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March 9, 2014

Not all IBS is stress related - Effective treatment with acupuncture and herbal medicine

Written by: Matthew Wagner, L.Ac., M.S.O.M.

Irritable Bowel Syndrome (IBS) is one of those functional diseases that usually responds well, and quickly, to Acupuncture and Herbology.  The common TCM diagnosis usually involves a large degree of “Liver qi stagnation”, elements of digestive weakness, and pathological accumulation of phlegm-damp in the intestines.  This pattern holds true in probably 85% of IBS cases, and a practitioner who follows a basic IBS = liver qi stagnation approach will generally see a lot of success in the clinic.  This can seem miraculous for those 85%.  However, easy success discourages thorough diagnosis.  This can damage long-term wisdom and professional development, if the practitioner doesn’t know how to treat the remaining, to say nothing of how aggravating it is for those TCM patients who aren’t getting the results they want.  Those remaining 15% require a more complete diagnosis and nuanced understanding.

From a western point of view, “Liver qi stagnation” generally translates as “stress”, and treatment often involves anti-depressants and laxatives.  As everybody has stress, this diagnosis generally isn’t helpful; it doesn’t explain why some people get it over others. Furthermore, while it may help to some extent, there are concerns over side effects and lifelong anti-depressant dependence.

This small percentage of IBS sufferers doesn’t fit the usual presentation.  These people aren’t overly stressed, don’t have abdominal pain, and don’t seem to be bothered by typically aggravating foods.  The key symptoms they do have are: 

  1. Difficult bowel movements, which are loose, thin, and incomplete.  They must NOT be dry and hard, unless bowel movement occurs only every few days.
  2. Fullness and bloating, generally without abdominal pain
  3. Some impairment of lung function.  This can manifest as; shortness of breath; difficult inhalation; stuffiness in the chest; “chest pressure” or phlegm in the lungs.
  4. Symptoms may be aggravated by the common cold, or flu, asthma, allergies, or anything else that effects the lungs
  5. Symptoms are not better with increased fiber or water, (NOTE: this can reflect damp-phelgm obstruction, as well)
  6. Symptoms are not better with exercise

From a TCM point of view, this presentation of IBS isn’t related to stress or liver qi stagnation, but rather lung function.  The Chinese pairing of the lung with the large intestine reflects the observation that the rhythmic movement of the lungs guides peristalsis.  Thus, nervous tension in the body, evidenced by a held, or tense breath, will translate into a holding of the large intestine.  This reflects the classic new-agey psych idea of you can’t go to the bathroom because you’re “holding on to something”.  While this is an appeal to the “stress as absolute cause” position of Western Medicine and Psychology, and while there may be elements of truth to it, it certainly isn’t 100% causative, or true in all cases.   Furthermore, if we dump this pattern into the garbage pail of “stress” and treat with SSRIs or “liver qi moving” herbs, we will probably be met with limited success, because neither of these approaches focuses specifically on lung function, which is where the patho-mechanism lies.

Therefore, the treatment principle in this case is to “open” and “downbear” the lungs, in order to regulate proper movement of the large intestine.  While it may be necessary to regulate the liver qi, it shouldn’t be the focus of treatment, and indeed, too much attention placed upon the liver detracts from the overall treatment principle and weakens the formula.

At this point, it is necessary to point out that patients often adopt their own treatment plan, and self-medicate with medicinals that are ultimately damaging to this particular pattern.  Specifically, senna leaf, rhubarb root, Epsom salts, and mineral oil, all of which are indicated only in conditions of heat and inflammation, which manifests as agitation, irritability, and dry, hard, bound, constipation.  These medicinals may all further weaken lung and digestive function.  Therefore, it may be necessary to repair damages done.

Key herbs in the treatment of this Irritable Bowel Syndrome (IBS) pattern have the characteristics of opening the lungs, downbearing lung qi, and releasing the exterior by promoting diaphoresis.  Chief among these are:

  • xing ren – armeniaca seed
  • zi su zi and ye – perilla leaf and seed
  • xuan fu hua – inula flower

These are paired with upper and middle jiao qi regulating and phlegm transforming herbs, such as:

  • Hou po – magnolia bark
  • Zhi ban xia – pinellia
  • Chen pi – citrus peel

And lower jiao qi regulators, such as

  • Zhi shi – aurantii 
  • Mu xiang – aucklandia lapis

Two, specific complications to this pattern are the following: 

Thin, difficult, loose constipation, accompanied by agitation, especially agitation in the chest at night, typically reflects heart fire stagnating fluids into phlegm, which in turn disrupts normal qi movement and peristalsis.  This often responds well to:

  • Zhi Zi – gardenia 
  • Zhi Shi – aurantii
  • Hou Po – magnolia.  

Constipation in the elderly requires special care, as “bearing down” can place undo stress on the heart.  Therefore, when moving the bowels, it is important to ensure that the bowel movement itself is loose enough to pass without stress or strain.  As elderly people are usually fluid and blood deficient, nourishing, moistening herbs should be added.  Xing Ren and Tao Ren is a useful combination that addresses the “upper” and the “lower” to help in the passage of dry, hard stool.  Xing Ren and Tao Ren both regulate the lungs and direct downward, and they are both high in oil content, which moistens the bowels and helps transit.  Lastly, Tao Ren moves the blood and helps alleviate the systemic blood stagnation found in elderly patients (CAUTION patient’s on blood thinners).

As the trained herbalist can see, none of these herbs specifically regulate liver qi.  Yet, they are very effective in these types of presentations. So, for that 15%, it's important to remember that not all Irritable Bowel Syndrome (IBS) is a stress-related, liver qi pathology.  With a more nuanced understanding of diagnosis, theory, and herbal selections, we will be much more able to help everybody.