By William C. Haas III, MD, MPH
Carolinas Medical Center,
Department of Family Medicine,
Charlotte, NC
Dr. Haas reports no financial relationships relative to this field of study.
Summary Points
- Despite some methodological flaws, the present study found that catgut acupuncture potentially reduces the symptoms of constipation-dominate irritable bowel syndrome (IBS).
- Four weeks after treatment, catgut acupuncture may decrease IBS pain by approximately 60%.
SYNOPSIS: Catgut-embedded acupuncture, which involves embedding fibers of animal intestines into the skin at acupuncture points, improved abdominal pain, constipation, and bloating as well as symptoms of depression among patients with irritable bowel syndrome compared to both sham acupuncture and conventional drug therapy.
SOURCE: R Rafiei, et al. A new acupuncture method for management of irritable bowel syndrome: A randomized double-blind clinical trial. J Res Med Sci 2014;19:913-917.
Irritable bowel syndrome (IBS) is a disorder characterized by chronic abdominal pain, bloating, and alteration of bowel habits. The precise etiology of the syndrome is unknown, with many factors, such as dietary, immunologic, and psychosocial factors, hypothesized to contribute to the disorder. By and large, IBS treatments target symptom relief and vary from conventional pharmacotherapy to integrative approaches such as acupuncture. The use of traditional acupuncture for IBS is somewhat controversial, as previous studies have yielded mixed results.1
The present study applies a different method of acupuncture, catgut embedding, in an attempt to decrease the symptom severity and/or pain associated with IBS. The technique of catgut acupuncture involves embedding fibers of sheep or goat intestines into designated acupuncture points and provides continuous stimulation until the fibers are absorbed. A form of this technique has been used in traditional Chinese medicine for thousands of years, but only more recently has it been shown to be effective in conditions such as perimenopausal syndrome, chronic urticarial, and insomnia.2-4 The method is generally regarded as safe, with only one case report referencing complications of tender subcutaneous nodules erupting at embedding sites approximately 1 month after treatment.5
The researchers designed a randomized, double-blind, sham-control trial to assess the efficacy of catgut acupuncture among patients meeting Rome III criteria for IBS. Sixty patients were enrolled from two academic medical centers and one private gastrointestinal clinic. Inclusion criteria were limited to Rome III symptom severity — recurrent abdominal pain or discomfort for ≥ 3 days per month over a 3-month period associated with, but not limited to, relief with defecation, change in stool frequency or form, and or abdominal bloating.6 Exclusion criteria included pregnancy, diabetes mellitus, scleroderma, inflammatory bowel disease, prior small intestinal surgery, or recent gastrointestinal infections.
Prior to randomization, patients were observed during a 2-week washout period and given 135 mg of Colofac (mebeverine) daily, an accepted drug regimen for IBS. After the washout period, patients were randomly assigned to one of three treatment groups: 1) catgut embedding acupuncture, 2) sham acupuncture, or 3) Colofac 135 mg. Details regarding sham treatments were not provided. Moreover, the number of acupuncture sessions was not clearly specified; however, sessions presumably occurred once, given that semi-permanent fibers were embedded in the catgut group. All acupuncture treatments were performed by the same trained professional. Acupuncture sites differed between the sham group and the catgut group, with the inclusion of sites for weight-loss in the catgut group. Acupuncture sites within the two treatment groups, however, were standardized according to the following designation: 1) sham group (GB26, SP8, 1 inch ST25, UB22, Ren5) and 2) catgut group (UB17, 23, 25. DU3, SP9, 15, ST25, 36, Ren12, and 4. Kid15).
Outcomes measured included frequency of IBS symptoms (diarrhea, constipation, and bloating) as well as mean gastrointestinal pain scores. Additionally, both depression and anxiety were assessed using the Beck inventory questionnaire. Baseline surveys were administered after the 2-week washout period and again 4 weeks after the treatment intervention.
There were no significant differences between groups among basic demographic characteristics (age, sex, or weight) at baseline. With regard to IBS symptoms, frequency of constipation and bloating declined in both the catgut and sham groups, with the catgut group experiencing a greater reduction in frequency. The drug-only group did not differ significantly from baseline with regard to constipation or bloating. No mention was made regarding changes in diarrhea frequency, but according to the corresponding figure, there did not appear to be a significant decline among or between the groups. Unfortunately, neither standard deviations nor the significance values were presented in the figure or accompanying text reviewing the changes in IBS symptoms. With regard to severity of gastrointestinal pain, the catgut group experienced an approximate 60% reduction in pain scores (P < 0.05), while the sham and drug groups experienced only a 33% and 19% reduction, respectively (P < 0.05). Depression scores were significantly lower among all groups, with the largest difference noted between the catgut and drug group (P = 0.002). Anxiety scores also trended toward improvement among all groups, but decreases were not noted to be significant (P = 0.077). Unfortunately, baseline scores for both depression and anxiety were not reported and relative changes could not be calculated accordingly. Finally, a 2 kg (± 0.88) weight loss was noted in the catgut group (P < 0.05), with no significant weight loss reported in the sham or drug group.
