Inflammatory+Bowel+Disease

Inflammatory Bowel Disease
Inflammatory bowel disease (IBD) is a general term for a group of chronic inflammatory disorders involving the gastrointestinal tract. It can be divided into two major groups, ulcerative colitis (UC) and Crohn's disease (CD). Clinically, these disorders are characterized by recurrent inflammatory involvement of intestinal segments with diverse clinical manifestations often resulting in a chronic, unpredictable course.

Epidemiology
-IBD is more common among Caucasians than among blacks and Asians with a three- to six-fold increased incidence among people of Jewish descent. -Both sexes are equally affected. -UC is a little more common than CD. -The peak occurrence of IBD is between the ages of 15 to 35 and it has been reported in every decade of life.

The cause of IBD is still unknown. Several factors are suspected to play a role in its pathogenesis including: -autoimmunity, -genetic predisposition, -infectious agents (viruses, L-bacteria,Mycobacteria, Chlamydia), -environment (diet), -psychologic (stress, occupation, trauma).

Extraintestinal manifestations that may accompany these disorders, such as arthritis, pericholangitis, and the response of these diseases to certain drugs with immunosuppresive properties are highly suggestive of autoimmune etiology. Inflammatory Bowel Disease: The “Hygiene Hypothesis"

The "hygiene hypothesis"
states that raising children in extremely hygienic environments negatively affects immune development which predisposes them to immunological diseases such as IBD. The decreasing frequency of helminthic colonization appears to correlate with the increasing prevalence of CD. Elliot DE et al, 14: FASEB 2000

Symptoms
The major clinical symptoms of UC and CD are similar: -Diarrhea with cramps, blood and mucus/pus -Abdominal pain/tenderness; tenesmus and rectal pain -Fever, anemia and weight loss in severe cases -With predominately rectal involvement, constipation rather than diarrhea may be present, and tenesmus may be a major complaint.

Differences between UC and CD
UC – typically, only the large intestine is affected although a small percentage of cases show ileal involvement; inflammation tends to be continuous, spreading from rectum up through the colon as disease progresses; mucosal inflammation only. CD – inflammation can occur anywhere along the GI tract, from the mouth to the anus; inflammation is often discontinuous, with diseased sections separated by healthy sections; all layers of bowel wall affected UC – patients tend to experience abdominal pain in LLQ; bleeding with b.m. common CD – abdominal pain more common in the RLQ; bleeding with b.m. less common UC - colon wall is thinner and shows continuous inflammation with no patches of healthy tissue in the diseased section; granulomas are not present. CD - colon wall may be thickened and have a "cobblestone" appearance because of the intermittent pattern of diseased and healthy tissue; granulomas present. UC –toxic megacolon, while rare, is more common than in CD CD – abscesses, stenosis/strictures, and internal fistulae are more common
 * Location and distribution of inflammation:**
 * Symptoms:**
 * Endoscopic features:**
 * Complications:** blood loss/anemia, dehydration, malnutrition, extra intestinal manifestations, toxic megacolon, and colon cancer are potential complications common to both UC and CD

Extraintestinal Manifestions of IBD
-Liver: chronic active hepatitis, cirrhosis, primary sclerosing cholangitis (3%), gallstones, cancer -Musculoskeletal: arthritis (up to 15%), ankylosing spondylitis (1-2%) -Eye: iritis, uveitis, conjunctivitis (10%) -Skin/mouth: variety of lesions (10%) -Kidney: oxalate stones -Above “wax and wane” with intestinal dz except spinal and liver dz -Extraintestinal symptoms are more common in CD than UC

Exacerbating Factors for IBD
Concurrent infections (upper respiratory tract, enteric) Smoking (CD only) Nonsteroidal antiinflammatory drugs Stress

Diagnosis of IBD
Clinical signs/symptoms (note: differentiating UC from CD on the basis of s/s can be very difficult) Upper/lower GI endoscopy/biopsy Radiology (BE, small bowel follow-through)

Inflammatory Bowel Disease: Biomedical Treatment
Conventional treatments are primarily medical. The aim of treatment is to control the inflammation. -Aminosalicylates (Mesalamine) -Corticosteroids (Prednisone, Methylprednisone) -Immune modulators (Azathioprine, Mercaptopurine and Methotrexate, Infliximab, Adalimumab) -Antibiotics (primarily in CD) -Antidiarrheals (Loperamide)
 * Mainstays of Rx tx:**


