Acupuncture Continuing Education

sample from Colitis, Crohn’s Disease, Chronic Appendicitis

Acupuncture CEU/PDA Online

Digestive system

Download the course, complete the online quiz and receive immediate acupuncture license credit! Learn herbal formulas for the treatment of hiccups, constipation, stomach pain and vomiting. Enjoy interesting case studies highlighting the material. This course is approved for 9 California acupuncture CEUs (category 1), 9 NCCAOM Diplomate recertification PDAs, 9 Texas CAEs, 9 Florida CEs and 9 CTCMA & CAAA CEs. Also approved for 9 California nursing contact hours.
 

About the Author
Professor Liao, L.Ac. has served as professor of herbology and acupuncture theory at the Academy of Chinese Culture & Health Sciences in Oakland, California. Prof. Liao has also served as faculty at Five Branches University in Santa Cruz, California. His many years of teaching experience bring the highest quality of interesting and useful courses to HealthCMi continuing education online. Prof. Liao has published many works of Traditional Chinese Medicine including original translations of Chinese Medicine classic texts. In addition, Prof. Liao has a private acupuncture practice in Walnut Creek, California and travels to China frequently with his students for advanced Qi Gong and meditation practices.  

 

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Colitis

Colitis refers to inflammation of the large intestine, however, surrounding areas may be affected. Discomfort and pain of the abdomen and diarrhea are primary symptoms. There are several types of colitis including ulcerative colitis, pseudomembranous colitis, ischemic colitis, infectious colitis (parasites, bacteria, virus or food poisoning), and colitis due to radiation treatments or chemical exposure. 

A rare form colitis is microscopic colitis, which is either collagenous colitis or lymphocytic colitis. The inflammation of the colon is caused by either collagen or lymphocytes engorging the large intestine. Watery diarrhea is common with microscopic colitis.

Common Types

  • Ulcerative colitis (UC) is a chronic illness involving bleeding ulcers of the inner lining of the large intestine. UC has a tendency to be genetically related and is considered an autoimmune disorder. 
  • Pseudomembranous colitis (PC) is due to the overgrowth of normally occurring bacteria (Clostridium difficile). Antibiotic use may precipitate PC by destroying healthy bacteria thereby allowing overgrowth of Clostridium difficile. 
  • Ischemia colitis (IC) is due to diminished blood flow to the large intestine. Atherosclerosis in blood vessels to the large intestine precipitates IC as does dehydration, colon cancer, diabetes, hernias, shock and vasculitis. Common causes of infectious colitis include the bacteria Shigella, E Coli, Salmonella, and Campylobacter and the parasite giardia. 

Symptoms, Diagnostics, Medications
Primary symptoms include abdominal cramping, pain and bloating. There may be diarrhea, blood in the stool, mucus in the stool, urgent bowel movements, tenesmus (continual or recurrent inclination to evacuate the bowel) vomiting, fatigue, loss of appetite, weight loss, chills, or fever. 

Diagnostics include several tests: colonoscopy, barium enema, sigmoidoscopy, magnetic resonance imaging (MRI) imaging and computed tomography (CT) scans. Doctors often prescribe anti-inflammatory, immunosuppressant and antibiotic medications to control this condition. Surgical removal of some or all of the large intestine or rectum is performed in some cases. 

Chinese Medicine Theory
External pathogens, genetics, irregular food intake and the seven emotions are important exacerbating or causative factors. Colitis is typically due the spleen’s ability to transform and transport fluids and nutrients, often due to an external pathogen. Dampness accumulates and consequently transforms into damp-heat in the large intestine. This causes qi and blood stasis and leads to the formation of mucus or blood in the stools, abdominal pain or diarrhea.

Much of this course focuses on common presentations of chronic colitis seen in the acupuncture clinic. Chronic colitis cases involve a mixture of excess and deficient conditions including:

  • Spleen and Stomach Deficiency
  • Kidney Yang Deficiency
  • Liver Excess and Spleen Deficiency (Liver and Spleen Disharmony)
  • Damp-Heat
  • Qi and Blood Stasis

Acute or Initial Onset
An initial acute onset or flare-up may present with a predominantly damp-heat condition. Symptoms include:

  • fever
  • abdominal pain
  • diarrhea
  • tenesmus
  • blood and mucus in the stool
  • Tongue: greasy-yellow coating
  • Pulse: slippery, rapid

Formulas such as Bai Tou Weng Tang and Xiang Lian Wan are often appropriate in this type of excess clinical presentation. However, chronic presentations are more common the acupuncture clinic and many of these chronic colitis patients will poorly react to these formulas due to underlying deficiencies.

