Inflammatory Bowel Disease (IBD) and TCM

What’s covered?

• Defining Irritable Bowel Disease (IBD), its symptoms, causes and treatment options
• Chinese medicine understanding of IBD
• Modern research into Chinese herbs and acupuncture for IBD
• TCM dietary/lifestyle tips for managing IBD symptoms
• A Crohn’s disease case study using Chinese herbs

What is IBD?

Inflammatory Bowel Disease (IBD) is a broad term that describes a group of autoimmune diseases affecting the gastrointestinal tract. IBD is broadly divided into Crohn’s Disease (CD) and Ulcerative Colitis (UC), both characterised by chronic inflammation, which commonly presents with gastrointestinal pain and bowel changes. Although their presentations are similar, Crohn’s Disease can affect any part of the gastrointestinal tract, including the mouth, eosophagus, stomach, small intestine, and large intestine. In contrast, Ulcerative Colitis primarily impacts the large colon and rectum and is more commonly associated with rectal bleeding or blood in the stool [1].

Common Symptoms

Many symptoms of Crohn’s Disease (CD) and Ulcerative Colitis (UC) are quite similar, though there are some differences. The two most commonly reported symptoms of CD are gastrointestinal pain and fatigue, while loose or watery stools with the presence of blood are more prevalent in UC [2]. However, symptoms that can manifest in IBD generally include:

• Abdominal bloating/distention and pains
• Urgent and frequent bowel motions with loose/watery stools
• Blood and mucus in the stool
• Flatulence
• Nausea and vomiting
• Reduced appetite
• Chronic fatigue
• Systemic joint aches and lower back pain
• Weight loss & nutritional deficiencies
• Insomnia and impacts on mental health

Causes & treatments

Although the exact cause of Inflammatory Bowel Disease (IBD) is not fully understood, early research suggests that a combination of genetic, environmental, and immunological factors increases the risk of developing IBD [3]. Recent studies have explored additional potential causes, such as dysregulated autoimmune responses to gut dysbiosis (imbalanced gut microbiome), certain medications, bowel surgeries, stem cells, or fecal transplants [4]. Conventional treatments for IBD focus on controlling symptoms through pharmacotherapy medications, including corticosteroids, immunomodulators, and biologics, as well as surgical interventions in severe cases [5]. However, since IBD is considered an ‘incurable’ disease, these treatments primarily aim to manage symptoms rather than address the underlying cause.

Link between IBD & SIBO

Previous research has revealed there is a likely correlation between small intestinal bacterial overgrowth (SIBO) and IBD, and some studies indicate that up to 78% of IBD sufferers have underlying gastrointestinal dysbiosis and/or SIBO infection [6]. A Systematic review and meta-analysis was conducted in 2019 which investigated the prevalence of SIBO in IBD patients [7]. The researches made the following conclusion:

“Overall, there is a substantial increase in the prevalence of SIBO in IBD patients compared to controls. Prior surgery and the presence of fibrostenosing disease are risk factors for SIBO in IBD”.

Shah, A., Morrison, M., Burger, D., Martin, N., Rich, J., Jones, M., Koloski, N., Walker, M. M., Talley, N. J., & Holtmann, G. J. (2019). Systematic review with meta-analysis: the prevalence of small intestinal bacterial overgrowth in inflammatory bowel disease. Alimentary pharmacology & therapeutics, 49(6)

Chinese herbal medicine & IBD

Some of the earliest Chinese medical records of IBD-type presentations come from the Jingue Yaolue (Essential Prescriptions from the Golden Cabinet), authored by Zhang Zhongjing in the Eastern Han Dynasty (150 -219 AD). Both CD and UC fall into the categories of dysentery, small intestinal abscess, cold of the small intestine and distant bleeding.

“When the small intestine has cold, the person has downward heaviness and bloody stool.”

Zhang Zhongjing, Jingue Yaolue Chapter 11

Within the Chinese medicine framework, multiple internal patterns are associated with IBD, depending on the individual’s pulse and symptoms. However, during the acute stage of treatment, the primary focus is placed on stopping loose stools and preventing further loss of blood and Yang. Two representative formulas for addressing acute IBD symptoms are Tao Hua Tang (“Peach Blossom Decoction”) and Huang Tu Tang (“Yellow Earth Decoction”).

For diarrhoea with pus and blood in the stool, Tao Hua Tang governs.’