 * Nutritional replacement, correction of electrolyte and fluid balance and anemia, and stopping diarrhea are other important treatment considerations.**

-Severe acute cases need to be hospitalized. The majority of IBD patients are chronically sick and under out-patient care. Since these patients have a history of long term use of steroids, non-steroidal anti-inflammatory drugs (NSAID), such as sulfasalazin, many of them develop complications, such as Cushing's Syndrome, low white blood cell count, caused by the side effects of these drugs.

-UC: curative colectomy in 10-30% of cases after 10 years; -CD: 6%/yr. need surgery for complications with repeat surgery at 50-70%; lifetime risk for surgery nearly 50%; rarely curative
 * Surgical intervention is reserved for "intractable" cases:**

Summers and colleagues report the results of their open study of live Trichuris suis ova therapy in 29 patients with Crohn’s disease (CD). Treatment for 24 weeks yielded a response rate of nearly 80% and a remission rate of nearly 73%, which was much greater than the anticipated placebo effect. The treatment caused no side effects or complications even in patients receiving multiple immunosuppressants. Summers et al., 54: Gut 2005

-UC: 10-15% after 20 years; 30% after 35 years; therefore, surveillance colonoscopy every year recommended -CD: less established association
 * Colon Cancer and IBD**

IBD and TCM
IBD can be categorized in terms of the following TCM disease categories: -Diarrhea (xìe xìe) -Abdominal pain (fù tòng) -Dysentery (lì jí)

Note: consensus does not currently exist among TCM practitioners around the pathology and, consequently, treatment of IBD. Nevertheless, it can generally be analyzed and treated by applying the principles that apply to diagnosis and treatment of the above three TCM diseases.

Damp-Heat
[Bai Tou Weng (30g.), Qin Pi (10g.), Huang Lian (6g.), Huang Bai (10g.), Che Qian Zhe (10g.), Mu Xiang (10g.)]
 * Symptoms:** abdominal pain, tenesmus, stools mixed with mucous/pus and blood, burning sensation around the anus, dark scanty urine, fever
 * Tongue:** yellow, greasy coat
 * Pulse:** slippery and rapid
 * Treatment Principle:** Clear Heat, transform Dampness, rectify Qi and Blood
 * Herbal Treatment:** Bai Tou Weng Tang Jia Wei (Pulsatilla Decoction with Additional Flavors)

Cold and Heat
[Wu Mei (15g.), Chuan Jiao (6g.), Zhi Fu Zi (6g.), Gan Jiang (10g.), Dang Shen (10g.), Huang Bai (6g.), Huang Lian (10g.), Bai Zhu (10g.), Mu Xiang (10g.), Che Qian Zi (10g.)]
 * Symptoms:** recurrent, intermittent dysentery showing no improvement over an extended time, abdominal pain, tenesmus, stools mixed with pus and blood during flare ups, fatigue, lethargy and loss of appetite
 * Tongue:** pale tongue with white, greasy coating
 * Pulse:** deep, rapid
 * Treatment Principle:** Warm and strengthen Spleen, clear Heat rectify Qi, remove stagnation
 * Herbal Treatment:** Wu Mei Wan Jia Jian (Mume Fruit Pill w/additions and subtractions)

Liver Qi Attacking the Spleen
[Bai Zhu (15g.), Bai Shao (12g.), Chen Pi (6g.), Fang Feng (6g.), Chai Hu (10g.), Yi Yi Ren (15g.), Chao Shan Zha (10g.)]
 * Symptoms:** recurrent cycles of abdominal pain and diarrhea with abdominal pain temporarily relieved after diarrhea, loose stools with possible mucus, episodes induced by anger or emotional strain, stuffiness or distention in the chest and hypochondrium, borborygmus, poor appetite, belching, gas, depression, anger/irritability, moodiness, breast distention and menstrual irregularities in females
 * Tongue:** thin, white coat
 * Pulse:** thin, wiry
 * Treatment Principle:** Soothe the Liver, regulate Qi, strengthen the Spleen
 * Herbal Treatment:** Tong Xie Yao Fang Jia Wei (Pain and Diarrhea Formula with Additional Flavors)