Bai Tou Weng Tang
Function: clear heat toxins, clear lower jiao damp-heat, cool the blood

Dosage: decoct 3:1 (all formulas in this course follow this preparation unless otherwise noted)

  • Bai Tou Weng (Pulsatillae radix) 6g
  • Huang Bai (Phellodendri Cortex) 9g
  • Huang Lian (Coptidis rhizoma) 9g
  • Qin Pi (Fraxini cortex) 9g

Xiang Lian Wan (Xiang Lian Pian)
Function: clear damp-heat, promote qi flow to alleviate pain

Dosage: take 1 pill of mass 3g, three times per day

    • Mu Xiang (Saussureae Radix ) 3g
    • Huang Lian (Coptidis rhizoma) 12g

 

Common Chronic Colitis Presentations

Symptoms
Diarrhea one or many times per day, early morning diarrhea, abdominal bloating or pain, diarrhea induced by stress or certain foods, fatigue

Tongue
Dark red with white moist coating

Pulse
Slippery and weak

Diagnosis
Qi, blood and phlegm stagnation
Spleen and Kidney Qi and Yang deficiency

Treatment Strategy
Strengthen Spleen and Kidney Qi and Yang
Promote blood and Qi circulation

 

Acupuncture

Primary Points

      • CV4 (Guanyuan)
      • SP4 (Gongsun)
      • ST25 (Tianshu)


Secondary Points

      • UB20 (Pishu)
      • GV4 (Mingmen)
      • UB23 (Shenshu)
      • ST36 (Zusanli)

Use the primary points combined with 2 -3 secondary points. Manual acupuncture and acupuncture combined with moxibustion are appropriate. Treatment frequency is recommended no less than three times per week for the first three weeks of treatment.

Base Formulas
Xue Fu Zhu Yu Tang modified with Shen Ling Bai Zhu San and Li Zhong Wan

The flow of the course will start with an in-depth look at the base formulas then looking at special modifications for treating specific patterns of colitis and finally looking at case histories….

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Case Study 2

A female, age 36, had chronic morning diarrhea for a few years. Whenever she felt abdominal pain, she had to quickly go to the toilet with urgent stools. She took herbs to warm her Spleen and Kidney Yang without remarkable improvement. Her face and lips were dark purple. Her tongue was a purple color with a dry coating. Her pulse was wiry and choppy. Her MD doctor made a diagnosis of colitis.

Diagnosis
Qi and blood stagnation
Liver and Spleen disharmony

Treatment Strategy
Promote and regulate Qi and blood circulation 

Base Formula
Xue Fu Zhu Yu Tang modified with Xiao Yao San

Ingredients
Chi Shao Radix Paeoniae Rubrae 10 g 
Dang Gui Radix Angelicae Sinensis 3 g 
Chuan Xiong Radix Ligustici Chuanxiong 3 g 

All of the above herbs promote blood circulation. The herbs can be differentiated as follows: Chi Shao cools heat in the blood. Dang Gui nourishes the blood and moistens the intestines. Chuan Xiong moves the Qi in the blood and tends to flow to the body’s surface and upper body.

Tao Ren Semen Persicae 9 g
Hong Hua Flos Carthami Tinctorii 10 g
Tao Ren and Hong Hua break up congealed blood. Tao Ren remains in the bloodstream longer and moistens dryness. Hong Hua acts faster and flows to surface.

Chai Hu Radix Bupleuri 3 g
Zhi Ke Fructus Citri Aurantii 3 g 
Jie Geng Radix Platycodi Grandiflori  12 g 
All of the above herbs regulate Qi. Chai Hu regulates Liver Qi and promotes its flow upward through the body. Jie Geng regulates Lung Qi and opens the Lungs. It also guides the other herbs to the upper body.

