Editor's note: Part I of Dr. Chen's article appeared in the November 2000 issue of Acupuncture Today.
Oriental Medicine
Etiology: According to the theories of Oriental medicine, Crohn's disease may be caused by constitutional deficiencies, invasion of the exterior pathogenic factors, or unbalanced diet. Constitutional deficiencies usually refer to spleen and kidney deficiencies. Invasion of exterior pathogenic factors refers to damp heat in the large intestine. Lastly, unbalanced diet high in raw or cold injures the spleen and stomach and obstructs their functions in transforming and transporting food and nutrients.
Differential Diagnosis: Crohn's disease can be divided into four general categories: damp heat; spleen deficiency; spleen and kidney deficiencies; and qi and blood stagnation.
Invasion of damp heat in the large intestine is characterized by an acute and sudden onset of gastrointestinal symptoms. Damp heat in the large intestine is illustrated by diarrhea; presence of mucous and blood in the stool; foul-smelling stools; yellow urine; and abdominal fullness and pain. Defecation is characterized by extreme urgency, tenesmus, and a burning sensation of the anus after passing the stool. As heat travels upwards, patients may feel irritable, thirsty, and have a preference to drink cold water. The tongue is dark red with a yellow, greasy coat; the pulse is wiry, slippery or rapid.
Spleen deficiency may be due to constitutional deficiency or secondary due to excessive intake of cold and raw food. Patients with chronic Crohn's disease usually have spleen deficiency, which is characterized by a compromised ability of the spleen to transform and transport food. Clinically, the patient will show symptoms such as frequent and severe diarrhea; watery stool with undigested food; dull abdominal pain; poor appetite; poor digestion; and gastric discomfort after food intake. Sallow facial appearance, fatigue and lethargy are due to chronic malabsorption and malnutrition. The tongue is pale with a white coat; the pulse is soft and weak.
Spleen and kidney deficiencies may be due to constitutional deficiency or secondary due to chronic nature of the illness. One diagnostic key of spleen and kidney deficiency is early morning diarrhea around 5:00 am. In addition, patients may have abdominal pain that increases with cold but decreases with defecation. Patients may also have intolerance to cold and cold extremities. The tongue is pale with a white coat; the pulse is thready and weak.
Lastly, qi and blood stagnation resembles an acute phase of Crohn's disease in which the patient has severe abdominal pain and fullness with a palpable mass in the right lower quadrant. This condition mimics acute appendicitis. It is essential to make a correct differential diagnosis prior to treatment. In addition, patients may experience diarrhea, lack of appetite, muscle wasting and lethargy. The tongue is dark purple with petechia; the pulse is thready and knotted.
Herbal Treatment
I. Damp Heat in the Xia Jiao (lower burner)
Clinical Manifestation: An acute and sudden onset of gastrointestinal symptoms and signs (diarrhea; presence of mucous and blood in the stool; foul-smelling stools; yellow urine; abdominal fullness and pain; extreme urgency to defecate; tenesmus; burning sensation of the anus after passing stools; irritability; thirst; preference to drink cold water; dark red tongue; yellow, greasy tongue coat; wiry, slippery, or rapid pulse.
Herbal Formula
- Peony combination (shao yao tang). This formula eliminates damp heat and toxin from the xia jiao and is commonly used to treat inflammation of the intestines.
Modification
- Excessive heat and toxin: add pulsatilla (bai tou weng) and dandelion (pu gong ying)
- Excessive damp: add coix (yi yi ren) and poria (fu ling)
- Abdominal fullness and swelling: add scirpus (sang leng) and zedoaria (e zhu)
II. Spleen Deficiency
Clinical Manifestation: frequent and severe diarrhea; watery stool with undigested food; dull abdominal pain; poor appetite; poor digestion; gastric discomfort after food intake; sallow facial appearance; fatigue; lethargy; pale tongue with white tongue coat; soft and weak pulse.
Herbal Formula
- Ginseng & atractylodes formula (shen ling bai zhu san). This formula tonifies qi and strengthens the spleen and stomach. It may be used for chronic diarrhea due to enteritis.