Spleen and Stomach Qi Vacuity
[Dang Shen (10g.), Bai Zhu (10g.), Fu Ling (10g.), Bai Bian Dou (10g.), Yi Yi Ren (10g.), Shan Yao (10g.), Lian Zi (10g.), Zhi Gan Cao (3g.), Sha Ren (5g.), Chen Pi (8g.), Ban Xia (10g.), Ge Gen (15g.)]
 * Symptoms:** occasional loose stools or diarrhea that may contain undigested food, mucus and occasionally blood, increased frequency of bowel movement after eating rich and greasy foods, epigastric and abdominal fullness and distention (particularly after eating), poor appetite, sallow complexion, lassitude, fatigue
 * Tongue:** pale, puffy, scalloped with white coating
 * Pulse:** moderate (i.e., slightly slow), thin, weak
 * Treatment Principle:** Strengthen the Spleen, boost the Qi, benefit the Stomach, resolve Dampness
 * Herbal Treatment:** Shen Ling Bai Zhu San Jia Jian (Ginseng, Poria, and Atractylodes Powder with Additions and Subtractions)

Spleen and Kidney Yang Vacuity
[Bu Gu Zhi (10g.), Wu Zhu Yu (3g.), Wu Wei Zi (6g.), Rou Dou Kou (10g.)] + [Chen Pi (6g.), Zhi Gan Cao (6g.)]+ Zhi Fu Zi (10g.), Dang Shen (10g.), Bai Zhu (10g.), Gan Jiang (3g.)]
 * Symptoms:** watery diarrhea with undigested food that occurs at dawn, bowel movement preceded by cold abdominal pain that is relieved after diarrhea, aversion to cold, cold limbs, sore, cold and weak lower back and knees
 * Tongue:** pale with a white coating
 * Pulse:** deep, fine, weak
 * Treatment Principle:** Warm and supplement Spleen and Kidney Yang qi, astringe the intestines, stop diarrhea
 * Herbal Treatment:** //Si Shen Wan Jia Wei// (Four Spirits Pill) + Fu Zi Li Zhong Wan (Aconite Center-Rectifying Decoction)

Qi and Yin Dual Vacuity
[Schizandra (wu wei zi) 10g Ophiopogonis (mai men dong) 10g Anemarrhenae (zhi mu) 10g
 * Symptoms:** chronic diarrhea with mucus/pus and blood in stools, dull abdominal pain, afternoon fever, dizziness, insomnia, restlessness, weight loss, fatigue
 * Tongue:** read with little coating
 * Pulse:** thready, rapid
 * Treatment Principle:** Nourish Yin, clear Heat, boost Qi, stop diarrhea
 * Herbal Treatment:** //Sheng Mai San Jia Wei// (Restore the Pulse Powder)

+ Astragalus (huang qi) 15g Dioscorea (shan yao) 12g Euryales (qian shi) 12g Mume (wu mei) 10g

+ //Liu Jun Zi Tang// (Six Gentlemen Decoction) Codonopsis (dang shen) 15g White Atractylodis (bai zhu) 10g Poria (fu ling) 10g Prepared Licorice (zhi gan cao) 6g Pinellia (ban xia) 6g Tangerine peel (chen pi) 6g

**Qi Stagnation and Blood Stasis**
]Angelica (dang gui) 10g Ligusticum (chuan xiong) 10g Red Peony (chi shao yao) 10g Bulrush (sheng pu huang) 10g Pteropous (wu ling zhi) 10g Myrrh (mo yao) 5g Corydalis (yan hu suo) 10g Cinnamon bark (rou gui) 3g Dried ginger (gan jiang) 3g Fennel (xiao hui xiang) 6g]
 * Symptoms:** fixed abdominal pain that is aggravated by pressure, palpable lumps in the lower abdomen, borborygmus and abdominal distention, incomplete sensation of defecation after diarrhea, blood clots in stool or black stool, dark, dusky complexion
 * Tongue:** the dark, purplish with echymoses
 * Pulse:** deep, choppy or wiry
 * Treatment Principle:** Quicken the Blood, transform stasis, move Qi, stop pain
 * Herbal Treatment:** //Shao Fu Zhu Yu Tang// (Lesser Abdomen Stasis Expelling Decoction)

