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Johns Hopkins Health Alert

Alternative Goes Conventional for IBS

If you have irritable bowel syndrome (IBS), you may have tried a variety of alternative therapies -- probiotics, cognitive behavioral therapy, biofeedback, acupuncture, or simple dietary changes -- to reduce your painful symptoms. In this excerpt from a longer article from our Health After 50 newsletter, Linda Lee, M. D., Assistant Professor of Gastroenterology at Johns Hopkins talks about alternative treatment for IBS.

IBS is one of the most commonly diagnosed conditions in the United States. People with IBS generally experience abdominal pain, bloating, constipation, and diarrhea, but symptoms vary greatly. For some patients, IBS is just a mild inconvenience, while others have such severe IBS symptoms they fear leaving the house.

Relief can be hard to find, because IBS is poorly understood; the cause is unknown, and not all people respond to available medications. So many patients, particularly those who already take drugs for other conditions, are turning to nonmedical, alternative strategies to manage IBS.

According to one estimate from the University of Washington, as many as half of IBS patients seek alternative care. The National Institutes of Health has formed the National Center for Complementary and Alternative Medicine to promote research into this area of medicine, and several major medical institutions, including Johns Hopkins, Duke, Harvard, the Mayo Clinic, and Stanford (among others), have joined the Consortium of Academic Health Centers for Integrative Medicine.

While "alternative" implies that patients use natural or nonmedical therapies instead of conventional medicine, in fact, many patients couple these approaches with conventional care under the supervision of medical doctors. This combination is commonly referred to as integrative medicine. For instance, at the Johns Hopkins Integrative Medicine and Digestive Center, patients meet with specialists in complementary medicine and a board-certified gastroenterologist.

While evidence for complementary therapies is inconclusive, Linda Lee, M. D., Assistant Professor of Gastroenterology at Johns Hopkins points out, "Not many data support standard pharmacological interventions for IBS, either. Medicine can treat certain symptoms of IBS, but there isn't a proven cure in either conventional or complementary care. Since these symptoms are highly subjective, an integrative approach may be the best way to control IBS."


Irritable Bowel Syndrome: A TCM Perspective
By Toni Balfour, L.Ac., Dipl. Ac. & C.H.


Irritable Bowel Syndrome in Western Medicine

Irritable Bowel Syndrome (IBS) is an intestinal disorder causing a variety of symptoms which may include cramping, abdominal pain, gas, bloating, and irregular bowels. Some people with IBS have diarrhea with frequent loose stools, while others have constipation causing infrequent bowel movements that are difficult to pass. Still other IBS patients will suffer from alternating diarrhea and constipation. Symptoms are frequently triggered by stress, emotional factors, or the ingestion of food.

IBS is the most common gastrointestinal disease seen by general practitioners and makes up 30-50% of all referrals to GI specialists. Women are affected three times more than men, with the average age of onset being between 20 and 40.

IBS is described as a 'functional' illness -- the small and large intestines aren't functioning appropriately although there is no structural damage found through diagnostic testing. No anatomic defect can be found in IBS patients, and the cause of the illness is not known. What is known is that there is a link between the onset of symptoms and emotional triggers.

There are two major clinical types of IBS described in Western medicine: diarrhea-predominant IBS and constipation-predominant IBS.

Diarrhea-predominant IBS is characterized by diarrhea which occurs immediately after waking up or immediately after eating. Other common symptoms include pain, bloating, urgency, and urinary incontinence.

Constipation-predominant (or 'spastic colon' type) IBS manifests with pain over at least one area of the colon and periodic constipation. This pain may be continuous or it may come in bouts, and is frequently relieved by moving the bowels. There may be constipation alternating with normal stools or constipation alternating with diarrhea. The stool often contains mucus. Associated symptoms include bloating, gas, nausea and dyspepsia. Eating can commonly trigger these symptoms.

Western medicine treats IBS with anti-spasmodic or anti-diarrhea medication, diet modification and stress reduction techniques.

What is Traditional Chinese Medicine?

Traditional Chinese Medicine (TCM) is a holistic medical system which combines the use of acupuncture, Chinese herbs, nutrition, massage, and movement exercises (known as Tai Chi or Qi Gong) to bring the body into balance.

