Leading Off

Acupuncture in Inflammatory Bowel Disease

Gengqing Song, MD, Claudio Fiocchi, MD , and Jean-Paul Achkar, MD

Scientific research into the effects and mechanisms of acupuncture for gastrointestinal diseases including inflammatory bowel disease has been
rapidly growing in the past several decades. In this review, we discuss the history, theory, and methodology of acupuncture and review potentially
beneficial mechanisms of action of acupuncture for managing inflammatory bowel disease. Acupuncture has been shown to decrease disease ac-

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tivity and inflammation via increase of vagal activity in inflammatory bowel disease. Acupuncture has demonstrated beneficial roles in the regu-
lation of gut dysbiosis, intestinal barrier function, visceral hypersensitivity, gut motor dysfunction, depression/anxiety, and pain, all of which are
factors that can significantly impact quality of life in patients with inflammatory bowel disease. A number of clinical trials have been performed
to investigate the therapeutic effects of acupuncture in ulcerative colitis and Crohn’s disease. Although the data from these trials are promising,
more studies are needed given the heterogeneous and multifactorial aspects of inflammatory bowel disease. There is also an important need to
standardize acupuncture methodology, study designs, and outcome measurements.
Key Words: Inflammatory bowel disease, ulcerative colitis, Crohn’s disease, acupuncture, electroacupuncture

INTRODUCTION THE HISTORY OF ACUPUNCTURE

Inflammatory bowel disease (IBD) is a complex chronic
disease with a prevalence of 0.3% to 0.5% in North America,
Europe, and Oceania.1–3 It affects approximately 1.6 million
Americans,4 with an annual financial burden of approximately
$31 billion.5–7 Although various medications are available
to reduce disease activity, all have limitations and potential
complications.8 In addition, current medical therapies mainly
focus on immune modulation but lack a systemic approach to
address the multifaceted aspects of IBD that go beyond in-
flammation and include gut microbial imbalance,9, 10 intestinal
barrier dysfunction,11 gut motor/sensory dysfunction,12–17
and psychological factors.18–20 It has been estimated that al-
most half of IBD patients seek complementary and alterna-
tive therapies, including acupuncture.21–24 Numerous studies
have been performed to assess the therapeutic potential of
acupuncture for management of various gastrointestinal (GI)
disorders, with some promising effects on GI symptoms and
inflammation.
The aim of this review is to evaluate the mechanisms
of action and efficacy of acupuncture in IBD and associated
symptoms.
Received for publications July 13, 2018; Editorial Decision November 12, 2018.
From the Department of Gastroenterology, Hepatology & Nutrition,
Department of Inflammation and Immunity, Cleveland Clinic, Cleveland, Ohio
Conflicts of interest: There are none to report.
Supported by: No funding support was received.
Address correspondence to: Jean-Paul Achkar, MD, FACG, Department of
Gastroenterology, Hepatology & Nutrition, Cleveland Clinic, 9500 Euclid Ave, A30,
Cleveland, OH 44195 (achkarj@ccf.org).
© 2018 Crohn’s & Colitis Foundation. Published by Oxford University Press.
All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
doi: 10.1093/ibd/izy371
Published online 11 December 2018
Acupuncture is one of the oldest therapies of tradi-
tional Chinese medicine, dating back more than 3000 years.
The first document describing principles of acupuncture, in-
cluding the channel/meridian theory, location of points, and
clinical applications, was found in the book Inner Classic of the
Yellow Emperor (Huangdi Neijing) around 100 BC.25, 26 In the
past 4 decades, scientific research and clinical applications of
acupuncture have expanded worldwide. In 1971, James Reston,
Press Secretary for Richard Nixon, went to China in prepara-
tion for a historic presidential visit, but unfortunately he needed
an emergency appendectomy. He later published an article in
the New York Times describing how acupuncture eased his post-
surgical pain.27 This further increased the interest in and growth
of modern research on the use of acupuncture.28 In the 1990s,
acupuncture was approved as a medical therapy in the United
States based on positive evidence of its effectiveness for pain
control.29 A survey in 2007 estimated that 14 million Americans
had used acupuncture, a significant increase from 8 million in
2002.30 Approximately 42% of hospitals in the United States
provided at least 1 type of alternative medicine in 2011,31 and
many top US hospitals are now embracing and promoting acu-
puncture services. In 2017, the Food and Drug Administration
(FDA) recommended that doctors be aware of acupuncture
as a potential management tool for pain that may help avoid
opioid prescriptions and prevent opioid dependence.32–34 In ad-
dition, several clinical practice guidelines are now recommend-
ing acupuncture therapy for treating pain.35 For example, the
American College of Physicians suggested that physicians and
patients treat lower back pain with nonpharmacologic thera-
pies including acupuncture before considering opioids.36
METHODOLOGY OF ACUPUNCTURE
In traditional acupuncture, a thin metal needle is
inserted (Fig. 1A) into an acupoint and manually manipulated

