessed by means of recto-anal manovolumetry. Patients experienced a significant improvement in anal continence, with overall mean continence score changing from 10 before treatment to zero at 10 weeks. Patients with irregular bowel habits and/or loose stools also reported significant improvement. On manovolumetric testing, a mean increase of resting pressure (from 25 to 36 mmHg) and sustained squeeze anal pressure (from 41 to 60 mmHg) was reported. The authors suggest that acupuncture may achieve this effect via neuromodulation of recto-anal function, similar to that achieved by sacral nerve stimulation, which is a conventional medical treatment for faecal incontinence. (Fecal incontinence treated with acupuncture - a pilot study. Auton Neurosci. 2008 Dec 4. [Epub ahead of print]).

ACUPUNCTURE BETTER THAN MORE HEARTBURN DRUGS
If proton pump inhibitors fail to control the symptoms of gastro-oesophageal reflux disease, current standard management is to double the drug dose, despite limited therapeutic gain. An American clinical trial has compared this protocol against use of acupuncture. Thirty patients with classic heartburn symptoms who continued to be symptomatic on standard-dose proton pump inhibitors were enrolled into the study. Patients were randomised to either two acupuncture sessions per week in addition to their proton pump inhibitor regimen, or to doubling the proton pump inhibitor dose, over a period of four weeks. The acupuncture plus proton pump inhibitor group demonstrated a significant decrease in the mean daytime heartburn, night-time heartburn and acid regurgitation scores at the end of treatment when compared with baseline, while the double-dose proton pump inhibitor group did not demonstrate a significant change in their clinical endpoints. (Clinical trial: acupuncture vs. doubling the proton pump inhibitor dose in refractory heartburn. Aliment Pharmacol Ther. 2007 Oct 30;26(10):1333-1344).

ACUPUNCTURE FOR GASTROINTESTINAL DISEASES
A systematic review has assessed the evidence for the effectiveness of acupuncture treatment in gastrointestinal diseases. German authors searched Medline-cited literature for controlled clinical trials performed before May 2006, identifying 18 relevant trials that met their inclusion criteria. Of these, only four were robustly designed random controlled trials (RCTs) - two irritable bowel syndrome (IBS) trials and two inflammatory bowel disease (IBD) trials (one for Crohn's disease and one for ulcerative colitis). In all four trials, quality of life (QoL) was found to improve significantly, independently of whether the acupuncture was real or sham. Real acupuncture was significantly superior to sham acupuncture with regard to disease activity scores in the IBD trials. The authors postulate that psychoneuroimmunologic mechanisms may explain the acupuncture-specific effects leading to clinically relevant improvement of disease activity in Crohn’s and Colitis patients. They also suggest that the efficacy of acupuncture in respect of QoL may be explained by nonspecific treatment effects operating on a psychological and/or physiological level. While recommending further trials, they point out that demystification of the mechanism of acupuncture could be detrimental to its placebo-mediated effects, potentially destroying some of its healing capacity. (Acupuncture treatment in gastrointestinal diseases: a systematic review. World J Gastroenterol. 2007 Jul 7;13(25):3417-24).

ACUPUNCTURE FOR ULCERATIVE COLITIS
In a prospective, randomised, controlled clinical trial, 29 patients with mild to moderately active ulcerative colitis were randomly assigned to receive either traditional acupuncture and moxibustion, or sham acupuncture consisting of superficial needling at non-acupuncture points. Patients were treated in 10 sessions over a period of five weeks and followed up for 16 weeks. Colitis Activity Index (CAI) decreased in both acupuncture and sham groups and in both cases these changes were associated with significant improvements in general well-being. Differences in efficacy between traditional acupuncture and sham acupuncture were small and significant only for CAI as the main outcome measure. The authors conclude that both traditional and sham acupuncture seem to offer therapeutic benefit in this condition. (Acupuncture and moxibustion in the treatment of ulcerative colitis: a randomized controlled study. Scand J Gastroenterol. 2006 Sep;41(9):1056-63).

ACUPUNCTURE & THE GASTRIC SPHINCTER
Inappropriate relaxation of the muscular lower oesophageal sphincter (LES) is associated with gastric reflux and heartburn. Now a study has shown that electrical non-needle stimulation of Neiguan P-6 can reduce the rate of LES relaxation by 40%. Fourteen healthy (no heartburn) volunteers were treated either at Neiguan P-6 or a sham point on the hip. A separate study ruled out endorphins or enkephalins as the mechanism of action of the point stimulation by giving the volunteers naloxone, which blocks the effect of these chemicals. (Am J Physiol Gastrointest Liver Physiol, 2005; 289: G197-G201).