Chao Bai Zhu Atractylodis Macrocephalae Rhizoma 15 g
Chao Bai Zhu is the fried preparation of Bai Zhu. It warms and dries dampness in the Middle Jiao. Frying it helps to enhance its warming nature.

Chao Bai Shao Fryed Paeoniae Radix Alba 15 g
Chao Bai Shao is the fried preparation of Bai Shao. It smooths the Liver Qi and harmonizes the Ying and Wei. Fried Bai Shao has an even stronger moving function than the unprepared herb.

Yan Hu Suo Rhizome Corydalis Yanhusuo 12 g
Yan Hu Suo promotes blood circulation. It also stops pain. 

Huang Qi Radix Astragali Membranaceus 15 g
Huang Qi strengthens and lifts the Qi.

Huang Lian Coptidis Rhizoma 12 g
Huang Lian clears damp heat. It also stops diarrhea.

Gan Cao Radix Glycyrrhizae Uralensis 6 g
Gan Cao has a sweet taste and character. It harmonizes the actions of the other ingredients.

Results of Treatment
She took six bags for six days and her morning diarrhea reduced by 80%. She continued taking the above formula modified with Shen Ling Bai Zhu Tang. She also followed dietary recommendations for 6 months. As result, her chronic diarrhea stopped completely and…

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Qing Dai Colitis Research

The World Journal of Gastroenterology published this research of patients suffering from intractable ulcerative colitis that were unresponsive to conventional drug therapy. After use of the herbal medicine, 6 of the 7 patients in the study were able to completely discontinue the use of anti-inflammatory medications. This included the use of aminosalicylates, corticosteroids and azathioprine. Endoscopy and symptomatic responses showed everything from significant clinical improvements to a complete resolution of the condition.

Herbal Powder
The patients orally self-administered 1 gram of Qing Dai (Indigo Naturalis) powder, 2 times per day for 4 months. The results of the herbal program demonstrated significant clinical and objective improvements such that 6 of the 7 patients completely discontinued the use of prednisolone, a corticosteroid used to control ulcerative colitis. The researchers examined Qing Dai to learn more about its effective mechanisms of action. Using electron spin resonance, they discovered that Qing Dai has potent hydroxl radical scavenging activity. This discovery prompted the researchers to recommend further investigation into the mechanisms of Qing Dai’s anti-inflammatory effects.

This research coincides with other recent research demonstrating that acupuncture and herbal medicine are effective in the clearing of chronic ulcerative colitis. Published in the Clinical Journal of Chinese Medicine, the study showed that a combination of herbal enemas consisting of Ku Shen and Bai Tou Weng combined with an acupuncture treatment regime was significantly more effective than taking antibiotics for resolving ulcerative colitis.

The Qing Dai study examined the oral administration of Qing Dai in its powdered form. Qing Dai has received a great deal of attention in modern research. One recent research study found that I3M, synthesized from the indirubin found in Qing Dai, downregulates cancerous tissues when applied topically to oral cancer. This shows great potential for the treatment of oral cancer. Historically, TCM documents Qing Dai as an important herb in the treatment of ulcers in the mouth and tongue. TCM also documents the use of Qing Dai as a topical paste for the treatment of acne and topical ointment for the treatment psoriasis. 

The I3M study cited the TCM formula Dang Gui Long Hui Wan as an historically important herbal compound for the treatment of chronic myelocytic leukemia. Many sources include Qing Dai as one of the ingredients in this formula that contains Dang Gui, Long Dan Cao, Zhi Zi, Huang Lian, Huang Bai, Huang Qin, Lu Hui, Da Huang, Qing Dai, Mu Xiang, She Xiang and Sheng Jiang. The researchers suggest that the indigo dye found in Qing Dai is partially responsible for the herbal formula’s efficaciousness given the modern research demonstrating that indirubin powerfully inhibits several types of human cancer cells. The Qing Dai researchers noted that modern studies demonstrate that indirubin has anti-inflammatory effects by suppressing interferon-alpha, interleukin-6 and nuclear factor. They added that Qing Dai has been shown to exert anti-inflammatory “effects on human neutrophils based on its ability to suppress superoxide generation.”