Inflamm Bowel Dis • Volume 25, Number 7, July 2019 1129

Song
 et al
FIGURE 1. A, Traditional acupuncture: manual manipulation of
an inserted needle at acupuncture points. B, Electroacupuncture:
electrical stimulation of an inserted needle at acupuncture points. C,
Transcutaneous electroacupuncture: electrical stimulation of surface
electrodes with no needles at acupuncture points.
in different ways including thrusting, lifting, twisting, twirling,
or combinations of these motions. Electroacupuncture uses
a pulse generator to electrically stimulate an inserted needle
(Fig. 1B). Electroacupuncture is easy to apply and is used more
often in research studies as it generates more consistent and re-
producible results compared with manual acupuncture without
electrical stimulation.37, 38
Recently, needleless electrical stimulation via surface
electrodes at acupuncture points, known as transcutaneous
electroacupuncture (TEA) (Fig. 1C), has been introduced and
found to be as effective as needle-based acupuncture in improv-
ing gastrointestinal symptoms and dysmotility.39 As TEA does
not involve the insertion of needles and the procedure is com-
pletely noninvasive, it has the advantage that it can be performed
at home or work without interruption of daily activities, and it
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FIGURE 2. Key differences of transcutaneous electroacupuncture and
transcutaneous electrical nerve stimulation. Compared with transcu-
taneous electrical nerve stimulation (B), transcutaneous electroacu-
puncture (A) stimulates a smaller area with frequently involvement of a
wider stimulation pulse width (>0.3 milliseconds).
is readily accepted by patients. TEA has similarities to transcu-
taneous electrical nerve stimulation (TENS), in which electrode
pads are placed on nerve dermatomes, muscle pain areas, or
even acupoints. Key differences between these 2 modalities are
that TENS stimulates a larger area than TEA (Fig. 2) and the
stimulation pulse width of TENS devices does not go above
0.3 milliseconds, as compared with TEA, which often requires
pulse widths ≥0.3 milliseconds.
Moxibustion is another type of traditional Chinese medical
therapy with similarities to acupuncture in which heat is applied
on acupoints by burning dried mugwort (moxa). Moxa can be
fluff or processed into a cigar-shaped stick. Practitioners can use
it alone or combine it with acupuncture.40 Other methods of acu-
puncture also include stimulating acupoints by pressure (acupres-
sure), laser irradiation, or magnetic/electromagnetic waves.
ACUPUNCTURE POINTS FOR
GASTROINTESTINAL DISEASES
Acupuncture points (acupoints) are special nodes (or
outlets) on the meridians that are channels that connect to spe-
cific organs, modulate related body function, and carry “qi,”
a vital force flowing throughout the body.41 It is believed that
when “qi” flow in meridians/channels is imparied or out of bal-
ance, organ dysfunction occurs and associated illness ensues.24
According to the channel theory, acupuncture stimulates “qi”
Inflamm Bowel Dis • Volume 25, Number 7, July 2019
flow along an involved channel and normalizes “qi” imbalance,
thus restoring related organ function.41
Acupoints for GI disorders have been extensively studied
and have been shown to overlie major neural bundles, which