Whereas Western medicine looks closely at a symptom and tries to find an underlying cause, Traditional Chinese Medicine looks at the body as a whole. Each symptom is looked at in relationship to all other presenting symptoms. The goal of the TCM practitioner is to assess the entire constitution of the patient -- considering both physiological and psychological aspects.

The practitioner first observes the general characteristics of the patient, then tries to discern a relationship between symptoms in order to establish what is called a "pattern of disharmony". Treatment is aimed at restoring harmony and bringing the body into balance.

The fundamental TCM theory used to determine the pattern of disharmony is the theory of "Yin and Yang". Yin and Yang are terms used to describe two polar opposites. Each body part, each organ, and even each symptom in the body can be described in terms of Yin and Yang. Levels of Yin and Yang are constantly changing in the body and there are four possible states of imbalance:

  • Excess of Yin
  • Excess of Yang
  • Deficiency of Yin
  • Deficiency of Yang

It is rare for one of these states of imbalance to exist by itself. Excesses and deficiencies of Yin and Yang almost always appear in combination. For example, in Irritable Bowel Syndrome the symptom of loose stools shows an excess of yin; but if the patient feels a burning sensation along with the loose stools, this indicates an additional excess of yang.

In treating the overall pattern of disharmony, the TCM practitioner uses acupuncture and Chinese herbs to address all imbalances of yin and yang.

To look at the body as an integrated whole, one also looks at the theory of the 'Internal Organs'. The TCM definition of an Internal Organ is very different from the Western concept. In Western medicine, an organ is a material-anatomical structure. In Chinese medicine each Internal Organ encompasses much more. There can be an anatomical structure, but there is also a corresponding emotion, tissue, sensory organ, color and element.

In addition, 12 of the Internal Organs correspond to the 12 main acupuncture meridians (or channels) that run through the body. There is qi (or energy) flowing through each meridian. If an Internal Organ is out of balance, the qi of that organ will be damaged.

Therefore, the Chinese Large Intestine (which is capitalized to distinguish it as the Chinese organ) shouldn't be equated with the Western organ.

Irritable Bowel Syndrome affects the large and small intestines in Western medicine, but in Chinese medicine, the Spleen, Liver, Kidney, and Large Intestine can all play a role in the pattern of disharmony.

Common Patterns of Disharmony in Irritable Bowel Syndrome

Spleen Qi Deficiency

In TCM the Spleen is considered to be the key organ to regulate digestion. Keep in mind, this is not the same as the Western spleen. Its functions actually have a closer connection to the Western pancreas.

IBS patients with a pattern of Spleen qi deficiency will suffer from fatigue and diarrhea which is worse when they are overexerting themselves. This is often accompanied by abdominal pain which may be relieved by exerting pressure over the painful area. Patients may also have gas and bloating. Hemorrhoids are an additional indication of Spleen qi deficiency.

Acupuncture points are chosen which will help nourish the Spleen qi. There are also specific techniques used in needling that strengthen the body when the patient is deficient.

Another important part of treatment is the Chinese herbal formula. In Chinese herbalism, a group of herbs is combined together to specifically address a person's unique constitution. This is one way in which treatment is very individualized -- a master herbalist treats no two patients with the same combination of herbs.

Most herbalists use a "classical formula" as a foundation. Many classical formulas written up to 2,000 years ago are still commonly used today. Groups of herbs can be added or taken out of classical formulas to customize them for patients.

One classical formula used for Spleen qi deficiency is called Bu Zhong Yi Qi Tang. By adding and subtracting herbs from this formula, it can be individualized to fit the precise needs of the patient.


Spleen Distressed by Dampness

In this pattern, the patient may experience symptoms of Spleen qi deficiency along with a feeling of nausea or heaviness. Bowel movements may feel incomplete, or the patient may even have constipation lined with mucus.

This condition is often caused by eating too much fried or greasy food, but may also be caused by emotional factors such as over-thinking or over-worrying.

Acupuncture points are chosen to nourish the Spleen and eliminate dampness. The classical herbal formula to address this pattern is called Shen Ling Bai Zhu San.

Patients are additionally advised to keep a very clean diet. In Chinese medicine dairy foods and excessive sugar intake create dampness, so these foods should be avoided altogether.