COMMENTARY
Based on these results, catgut-embedded therapy appears to be superior to both traditional acupuncture and Colofac therapy in the management of IBS, especially with regard to abdominal pain and colonic symptoms of constipation and bloating. Traditional acupuncture is hypothesized to influence the serotonergic, cholinergic, and glutaminergic pathways of the brain-gut axis,7 thereby altering the perception of gastrointestinal pain and discomfort among patients suffering from IBS. Catgut acupuncture is likely to act via the same mechanism, with the benefit of providing more constant activation to the acupuncture sites, which may account for improved outcomes in the present study. Several issues, however, should be considered before clinicians can feel confident recommending catgut acupuncture to patients suffering from IBS.
The researchers made a concerted effort to eliminate selection bias through the design of a randomized, double-blind, sham-control study. Unfortunately, eliminating internal sources of bias was not as easily achieved. Blinding the acupuncture practitioner was not feasible, as the technique of catgut embedding is significantly different from sham acupuncture. The acupuncture practitioner, therefore, may have inadvertently introduced an important source of performance bias, as he/she was aware of which patients were in the treatment group.
Given their focus on evaluating the efficacy of a new acupuncture method for IBS, the researchers could have opted for greater standardization with regard to the acupuncture protocol, especially between the catgut and sham groups. Although different acupuncture sites may be used to treat the same condition according to principles of traditional Chinese medicine, the researchers reportedly selected acupuncture sites that differed between the groups, with the inclusion of sites hypothesized to target weight-loss in the catgut group.5 Therefore, the results of the study should not be solely attributed to the method of embedding semi-absorbable filaments, but perhaps due to the effects of the acupuncture sites chosen as well.
Interestingly, researchers opted to report on weight loss associated with the catgut acupuncture. Caution should be advised when interpreting these results, as the study was not designed to assess weight loss, which was a secondary variable. Several other unaccounted variables could have affected weight loss or gain, such as self-imposed differences in diet or exercise between treatment groups. Furthermore, the catgut group included acupuncture sites for weight loss as mentioned above.
Aside from the potential shortcomings in the methods, there were also several places where interpreting the results was challenging. Neither standard deviations nor significance values were reported in the figure displaying IBS symptoms. The corresponding text also inconsistently reported significance values. Additionally, baseline depression and anxiety scores were not reported; hence, the relative change in depression and anxiety could not be assessed. In the end, a more detailed presentation of the results would have provided a clearer understanding regarding the effect of catgut acupuncture on IBS.
Although the results of the present study are intriguing and provide a positive association between catgut acupuncture and IBS, health care providers should heed caution in recommending this modality until the results are replicated and the methodology improved. Furthermore, while the present study did not report any adverse events, the introduction of semi-permanent fibers into the skin could serve as a nidus for infection or an inflammatory response if proper technique is not used. Finally, the identification of practitioners with excellent technique may prove difficult, as this form of acupuncture is not widely available in the United States.
References
- Yoon SL, et al. Management of irritable bowel syndrome (IBS) in adults: Conventional and complementary/alternative approaches. Altern Med Rev 2011;16:134-151.
- Liu BX, et al. Postmenopausal osteoporosis of liver and kidney deficiency type treated with acupoint catgut embedding by stages. Zhongguo Zhen Jiu 2011;31:315-319.
- Yang XL, et al. Efficacy observation on acupoint catgut embedding therapy combined medication for treatment of chronic urticaria induced by Helicobacter pylori infection. Zhongguo Zhen Jiu 2010;30:993-996.
- Wei Y. Clinical observation on acupoint catgut embedding at head-acupoint combined with massage of sole for treatment of refractory insomnia. Zhongguo Zhen Jiu 2010;30:117-120.
- Chuang YT, et al. An unusual complication related to acupuncture point catgut embedding treatment for obesity. Acupunct Med 2011;29:307-308.
- Drossman DA. The functional gastrointestinal disorders and the Rome III process. Gastroenterology 2006;130:1377-1390.
- Chan J, et al. The role of acupuncture in the treatment of irritable bowel syndrome: A pilot study. Hepatogastroenterology 1997;44:1328-1330.
Catgut-embedded acupuncture, which involves embedding fibers of animal intestines into the skin at acupuncture points, improved abdominal pain, constipation, and bloating as well as symptoms of depression among patients with irritable bowel syndrome compared to both sham acupuncture and conventional drug therapy.
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