provides anatomic evidence for neural modulation as a primary
mechanism of action of acupuncture (Fig. 3). For example,
stomach acupoints 36 and 37 overlie the deep median nerve.
A summary of the main meridians and acupoints related to GI
function is listed in Table 1.25, 26, 42 Stimulation of these specific
points has been reported to improve multiple GI symptoms
including abdominal pain, inflammation, diarrhea, constipa-
tion, gas, bloating, and nausea.
ACUPUNCTURE FOR INFLAMMATORY BOWEL
DISEASE
Vagal Control of the Immune Response
In discussing the role of acupuncture in IBD, it is import-
ant to understand vagal control of the immune response
(Fig. 4). Inflammatory responses are complex and modulated
by multiple factors including the nervous system. The vagus
nerve innervates most of the GI tract and plays a crucial role
in the homeostatic regulation of visceral functions via its para-
sympathetic effects.43 The anti-inflammatory role of the vagus
nerve occurs through 3 pathways44–46:
1. The cholinergic anti-inflammatory pathway (CAP) is mediated
through vagal efferent fibers that synapse onto enteric neurons,
which release acetylcholine (ACh) at the synaptic junction with
immune cells. ACh binds to alpha-7-nicotinic ACh receptors of
FIGURE 3. Locations of the acupoints listed in Table 1.
Acupuncture in Inflammatory Bowel Disease
immune cells, leading to inhibition of release of tumor necrosis
factor–α (TNF-α), a pro-inflammatory cytokine47, 48 that has been
shown to play important roles in the pathogenesis of IBD.49
2. The splenic sympathetic anti-inflammatory pathway is where the
vagal nerve stimulates the splenic sympathetic nerve. Norepinephrine
released at the distal end of the splenic nerve links to the beta 2
adrenergic receptor of splenic lymphocytes releasing Ach, which in
turn inhibits the release of TNF-α by spleen macrophages through
alpha-7-nicotinic ACh receptors.50, 51
3. The anti-inflammatory hypothalamic–pituitary adrenal axis is stim-
ulated by vagal afferent fibers, which leads to the release of cortisol
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by the adrenal glands.52–54
Several recent clinical trials have evaluated the efficacy of
vagal nerve electrical stimulation (VNS) to alleviate chronic
inflammation. Koopman et al. reported that VNS (via stimu-
lation of the CAP) improved an experimental model of arthri-
tis, whereas unilateral cervical vagotomy led to aggravation
of arthritis activity.55 Based on these preliminary results, the
authors subsequently assessed VNS effects in patients with
rheumatoid arthritis: 12 of 17 patients responded to VNS
and had decreased TNF levels and a reduced C-reactive pro-
tein (CRP)–based disease activity score.56 Similarly, Bonaz
et al. reported that VNS reduced inflammatory markers and
improved the multivariate index of colitis in a rodent model
of 2,4,6-trinitrobenzenesulfonic acid (TNBS)-induced colitis
(Th-1-mediated inflammation).44 Based on these results, they
performed a pilot study of VNS in patients with Crohn’s dis-
ease and reported that 5 of 7 patients responded to VNS with
improvement of the Crohn’s Disease Activity Index, CRP and/
or fecal calprotectin, and an endoscopic index of severity.57
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 et al Inflamm Bowel Dis • Volume 25, Number 7, July 2019