Jingui Yaolue, Chapter 17

Once the small intestine is warmed and the patient’s stools begin to normalise, a follow-up Chinese herbal formula is typically prescribed to further stabilise digestion, aiming to prevent a relapse of symptoms. Two examples are Li Zhong Wan (“Regulating the Centre Decoction”) and Gui Zhi Ren Shen Tang (“Cinnamon Twig and Ginseng Decoction”). These formulas are commonly used during the sub-acute phase to address various symptoms, including nausea, abdominal bloating, lack of appetite, fatigue, cold limbs, and an aversion to cold weather.

It is important to emphasise that these are just a few examples of classical Chinese herbal formulas that have historically been used for patients with IBD-type symptoms. In a clinical setting, the appropriate herbal formula and any necessary modifications will be determined based on the patient’s pulse and symptoms. Additionally, it is crucial for the patient to commit to dietary and lifestyle changes, while minimising suspected triggers such as irregular eating habits, specific foods, external stress, and imbalanced lifestyle patterns.

Chinese herbs / evidence-based research

Small-scale preliminary studies have investigated the use of Chinese herbal medicine in treating IBD, using both animal and human models. A recent paper by Yuan, S., Wang, Q., Li, J. et al., titled “Inflammatory Bowel Disease: An Overview of Chinese Herbal Medicine Formula-Based Treatment”, provided an overview of the proposed mechanisms by which Chinese herbal medicines may benefit IBD. The authors concluded that TCM formulas may help maintain intestinal integrity, reduce inflammation, and decrease oxidative stress of the gastrointestinal tract in IBD patients [8].

Other recent research has focused on specific Chinese herbal formulas and their roles in alleviating IBD symptoms and promoting recovery. Specifically, formulas such as Huang Qin Tang and Bai Tou Weng Tang have been shown to reduce the symptoms of ulcerative colitis by restoring normal gut microbiome balance [9]. Additionally, formulas like Li Zhong Wan may reduce inflammation in the gastrointestinal tract by inhibiting harmful bacteria, such as Clostridium sensu stricto, Enterobacter, and Escherichia-Shigella, while increasing the proportion of beneficial gut bacteria [10].

Acupuncture & IBD

A double-blind, randomised controlled trial was conducted to investigate the effects of acupuncture on symptoms, intestinal microbiota, and circulating inflammatory markers in patients with Crohn’s Disease (CD). A 48-week, sham-controlled trial was carried out at a tertiary outpatient clinic in China from 2015 to 2019. Sixty-six patients with mild to moderate active CD were enrolled and randomly assigned to either an acupuncture group or a sham group.

At week 12, the clinical remission rate was significantly higher than that of sham group, which was maintained at week 48. The acupuncture group had significantly lower CD activity index and C-reactive protein level (an inflammatory marker) at week 12, which maintained at the 36-week follow-up. The authors of the study concluded that, “acupuncture was effective in inducing and maintaining remission in patients with active CD, which was associated with increased abundance of intestinal anti-inflammatory bacteria, enhanced intestinal barrier, and regulation of circulating Th1/Th17-related cytokines” [11].

How important is diet & lifestyle?

In recent years, various dietary approaches have been investigated for their effectiveness in conjunction with conventional treatments for the management of IBD symptoms. Notable diets include the Crohn’s Disease Exclusion Diet, the Autoimmune Paleo Diet, and the low-FODMAP diet. Each of these dietary strategies has been explored to varying degrees for their potential benefits in managing IBD symptoms and improving patient outcomes, complementing standard medical interventions. Additionally, research has highlighted that other factors such as stress, illness, and environmental triggers can also contribute to flare-ups, underscoring the complex interplay of dietary and lifestyle elements in the effective management of IBD.

The Crohn’s Exclusion Diet (CDED)

The Crohn’s Disease Exclusion Diet (CDED) involves a three-phase process with two initial phases and one maintenance phase. In the first 6 weeks, the individual receives half of their nutrients from liquid nutrition (known as PEN) while avoiding foods like insoluble fiber, red or processed meats, and more. During the second phase, typically from weeks 6 to 12, they receive 25% of their calories from liquid nutrition and begin reintroducing certain foods. In the final phase, they continue with the diet from phase 2 but are allowed two free meals each week [12]

Recently, the effectiveness of the CDED was evaluated in adults with Crohn’s Disease (CD). In an uncontrolled study, Szczubelek et al. tested the CDED’s impact on clinical remission in 32 adults with CD who had not responded to biologic suppressive medication. By the 12-week mark, 82.1% of the patients had achieved clinical remission [13]. Following this study, Yanai et al. conducted a randomised controlled pilot study involving 44 adults with active Crohn’s Disease (CD) to assess clinical remission without the use of liquid nutrition.