Clinical Highlight
The Qing Dai study highlighted specific clinical results of its participants. One patient vignette was of a man suffering from ulcerative colitis with hematochezia, the passage of fresh blood through the anus. This patient had taken antibiotics and prednisolone to control the hematochezia. However, he was unable to reduce the dosage of prednisolone without the return of hematochezia. Over time, the patient needed to increase the drug dosages to maintain clinical results and he showed no clinical improvements in his baseline condition. After 3 years, he began the Qing Dai treatments and after one month the hematochezia resolved completely. Objective testing also showed a marked decrease in serum C-reactive protein levels. The patient was able to discontinue the use of all drugs. Endoscopy revealed that his ulcers completely disappeared. A follow-up confirmed that the therapeutic effect of Qing Dai therapy lasted for more than 2 years.

The researchers note that other related research finds important clinical results from the use of Qing Dai. Yuan, et al, discovered that Qing Dai enemas are clinically effective for the treatment of chronic hemorrhagic radiation proctitis. Given the recent research combining acupuncture with herbal medicine demonstrating that enemas of Ku Shen combined with Bai Tou Weng are effective for the treatment of ulcerative colitis, it may be consistent that adding Qing Dai to the enema will enhance its therapeutic effects.

Distinct from Qing Dai used as a one herb formula for the treatment of chronic ulcerative colitis is its use within herbal formulas within the scope of Traditional Chinese Medicine (TCM). Differential diagnostics within the TCM system recognise Qing Dai’s appropriate application for this biomedically defined disorder in cases of Heat in the Blood, Damp Heat and Heat and Toxins. However, some clinical presentations of chronic ulcerative colitis may be due to cases of cold and deficiency. In these instances, herbal medicines with very different biological functions may exert more effective clinical actions for…

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Crohn's Disease

Crohn’s disease, also known as regional enteritis, is an inflammatory bowel disease of the intestines. The disorder is named after Dr. Burrill Crohn who documented the disease with Dr. Leon Ginzburg and Dr. Gordon Oppenheimer. Crohn’s disease affects anywhere in the gastrointestinal tract from the mouth to the anus. Typically, Crohn’s disease involves the ileum (the most distal aspect of the small intestine that connects to the cecum) and the first part of the large intestine. 

Signs and Symptoms

      • abdominal bloating and pain
      • chronic bloody or watery diarrhea
      • rectal bleeding
      • urgent need for bowel movements
      • abdominal cramping
      • constipation
      • floating stools (caused by poor fat digestion)
      • nausea
      • vomiting
      • mouth ulcers
      • weight loss
      • eye disorders
      • arthritis
      • fever
      • loss of appetite
      • dermatological disorders
      • iron deficiency anemia
      • fatigue

Crohn’s disease is considered an autoimmune system disorder. Genetics may play a role in its etiology; those with Scandinavian or Ashkenazim Jewish heritage have an increased risk of developing Crohn’s disease. Environmental factors may also contribute to this pathology. Smokers are twice as likely to develop Crohn’s disease than non-smokers. Other risk factors include low exposure to sunlight, obesity, diets high in sugar and saturated fat but low in fruits and vegetables, and urban living. 

No biomedical cure exists for Crohn’s disease. Medical doctors use colonoscopies, sigmoidoscopies, capsule endoscopies, barium enemas and CT scans to confirm the diagnosis. Doctors focus on controlling symptoms by suggesting dietary and lifestyle changes plus pharmaceutical medications to suppress symptoms and control infections. Surgery may be used to remove affected parts of the digestive tract including life threatening obstructions. In some cases, long-term remission occurs.

Crohn’s disease differs from ulcerative colitis. Crohn’s disease commonly affects the colon, anus and the terminal ileum. Ulcerative colitis rarely affects the terminal ileum and anus but always affects the colon. Crohn’s disease causes patchy or serpiginous (snake-like) intestinal ulcerations whereas ulcerative colitis causes a continuous area of ulceration. Shallow ulcerations are typical with ulcerative colitis. Deep and penetrating ulcerations often occur with Crohn’s disease and may cause stenosis, a narrowing of the intestinal passage. 