TABLE 1. Acupoints With Corresponding Anatomical Locations and Gastrointestinal Effects25, 26, 42
Acupoint Location GI Symptoms Reported to Treat

LI4 (Hegu) Webbing between the index finger and the thumb
LI11 (Quchi) Lateral end of the transverse cubital crease midway
between LU5 and the lateral epicondyle of the humerus
ST36 (Zusnali) 1 finger lateral of the tibia, 3 cm below the lower patella
ST37 (Shangjuxu) 6 cm below lower board patella, 1 finger-width lateral
from the anterior border of the tibia
ST39 (Xiajuxu) 3 cm inferior to Shangjuxu ST-37, 1 finger-breadth lateral
Diarrhea, constipation, and abdominal pain
Diarrhea, constipation, and abdominal pain
Enteritis, abdominal pain, nausea, gas, and bloating
Diarrhea, dysentery, borborygmus, abdominal pain,
bloating, distention, constipation
Lower abdominal pain, diarrhea

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to the anterior crest of the tibia
ST21 (liangmen) 4 cm above the belly button, 2 cm lateral to the median Diarrhea, pain, and burning in the stomach
line
ST25 (Tianshu) 2 cm lateral to the belly button Gas, distention and abdominal pain, constipation
BL20 (Pishu) 1.5 cm lateral to GV6, level with T11 Poor appetite, tiredness
BL21 (Weishu) 1.5 cm lateral to GV line, level with T12 Reflux, dampness, phlegm, heartburn, stomach pain,
fullness
BL25 (Dachangshu) 1.5 cm lateral to GV3, level with L4 Borborygmus, gas, diarrhea, blood in feces, constipation
BL27 (Xiaochangshu) 1.5 cm lateral to GV line, level with 1st PSF Diarrhea, blood in stool, constipation, gas
BL18 (Ganshu) 1.5 cm lateral GV8, level with T9 Abdominal distension and pain
BL23 (Shenshu) 1.5 cm lateral GV4, level with L2 Diarrhea
BL60 (Kunlun) In a depression between the tip of the external malleolus Abdominal pain, constipation
and the Achilles tendon
PC6 (Neiguan) 2 cm above the wrist crease between the tendons of pal- Stomach ache, reflux, nausea, hiccup, vomiting, anxiety
maris longus and flexor carpi radialis
CV12 (Zhongwan) 4 cm above the belly button, at the midline of the body Nausea, heartburn, abdominal pain
CV4 (Guanyuan) 2 cm above pubic symphysis Fullness, diarrhea
GV4 (Mingmen) Below L2 Hemorrhoids, blood in the stool
GV20 (Baihui) Meeting point of the midline and the top of the ears Hemorrhoids
GV26 (Renzhong) In the first third of the distance between the nose and the Loss of smell
upper lip
SP6 (Sanyingjiao) 3 cm directly above the tip of the medial malleolus on the Colitis, abdominal distension, and flatulence
posterior border of the tibia
SP4 (Gongsun) In a depression distal and inferior to the base of the 1st Fullness, epigastric distension, abdominal or chest pain
metatarsal bone at the junction of the red and white
skin
SP9 (Yinlingquan) Lower border of the medial condyle of the tibia in the Abdominal distension and pain, poor appetite
depression posterior and inferior to the medial condyle
of the tibia
SP14 (Fujie) 4 cm lateral to the midline, 1.3 cm below the navel Abdominal pain
SP15 (Daheng) 4 cm lateral to the navel Chronic diarrhea, mucus in the stool, constipation
LV3 (Tai chong) Dorsum of the foot in a depression distal to the junction Nausea, vomiting, and abdominal pain
of the 1st and 2nd metatarsal bones
TB5 (Waiguan) 3-cm width above the wrist crease, on the outer side of the Nausea and vomiting
hand

Abbreviations: BL, bladder meridian; CV, conception vessel; GV, governor vessel; LI, large intestine meridian; LV, liver meridian; PC, pericardial meridian; SP, spleen meridian;
ST, stomach meridian; TB, 3-burner meridian.

ANIMAL STUDIES OF ACUPUNCTURE IN
INFLAMMATORY BOWEL DISEASE
Acupuncture, electroacupuncture, and moxibustion
have been shown to have several beneficial effects in rats with
TNBS-induced colitis, including (1) improving weight loss
and diarrhea; (2) ameliorating inflammatory profiles with re-
duction of neutrophil myeloperoxidase activity (MPO), de-
crease of inducible nitric oxide synthase expression, increase
of serum IL-10,58, 59 and downregulation of serum TNF-α
and IL1-β and colonic TNF-α mRNA expression58, 60; and (3)