Acupuncture for Inflammatory Bowel Disease

 * Primary Points**: ST 36
 * Supplementary Points:**
 * Damp-Heat:** LI 4, LI 11, GB34, ST 37, ST 39, ST 44
 * Cold & Heat:** LI 4, LI 11, ST 25, ST 37, CV 4
 * LV Qi Attacking SP:** LV 3, GB 34, CV 12, ST 25
 * SP/ST Qi vacuity:** ST 25, SP 6, BL 20, BL 21, CV 6, CV 12
 * Qi & Yin vacuity:** ST 25, SP 6, SP 9, KI 7
 * Qi Stag., Blood Stasis:** ST 25, SP6, SP 10, BL 17

Herbal Retention Enemas for IBD
Herbal retention enemas often play an important adjunctive role in the treatment of IBD. By directly acting on the lesions in the intestines, improved therapeutic effects can be achieved. Furthermore, strong, frequently bitter and cold medicinals can be used without injuring the Spleen and Stomach.

Bowel preparation with cleansing enema is needed prior to introducing therapeutic enema. Administer enema of 200 ml of herbal formula at roughly body temperature (98.6 ° - 102° F). Retain herbal enema for 3 hours. Continue the therapy on a daily basis for 2-3 weeks. Select formula prescriptions based on pattern identification. Standard dosages or even higher may be used.

Herbal Retention Enemas for IBD (per G. Liu)
 * For the effects of debridement and granulation (basic formula for all patterns):** Dang Gui, Hua Shi, Hu Po, Bing Pian, Xue Jie, Bai Zhi, Lu Gan Shi, Gan Cao
 * For Damp-Heat accumulation:** Huang Qin, Bai Zhi, Huang Lian, Hai Piao Xiao, Bai Jiang Cao, Huai Hua Mi, Gan Cao
 * For Liver Qi attacking Spleen:** Bai Shao, Bai Zhu, Wu Yao, Chen Pi, Fang Fen, Yu Jin, Chai Hu, Gan Cao
 * SP/ST Qi vacuity:** Huang Qi, Dang Gui, Gan Cao, Dang Shen, Chai Hu, Bai Zhu, Zhi Ru Xiang, Zhi Mo Yao, Chen Pi
 * SP/KI Yang vacuity:** Zhi Fu Zi, Shi Liu Pi, Liu Huang, Bai Zhi, Yin Yang Huo, Gan Cao, Bu Gu Zhi
 * Damp-Heat:** Bai Tou Weng 30-60g, Bai Jiang Cao 30g, Da Huang 15g, Ku Shen 20g, Di Yu 15g, Bai Zhi 15g, Yi Yi Ren 30g
 * Qi Stag. & Blood Stasis:** Xue Ji 10g, Shan Zha Tan 15g, Da Huang Tan 10g, Bai Ji 15g

Instructions for Herbal Retention Enemas for IBD (per G. Liu)
Let the decoction stand in the pot for 24 hours, then pour off the clear fluid and cook until half of it is left. Pour this fluid into a glass bottle and let it steam/sterilize the bottle and cool down for approximately 30 minutes. Ask the patient to lie on the left side while the herbal fluid is being administered. Insert a tube through the anus and into the rectum approximately 15-30 cm. It is not uncommon for the patient to experience some intestinal spasms after injection of the herbal fluid.
 * Preparation:** use 2.5-3.5L of water to soak herbs for one and half hours. Bring herbs to a boil and simmer for one hour; strain herbs for the first decoction. Add 1.5L water and cook another hour, then strain the herbs for the second decoction. Mix both decoctions together and cook until half the fluid is left.
 * Administration:** Enema should be applied three to four hours before going to bed. Ask the patient to defecate first, then rest for 15 minutes.
 * Position of patient during retention enema:** After herbal fluid has been administered, patient should get on all fours, then lower the chest to the floor while keeping buttocks raised, maintaining this position for half an hour. Then patient should lie on the left and right sides for a period of time. After spasms subside, patient may stand and do some gentle exercise to facilitate absorption of the herbs. Ideally, herbs should be retained for 3-4 hours.