- Crohn's formula. This formula is called a yan fan (an experienced formula). It is not a classic herbal formula, but one designed with years of clinical experience specifically for treating chronic Crohn's disease with deficiencies of qi, blood, spleen and kidney. Ingredients and dosage is as follows: salvia (dan shen), 15g; red peony (chi shao), 12g; white peony (bai shao), 12g; white atractylodes (bai zhu), 9g; angelica sinensis (dang gui), 12g; carthamus (hong hua), 9g; cinidium (chuan xiong), 9g; codonopsis (dang shen), 12g; aurantium fruit (zhi ke), 9g; saussurea (mu xiang), 9g; citrus peel (chen pi), 9g; pinellia (ban xia), 9g; and licorice (gan cao), 4g.
Modification
- Poor appetite: add crataegus (sha zha), massa medicata fermenta (shen qu) and barley sprouts (mai ya).
- Watery diarrhea due to spleen deficiency with interior cold: add decoction to regulate the spleen and stomach (li zhong wan) plus prepared aconite (fu zi) and cinnamon bark (rou gui).
III. Spleen and Kidney Deficiencies
Clinical Manifestation: early morning diarrhea at around 5:00 am; abdominal pain which increases with cold but decreases with defecation; aversion to cold/cold extremities; pale tongue with white tongue coat; thready and weak pulse.
Herbal Formula
- Pills of four miraculous drugs (si shen wan). This is an effective herbal formula to treat diarrhea due to spleen and kidney deficiencies. Codonopsis and white atractylodes are added to increase its overall effect to tonify qi and strengthen the spleen.
Modification
- Severe diarrhea: add terminalia (he zi), rubrum halloysitum (chi shi zi) and limonitum (yu liang shi).
- Cold extremities: add prepared aconite and cinnamon bark.
IV. Qi and Blood Stagnation
Clinical Manifestation: severe abdominal pain and fullness with a palpable mass in the right lower quadrant; diarrhea; lack of appetite; muscle wasting; lethargy; dark purple tongue with petechia; thready and knotted pulse.
Herbal Formula
- Tangkuei & corydalis combination (ge xia zhu yu tang). This formula is commonly used to relieve pain in the abdominal region due to qi and blood stagnation.
Modification
Diarrhea: add crataegus (shan zha), terminalia and dioscorea (shan yao). Qi deficiency: add codonopsis and white atractylodes.
Acupuncture Treatment
Point Selection: pishu (UB20); shenshu (UB23); dachangshu (UB25); zusanli (St26); zhongwan (Ren12); tianzhu (UB10); mingmen (Du4); guanyuan (Ren4); taixi (K3); zhangmen (Liv13); shanjuxu (St37).
Technique: Acupuncture points are selected according to the clinical presentation of the patients. Use moderate stimulation technique and leave the needles in for 15-30 minutes. Moxa may be applied to the points for 10-15 minutes when appropriate.
Prevention
Both Western and Oriental medicines recognize the importance of diet and its role in prevention and treatment of Crohn's disease. Western medicine acknowledges dietary intake of certain factors (such as excessive chemicals or lack of fiber) may be linked to increased incidence of Crohn's disease, while Oriental medicine recognizes that dietary intake with excessive cold or raw food may injure the spleen and stomach. Therefore, diet plays an important role in both preventive and effective treatment of the illness.
Patients should be encouraged to avoid any food that may trigger recurrence, such as certain chemicals, raw or cold food. Milk, cheese and other dairy products should be avoided, especially if the patients have lactase intolerance. High roughage, raw fruits or vegetables sometimes worsen intestinal obstruction and colic and may need to be avoided. Certain over-the-counter or prescription antidiarrheal drugs may worsen the condition and create toxic megacolon. The use of these drugs should not be taken unless supervised by a qualified health care provider. Lastly, in addition to avoiding the wrong food, it is equally important to make sure patients have adequate calorie and fluid intake as malnutrition and dehydration are common problems associated with Crohn's disease.
Discussion
According to Western medicine, Crohn's disease is a chronic, nonspecific, idiopathic gastrointestinal inflammatory disease. Several etiologic factors have been suggested, but none are proven at present. Since there is no known cause, specific therapy is not available and all available treatments focus on symptomatic relief. In addition, because Crohn's disease was first reported only in 1932, much work still needs to be done in understanding and effective treatment of this illness. Oriental medicine approaches treatment of Crohn's disease similar to treatment of abdominal pain and diarrhea. Herbs and acupuncture are effective in controlling the symptoms and signs of Crohn's disease. Optimal treatment, however, requires full cooperation of the patient to adhere strictly to treatment and preventative guidelines.
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