At 6 weeks, 57–68% of participants achieved clinical remission, with no significant difference between those on liquid nutrition and those following the whole food version of the CDED. These findings suggest that the CDED may be a promising treatment for active CD. Additionally, a modified version of the CDED, known as the Ulcerative Colitis Exclusion Diet (UCED), is being explored for ulcerative colitis (UC). Although this modified diet is still being investigated, initial results from a pilot study indicate that the UCED might be effective for UC treatment [14].

Low-FODMAP diet

The low-FODMAP diet, initially developed and studied for irritable bowel syndrome (IBS), has gained attention for its potential to alleviate symptoms in individuals with inactive IBD. This diet involves eliminating foods rich in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) for approximately 1-2 months, followed by a gradual reintroduction phase to identify specific food triggers [15].

Figure 1: Example high-FODMAP foods

Despite its potential benefits, the low FODMAP diet has several drawbacks. It is highly restrictive, especially during the initial six weeks, and there is limited evidence to support its effectiveness in reducing gut inflammation. Moreover, research suggests that following a low FODMAP diet long-term may not be beneficial, as it has been linked to changes in the gut microbiome, including an increase in dysbiosis and a reduction in beneficial bacteria like Bifidobacterium [16]. Additionally, the low-FODMAP diet may contribute to a higher risk of developing eating disorders in some individuals. When followed long-term, it can also lead to nutritional deficiencies, potentially exacerbating existing nutritional inadequacies in people with chronic SIBO [17].

Autoimmune Paleo Diet (AIP)

The Autoimmune Protocol (AIP) diet, an extension of the Palaeolithic diet, is designed to support gut health and reduce inflammation by initially eliminating a broad range of foods and additives that may trigger immune responses. This elimination phase excludes grains, legumes, nightshades, dairy, eggs, coffee, alcohol, nuts, seeds, refined sugars, and processed oils. The rationale behind these restrictions is to avoid potential triggers of intestinal inflammation and dysbiosis, which can exacerbate symptoms of autoimmune conditions, including IBD [18].

The AIP diet emphasises the consumption of fresh, nutrient-dense foods, bone broth, and fermented foods, and also addresses lifestyle factors such as sleep hygiene, stress management, and physical activity. After the elimination phase, a maintenance period follows, during which individuals may gradually reintroduce foods to identify those that affect their symptoms, allowing for a more tailored and potentially less restrictive long-term dietary approach [19].

What does Chinese medicine suggest?

In Chinese medicine, diet and lifestyle are pivotal in managing autoimmune and gut-related inflammatory bowel diseases (IBD). The philosophy of Yangsheng (養 生), or “nourishing life,” underpins this approach, emphasising the importance of a balanced diet and lifestyle to support overall health and prevent gut-related disorders. According to Chinese medicine, maintaining strong Spleen Qi—vital for proper digestion and nutrient assimilation—is essential for managing IBD. A key factor contributing to IBD in TCM is the pattern of Wood overacting on Earth (Liver/Spleen disharmony), where emotional stress or Liver Qi stagnation disrupts Spleen function, leading to symptoms like bloating, abdominal pain, and alternating diarrhoea and constipation. This pattern is commonly seen in IBD patients and exacerbates digestive and inflammatory issues.

To support Spleen Qi and reduce inflammation in the acute stage of IBD flare-ups, the diet should consist of bland, easily digestible foods that do not overwhelm the digestive system. This includes incorporating soothing options like chicken congee and meat stocks, which are not only gentle on the stomach but also rich in nutrients that promote healing. Additionally, foods that nourish Yin and calm Liver Qi, such as steamed vegetables and root-based soups, can help manage the underlying Liver/Spleen disharmony, providing a more comprehensive approach to IBD management in TCM. Incorporating stress-relieving practices like Yoga, Qi Gong, meditation, and acupuncture to soothe Liver Qi stagnation, can further help to alleviate stress-related digestive disruptions in IBD patients.

