Assessment of Irritable Bowel Syndrome Using Traditional Chinese Medicine-A Critique of Recent Studies

Irritable bowel syndrome (IBS) is a common complaint in the US. [1] It is characterized by abdominal pain relieved by defecation and the absence of any other identifiable bowel disorders. The differential diagnosis of IBS includes celiac disease, small intestinal bacterial overgrowth [2], bile acid diarrhea [3,4], exocrine pancreatic insufficiency [5], or inflammatory bowel disease. [6] It can be complicated by stress [7,8], large bowel dysbiosis [9], lactose intolerance [8] and other less common food intolerances, medications, nutrients (calcium can cause constipation; magnesium and vitamin C can cause diarrhea) and disorders characterized by prostaglandin/ leukotriene imbalances [10]. Biomedical diagnosis of IBS is one of exclusion only. The Rome Criteria [11] notes


Opinion
Irritable bowel syndrome (IBS) is a common complaint in the US. [1] It is characterized by abdominal pain relieved by defecation and the absence of any other identifiable bowel disorders. The differential diagnosis of IBS includes celiac disease, small intestinal bacterial overgrowth [2], bile acid diarrhea [3,4], exocrine pancreatic insufficiency [5], or inflammatory bowel disease. [6] It can be complicated by stress [7,8], large bowel dysbiosis [9], lactose intolerance [8] and other less common food intolerances, medications, nutrients (calcium can cause constipation; magnesium and vitamin C can cause diarrhea) and disorders characterized by prostaglandin/ leukotriene imbalances [10]. Biomedical diagnosis of IBS is one of exclusion only. The Rome Criteria [11] notes

IBS criteria
A.
Recurrent abdominal pain or discomfort at least 3 days/month in last 3 months associated with two or more of the following B.
Improvement with defecation C.
Onset associated with a change in frequency of stool D. Onset associated with a change in form (appearance of stool) E. Routine laboratory studies (complete blood count, chemistries) are normal in IBS. Diagnostic "red flags" such as weight loss, blood in the stool and night awakening from abdominal pain are absent.
IBS can manifest as "Diarrhea-predominant IBS" "Constipation-predominant IBS" or as a "Mixed IBS" syndrome where both constipation and diarrhea are present. [12] No specific studies can positively prove the presence of IBS. [12] Routine laboratory studies (complete blood count, chemistries) are normal in IBS. "Red Flag" or "Alarm" or atypical symptoms which are not compatible with IBS [12] include: Rectal bleeding B. Nocturnal or progressive abdominal pain C. Weight loss D. Laboratory abnormalities such as anemia, elevated inflammatory markers, or electrolyte disturbance In Traditional Chinese Medicine (TCM), the diagnosis of IBSlike syndromes is equally complex. Practitioners need to utilize all four exams to correctly identify both the root and branch issues that complicate bowel function. In a recent meta-analysis of acupuncture for the treatment of IBS [13], the authors found no significant evidence that acupuncture was effective in treating IBS. I propose that this conclusion could have been predicted by both the simplistic approach to the TCM treatments and the lack of sophistication of the TCM diagnoses of this disorder.
The TCM differential diagnosis of diarrhea/loose stools include: A.
Spleen IBS may be any combination of the above diagnoses. Treatment of these combination of problems can be quite complex. Treatment of IBS with acupuncture (alone or with electro acupuncture, moxibustion, cupping, etc.) is similarly complex. The recent "placebo-blinded" studies of acupuncture for IBS limit the treatment arm to six or fewer prescribed acupuncture points. [14,15,18,[29][30][31] The most commonly used points from these studies include LI 4 (Hegu), BL 60 (Kunlun) (as a placebo point), LR 3 (Taichong), ST 36 (Zusanli), SP 6 (Sanyinjiao), Ren 12 (Zhiongwan), ST 21 (Liangmen), ST 25 (Tianshu), HT 7 (Shenmen), Du 20 (Baihui), ST 37(Shangjuxu) With such simplified diagnostic and treatment parameters, it is not surprising that the meta-analysis does not match experienced practitioners' clinical experiences when applying personalized, individualized treatments of IBS. It is also possible that some of those enrolled in the studies did not, in fact, have IBS.
The TCM approach to IBS must include a thorough medical diagnosis to exclude other causes of bowel dysfunction, as well as a thorough TCM exam to identify both root and stem patterns that are affecting the functioning of the stomach, spleen, liver and small and large bowels. The treatment arms need to take into account the TCM pattern differentiation in the use of needles with or without electro acupuncture and moxibustion for the various patterns identified. While such study design is complex, it would better mirror the treatments being offered IBS patients in the US.