Excess Cold in the Spleen

An excess of cold in the Spleen causes severe pain. The patient may be "doubling over" in pain, feeling as if curling up will somehow offer relief. Here the patient cannot tolerate being touched. This pain may be accompanied by constipation.

Acupuncture is given to warm the Spleen, and the classical formula Da Jian Zhong Tang may be prescribed, although in severe cases of constipation additional herbs need to be added to give a laxative effect.


Spleen and Kidney Yang Deficiency

Yang energy provides warmth to the body and a deficiency of Spleen and Kidney Yang may result in feeling cold or having cold hands and feet. IBS patients with Spleen and Kidney Yang deficiency will have diarrhea first thing in the morning which may contain undigested food particles. Other symptoms include chronic low back pain, low libido, frequent urination, or in severe cases, urinary incontinence.

Acupuncture treatment focuses on building up this deficient Yang energy, and the classical formula Si Shen Wan can be used along with additions and subtractions to suit the exact needs of the patient.


Liver Qi Stagnation

The Chinese Liver is the organ most affected by stress, aggravation, and anger. The Liver is frequently involved in modern disease, most commonly when its qi becomes stagnant or stuck. There may be depression, moodiness, or simply a feeling of being 'wound up'. Women may suffer from irregular or painful periods.

The IBS patient with Liver Qi Stagnation may have pellet shaped stools and distending pain, particularly in the area below the ribs. There may also be nausea, belching, or acid reflux. Symptoms can be triggered or aggravated by stress.

Acupuncture is very effective at restoring the smooth flow of Liver qi, as are movement exercises such as Tai Chi or Qi Gong. The classical formula of choice for the IBS patient with Liver Qi Stagnation is Liu Mo Tang.


Liver/Spleen Disharmony

Disharmony between the Liver and Spleen causes irritability along with abdominal distension and pain. The IBS symptom of alternating constipation and diarrhea is common in a Liver/Spleen disharmony. Stress, frustration, and anger aggravate the condition.

Xiao Yao Wan is a very commonly used classical formula for Liver/Spleen disharmony, but does need to be modified in most IBS cases. Tong Xie Yao Fang is another classical formula used for Liver/Spleen disharmony and is the best choice when diarrhea is prevalent.

Acupuncture treatment will focus on soothing the Liver and nourishing the Spleen.


Damp-Heat in the Large Intestine

Abdominal pain and diarrhea with a sense of urgency are key symptoms indicating damp-heat in the Large Intestine. The diarrhea is commonly yellow and explosive with a strong odor and a sensation of burning. This heat indicates that there may be a low grade infection, although this type of chronic infection may not show up on lab tests. In addition, there may be a feeling of heaviness of the body and limbs and stuffiness in the chest.

Acupuncture is used to clear heat and eliminate dampness and a commonly used classical formula is Ge Gen Huang Qin Huang Lian Tang.

Irritable Bowel Syndrome is clearly a complicated illness in both Western and Chinese medicine. Its many manifestations require very different treatment approaches in Traditional Chinese Medicine. The patterns of disharmony mentioned above may even appear in combination and treatment must be adjusted appropriately. In any severe case of IBS, TCM treatment will be customized for the individual and classical herbal formulas will be modified for the patient.


Research on IBS & Chinese Herbs

An Australian study published in 1998 in the Journal of the American Medical Association lends strong scientific support to treating IBS with Chinese herbs. In this double-blind study, 116 patients with Irritable Bowel Syndrome were divided into three groups. One group was given a standard Chinese herbal preparation, a second group was given customized herbal formulas (individually written for each patient), and a third group was given a placebo. Each patient had regular consultations with both a Chinese herbal-medicine practitioner and a gastroenterologist. Both groups taking the Chinese herbs showed significant improvement over the patients taking the placebo. Positive results were reported by both the patients themselves and the gastroenterologists. Although there was improvement in both groups of patients taking herbs, it is important to note that the positive effects were shown to last longer in the group that was given individualized formulas. Only these patients had maintained improvement on a follow-up consultation 14 weeks after completing the treatment.

This study clearly shows that Chinese herbalism is most effective when each patient is treated not only for their condition, but also for their bodily constitution and other presenting symptoms. According to the principles of Chinese medicine, each patient must be treated as an individual. Optimal results will be obtained with both herbs and acupuncture when specific treatments are customized for each patient.



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