Crohn's disease may cause intestinal obstructions, ulcers, fistulas and anal fissures. Malnutrition may occur due to the inability of the intestines to absorb nutrients. Crohn’s disease may cause growth failure in children and increases the risk of cancer in the affected regions of the intestines.

Acupuncture & Moxibustion

Research demonstrates that acupuncture and moxibustion are efficacious in the treatment of Crohn’s disease., ,  Research published in the World Journal of Gastroenterology was randomized, blinded and used control groups to rule out the placebo effect. Moxibustion was applied to acupuncture points Tianshu (ST25), Qihai (CV6) and Zhongwan (CV12) using the herb partitioned moxibustion technique. This is accomplished by placing an herbal cake on the acupuncture points and then igniting the mugwort (Ai Ye) moxa cones on top of the herbal cake.

The herbal cakes consisted primarily of the following herbs: Coptis chinensis (Huang Lian), Radix Aconiti Lateralis (Fu Zi), Cortex Cinnamomi (Rou Gui), Radix Aucklandiae (Mu Xiang), Flos Carthami (Hong Hua), Salvia miltiorrhiza (Dan Shen), Angelica sinensis (Dang Gui). The ingredients were then ground into a fine powder, sifted through a sieve and mixed with maltose and water to form a thick paste. A mold was used to form a 28 mm diameter cake of 5 mm thickness. Refined moxa was used and applied twice at each point on top of the herbal cakes.

Acupuncture needling was applied to Zusanli (ST36), Shangjuxu (ST37), Gongsun (SP4), Sanyinjiao (SP6), Taixi (KI3), and Taichong (LR3) to a depth of 20 - 30 mm. The needles ranged in length from 25 - 40 mm and the diameter was a consistent 0.30 mm. Manual acupuncture was applied to achieve a de qi sensation. Needle retention time was a total of 30 minutes. Acupuncture and moxibustion were applied three times per week for twelve weeks for a total of 36 treatment sessions. 

The total treatment efficacy rate for acupuncture combined with moxibustion was 83.72%. Histopathological scores significantly improved…

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Chronic Appendicitis

Chronic appendicitis is characterized by scarring, fibrous adhesions, deformities and thickening of the vermiform appendix that was caused by prior inflammation. Chronic appendicitis is milder and develops more gradually than acute appendicitis. Subacute and acute flare-ups of appendicitis may occur along with persistent mild symptoms. Surgery may not be recommended by doctors for chronic appendicitis and symptoms may be difficult to detect. 

Symptoms may limited to fatigue and a sense of not feeling well. There may also be episodes of abdominal pain on the right lower quadrant of the abdomen for extended periods of time. Abdominal CT scan (computed tomography) and ultrasonography are used to confirm a diagnosis of chronic appendicitis. A CT scan is an imaging method employing X-rays to create pictures of cross-sections of the body. Undetected chronic appendicitis is a risk factor for local infections and an acute appendicitis emergency requiring appendectomy.

Acute Appendicitis, PID and Ectopic Pregnancy

Chronic appendicitis is treatable in an acupuncture clinic, however, acute appendicitis is a medical emergency and requires hospitalization. Differentiation of acute appendicitis and other emergency conditions from chronic appendicitis is paramount. Acute PID (pelvic inflammatory disease) often mimics acute appendicitis and ectopic pregnancies. These are emergency conditions requiring hospitalization.

An ectopic pregnancy is differentiated by a positive pregnancy test, irregular vaginal bleeding, and violent pain of the lower abdomen that usually starts on one side but may spread to the other as well. Acute appendicitis is often differentiated by initial pain around the umbilicus or upper abdomen then moving to the lower right abdomen with accompanying vomiting, nausea, or other digestive symptoms.

Rebound pain at McBurney’s point is often present in cases of acute appendicitis. McBurney's point is located over the right side of the abdomen and is one-third of the distance from the anterior superior iliac spine to the navel. This point roughly corresponds to the most common location of the base of the appendix where it is attached to the cecum. Note, however, rebound pain at McBurney’s point may also occur in cases of acute PID. Hospitalization is required for these surgical emergencies.