ACUPUNCTURE & CROHN’S DISEASE
In a single blind controlled trial of 51 patients with mild to moderately active Crohn’s disease, 27 were randomly assigned to receive traditional acupuncture, and 24 to receive sham acupuncture at non-points. The true acupuncture group showed significantly greater improvements in the Crohn’s disease activity index than the sham group, and significantly greater wellbeing scores. Serum markers of inflammation decreased in the traditional acupuncture group but not in the sham group. (Digestion. 2004;69(3):131-9. Epub 2004 Apr 26).

ACUPUNCTURE & COLONOSCOPY
In order to determine whether acupuncture can reduce the discomfort and anxiety of colonoscopy, 30 patients were randomly assigned to receive acupuncture, sham acupuncture, or no acupuncture. Patients were asked to report on their pain sensations when the endoscope reached four scheduled positions, and their requests for analgesia (midazolam) were recorded. A verbal rating scale was used to assess patient's satisfaction with the level of sedation achieved. Midazolam was required in three patients (30%)in the true acupuncture group, eight (80%) in the sham group, and nine (90%) in the control group. Six patients (60%) in the acupuncture group reported optimum acceptance of colonoscopy compared with only one (10%) in the sham group and none in the control group. The study concludes that acupuncture can decrease the demand for sedative drugs during colonoscopy by reducing discomfort and anxiety of the patient and help avoid the adverse effects of pharmacologic sedation. (Am J Gastroenterol 2003 Feb;98(2):312-6).

ACUPUNCTURE FOR CROHN’S DISEASE
A recent trial of traditional acupuncture for the treatment of Crohn’s disease carried out at the University of Nuremberg has shown it to be statistically more effective than sham acupuncture. 51 patients with Crohn’s disease were randomly assigned to two groups. Both groups received ten treatments over a four week period. The TCM group received needles at Pishu BL-20, Zhongwan REN-12, Zusanli ST-36 or Shangjuxu ST-37 and Tianshu ST-25, three points based on pattern differentiation (Spleen qi deficiency, damp-heat, Kidney deficiency or Liver insulting the Spleen), plus moxibustion where appropriate. Needles were manipulated as long as deqi was present. The control group received shallow sham acupuncture at non-acupuncture points without obtaining deqi. A survey showed that the sham group believed they were receiving real acupuncture to almost the same degree as in the treatment group. Outcome was measured by the Crohn’s Disease Activity Index which rates eight symptoms and signs such as diarrhoea, abdominal pain, well-being and red blood cell count. The real acupuncture group showed a significantly greater benefit which persisted when all patients were reassessed after 16 weeks. At this stage the treatment group showed a significant improvement in al-acid glycoprotein, a marker of bowel inflammation (Presented at the ARRC Symposium, October 7th 2001).

BOWEL OBSTRUCTION & ACUPUNCTURE
Writing in the journal Medical Acupuncture, Martha Grout MD describes 2 cases of small bowel obstruction treated by acupuncture. Obstruction is the most common surgical condition of the small bowel (intestine). Patients are frequently hospitalised for several days and may require surgical intervention for definitive treatment. Mean length of hospitalisation in 1 study was 15.3 days and mortality is reported to range from 5%-75% depending on the cause of the obstruction. In the first case a 27-year-old man who presented to the emergency department of Phoenix (Arizona) Memorial Hospital was treated with standard medical management and acupuncture treatment at Zhongwan REN 12 and Zusanli ST-36 bilaterally. No further needles were used because the treating physician was concerned that stimulating the small intestine directly, e.g. by needling Guanyuan REN-4, might lead to increased bowel motility against a closed obstruction with subsequent perforation. Within 6 hours the patient began to improve and the admitting surgeons expressed surprise that his system began to function so soon. In the second case a 65-year-old woman presented to the emergency department of John C. Lincoln Hospital in Phoenix, Arizona with recurrence of symptoms of obstruction she suffered approximately every 6 weeks. She was treated with the standard nasogastric tube and intravenous therapy and additionally received acupuncture at Zhongwan REN-12, Tianshu ST-25, Guanyuan REN-4, Zusanli ST-36 and Neiguan P-6. Within 3 hours, the patient was released feeling well and returned to work the next day, rather than 3-4 days later as had happened after previous episodes. Ten weeks after treatment, no further hospitalisations had occurred. (Medical Acupuncture,Volume 12/Number 2).