Chinese medicine diet therapy

Certain foods are known to contribute to internal dampness, which can weaken Spleen function and exacerbate the Wood/Earth disharmony. Specifically, grains, refined sugars (including those in fruits), processed foods, and dairy can generate dampness, impairing the Spleen’s ability to process and transport nutrients. This internal dampness further disrupts the balance between Liver and Spleen Qi, exacerbating IBD symptoms.

To effectively manage IBD, it’s crucial to eliminate or reduce these damp-producing foods from your diet in the initial treatment phase. Adopting dietary principles similar to those of the AIP diet can be beneficial, as these approaches emphasise whole, unprocessed foods and exclude common dietary triggers that may worsen inflammation and IBD symptoms. Additionally, consuming blander tasting foods is important because, in Chinese medicine, the bland flavour helps to reduce dampness and supports Spleen Qi. Examples of bland foods include steamed white rice, cooked carrots, and simple broths, all of which are gentle on the digestive system and nurture Spleen Qi.

This is why chicken congee and meat stocks are excellent choices for managing IBD. Both of these foods are considered bland and simple, which supports digestion and help replenish Qi, Yin, Yang, and Blood. Chicken congee provides a warm, easily digestible meal that aids in restoring Qi and Blood, which are often depleted due to diarrhea and blood loss. Meat stocks, rich in minerals and gelatin, contribute to healing the gut lining and restoring Yin and Yang. Including these nourishing can help support recovery for individuals with IBD. Once the gut begins to heal and bowel functions normalise, more aromatic spices and vegetables can be gradually introduced to enhance flavour and provide additional therapeutic benefits.

Crohn’s disease / a patient case study

This case involves a patient who had previously sought Chinese medicine treatment for Crohn’s disease. After 12 months of remission since her previous visit to the clinic, the patient returned for a follow-up consultation due to an acute flare-up lasting six weeks, likely triggered by significant stress. Her symptoms included severe bloating, blood and mucus in the stool, and pain with frequent bowel movements. She also reported fluctuating energy levels, a loss of appetite, and a general tendency to feel overheated, although her hands were cool and clammy to the touch. Additionally, she noted inconsistent sleep patterns with heightened daily anxiety. Her tongue was pale with a thin white coating, and her pulse was deep, rapid and weak on both radial pulses.

Herbal formula prescription / Li Zhong Wan

The patient was initially prescribed Li Zhong Wan, which included Pao Jiang (processed ginger), Bai Zhu (Atractylodes), Ren Shen (ginseng), Zhi Gan Cao (honey-fried licorice root), with the addition of Sheng Di Huang (rehmanniae root), E Jiao (gelatin), and Chi Zhi Shi (Halloysitum Rubrum). The base formula was prescribed to tonify Spleen Qi and stop loose stools, harmonise the Stomach, and address symptoms such as bloating, loss of appetite, and fatigue. E Jiao and Sheng Di Huang were added to tonify blood and calm the mind. Chi Zhi Shi was included to stabilize and bind the intestines, as this herb has been classically included in Chinese herbal formulas to treat diarrhoea, dysentery, and excessive loss of fluids.

After 5 days, the patient reported that her bowel movements had normalised to once daily, with well-formed stools without the presence of pus and blood. Her energy levels had also begun to improve, though she noted that her anxiety was persisting. A follow-up herbal formula, Gui Zhi Ren Shen Tang, was prescribed to further tonify Spleen Qi, support digestion, and strengthen Heart Yang, aiming to alleviate her anxiety symptoms. The patient was advised to continue taking the second herbal prescription as a maintenance formula for four weeks, whilst gradually reintroducing more foods into her standard meal plan.

Closing thoughts

Managing IBD with Chinese medicine often requires a comprehensive and individualized treatment strategy that combines diet therapy, lifestyle adjustments, stress reduction techniques, and the use of herbs and acupuncture. These approaches can complement conventional allopathic treatments to create a holistic care plan. If you or a loved one is experiencing IBD symptoms, it is essential to consult with an experienced Chinese medicine practitioner who can tailor treatments to your specific needs. Dr. Fraser Cobham (TCM) at Ancient Waters Acupuncture & Chinese Medicine has extensive experience helping patients get to the root cause of a wide range of digestive symptoms, and is dedicated to providing expert care to the Nowra Shoalhaven community.

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