Chronic Appendicitis Risk Factors
Dietary irregularities and overexertion are risk factors according to Traditional Chinese Medicine principles. Running and jumping after meals causes or exacerbates this condition. This type of physical activity after eating may cause injury to the appendix and consequent qi and blood stasis thereby leading to appendicitis. Patients with chronic appendicitis must be warned to avoid excess physical activity after eating.

Acupuncture
The following is the treatment protocol for diagnosed conditions of chronic appendicitis. In addition, this may also be used for patients with local abdominal pain caused by an appendectomy. 

Distal Points

ST36 (Zusanli, Leg Three Miles)

M-LE-13 (Lanweixue, Appendix Point)

ST37 (Shangjuxu, Upper Great Void)

Local Points

ST27 (Daju, The Great)

Mangchang (Appendix)

Protocol

Select one or more distal points and needle. If any one of these points is especially tender upon palpation, it is the optimal point. Use bilateral needle insertion when selecting ST36 and ST37. Next, select ST27 or Mangchang and needle on the right side only. For all needles, insert and apply vigorous stimulation to achieve deqi. Retain needles for 10 - 15 minutes and then apply vigorous stimulation again prior to removing the needles.

Point Analysis

ST36 is 3 cun below ST35, one finger-breadth from the anterior crest of the tibia. There is a notch in the tibia that may be felt upon palpation that exactly locates the vertical location of ST36. Locate the notch, which is approximately 3 cun below ST35, and the point is one finger-breadth lateral to the anterior crest of the tibia. ST36 is he sea and earth point. It is the lower he sea of the stomach and a sea of nourishment point. ST36 orders the spleen and stomach, regulates qi and blood, and strengthens weak and deficient conditions. ST36 is useful in the treatment of many conditions including: gastric Pain, vomiting, abdominal distention, diarrhea, constipation, mastitis, abscessed breast, enteritis, gastritis, edema, asthma, general weakness, emaciation, anemia, indigestion, apoplexy, shock, hemiplegia, neurasthenia, mania.

M-LE-14 (Lanweixue, Appendix Point) is located approximately 2 cun distal to ST36 on the right leg. To locate, determine the point of maximum tenderness in the region by palpation. This point actives both qi and blood circulation and also clears heat toxins (fire poison) from the large intestine. This point is notable for its unilateral location on the right leg. Along with rebound pain at McBurney’s point, sensitivity at Lanweixue is an important diagnostic tool for the presence of both chronic and acute appendicitis. This point is useful for the treatment of a variety of conditions including chronic appendicitis, gastralgia, stomachache and diarrhea.

ST37 is the lower he-sea point of the large intestine and is a point of the sea of blood. ST37 regulates the intestines and stomach, clears and cools damp heat, and eliminates accumulations and stagnation. This point is useful for the treatment of a variety of conditions including chronic appendicitis, abdominal pain and distention, diarrhea, dysentery, enteritis, paralysis due to stroke and hemiplegia, and beriberi. ST37 is located 3 cun below ST36, one finger-breadth lateral to the anterior crest of the tibia.

ST27 is located 2 cun below the umbilicus and 2 cun lateral to CV5 (Ren 5). This point regulates qi, promotes urination, and benefits the kidneys. This point is useful in the treatment of chronic appendicitis, abdominal pain, dysuria, cystitis, and spermatorrhea.

Mangchang is located 1.5 cun below ST25 (Tianshu). It is used for the treatment of appendicitis, stomach pain, abdominal swelling, and diarrhea. Mangchang is an older way of saying appendix whereas Lanwei is a newer expression for the word appendix. The distal point on the leg is Lanwei and the local point over the appendix area is Mangchang.Herbal Medicine and Pattern Differentiation Overview

 

Diagnostics and Herbs
Chronic appendicitis tends to present with qi and blood stasis combined with hot phlegm stagnation.

Tongue
Dark or purple with a white coating

Pulse
Wiry and slippery

Diagnosis
Qi, hot phlegm, and blood stagnation

Treatment Strategy
Regulate and move the Qi
Move blood and dissolve hot phlegm

Base Formulas 
Xue Fu Zhu Yu Tang modified with Si Ni San and Da Huang Mu Dan Pi Tang...

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