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FIGURE 4. Potential mechanism of action of acupuncture.
attenuating adhesion and macroscopic damage scores.58 In a re-
cent study, Jin et al. assessed the anti-inflammatory effects of
electroacupuncture and the combination of 2 therapies (elec-
troacupuncture plus VNS) in colitis rats and found that both
electroacupuncture and the combination therapy reduced dis-
ease activity index scores (including weight loss, stool consist-
ency, and bleeding), decreased pro-inflammatory cytokines
(TNF-α, IL-1β, and IL-6) and MPO, and improved macro-
scopic inflammation (including edema, hyperemia, bowel wall
thickening, mucosal erosions, and ulcers).61 They attributed the
anti-inflammatory effects to enhanced vagal tone and reduced
sympathetic activity, as assessed by measuring electrocar-
diography.61 Although they also reported that the combina-
tion of electroacupuncture plus VNS was more efficient than
electroacupuncture therapy alone,61 they did not optimize the
number of acupoints and stimulated only 1 acupoint (ST36).
Supporting these findings are the results of a study that showed
that moxibustion via multi-acupoint was superior to a single/2
acupoints in improving Disease Activity Index (DAI) and in-
flammatory markers such as TNF-α in colitis rats.62
Several other studies have demonstrated the effective-
ness of acupuncture in murine models of IBD and explored
additional mechanistic pathways, including (1) decrease of
NF-kappa protein and increased IL-463; (2) modulation of
splenic Treg and Th17 lymphocytes64; (3) stabilization of
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structures such as mitochondria and endoplasmic reticulum65;
(4) inhibition of the apoptosis of epithelial cells via Bcl-2/Bax
and Fas/FasL pathways.66
CLINICAL STUDIES OF ACUPUNCTURE FOR
INFLAMMATORY BOWEL DISEASE
Ulcerative Colitis Trials
There have been many studies evaluating various forms
of acupuncture and moxibustion for the treatment of ulcerative
colitis (UC). A recent review of Chinese and English literature
identified 63 randomized controlled trials (58 Chinese and 5
English articles) that studied these interventions in a total of
5404 UC patients.67 Multiple different and often combined ther-
apies were used, but the most common were acupuncture and
moxibustion with or without further therapies such as Western
medicines or other Chinese therapies. The most common acu-
points treated were ST25 (2 cm lateral to the umbilicus) and
ST36 (1 finger lateral to the tibia, 3 cm below the lower patella).
The authors found that there was heterogeneity in the quality
of the studies, interventions, and outcome measures.
Delving into a few of these studies yields further insights.
In a randomized controlled trial that involved 220 patients
with UC, Zhou et al. reported that treatment with acupunc-
ture and moxibustion plus oral sulfasalazine was superior to
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 et al
sulfaslazine alone in improving symptoms and reducing endo-
scopic and histologic inflammation.68 In another prospective
randomized controlled trial, Joos et al. assessed acupuncture
and moxibustion vs sham control in 29 patients with mildly to
moderately active UC. All patients received 10 treatment ses-
sions over a 5-week period and were followed up for 16 weeks.
Results showed that acupuncture and moxibustion significantly
improved the colitis activity index of the UC patients in com-
parison with sham control.69
Within the limitations noted above, a systematic review
and meta-analysis of 43 human studies (42 UC trials and 1 CD
trial) using acupuncture and/or moxibustion treatments for IBD
was published in 2013. Only 3 of the 43 studies were classified
as high quality, and there were wide differences in treatments
and reported outcomes, limiting the ability to summarize data.
Based on this, the authors limited the meta-analysis to 10 stud-
ies that compared acupuncture and/or moxibustion with sul-
fasalazine for the treatment of UC and found that acupuncture
and/or moxibustion were superior to sulfasalazine therapy (rel-
ative risk, 5.42; 95% confidence interval, 3.38–8.68).70 However,
it is important to note that the 10 selected studies involved sev-
eral acupuncture interventions, and a pooled analysis cannot
account for the differences in therapeutic techniques.
Crohn’s Disease Trials
There have been fewer trials of acupuncture or moxibus-
tion for Crohn’s disease (CD), and some of these have focused
mainly on the pathophysiology of the effects of these inter-
ventions. In a randomized controlled study from Germany, 51
patients with mild to moderate CD were randomized to receive
either 10 sessions of acupuncture at multiple acupoints with or
without moxibustion over 4 weeks or to a control therapy of
“minimal acupuncture,” defined as shallow insertion of needles
without manipulation into nonacupoints.71 Compared with the
control group, the acupuncture-treated patients had greater
reduction of Crohn’s Disease Activity Index (CDAI) scores that
persisted over a 12-week follow-up period and improvement
in general well-being at week 4. In addition, α1-acid glycopro-
tein concentrations (an inflammatory marker) fell more in the
acupuncture group than the control group, but the difference
between groups was not statistically significant.71 Another ran-
domized controlled trial in 92 patients with mild to moderate
CD by CDAI showed that both acupuncture combined with
moxibustion and sham control (burning bran and shallow
placement of needles at nonacupoints) significantly reduced
CDAI and improved quality of life, but the changes occurred to
a greater extent in the treatment group.72 After 12 weeks of treat-
ment, 74% of patients in the acupuncture/moxibustion group
achieved remission as assessed by CDAI compared with 36%
of patients in the control group. In addition, active treatment
led to significant decreases in C-reactive protein and increases in
hemoglobin levels. However, there were no significant changes in
endoscopic findings as assessed by Crohn’s Disease Endoscopic
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Inflamm Bowel Dis • Volume 25, Number 7, July 2019
Index of Severity in either group, but the treatment group had a
significant improvement in histologic score.
In trying to define mechanisms of action of acupuncture
in CD, a study comparing acupuncture plus moxibustion with
sham control in patients with active CD showed reduced IL-17
levels and a decreased ratio of Th17 and Treg cells, indicating
less immune cell infiltration in the therapeutic arm.73 In addi-
tion, Shang et al. reported that treatment with acupuncture
combined with moxibustion, in 60 CD patients, led to a greater
improvement than mesalamine treatment in repairing mucosal
lesions and relieving inflammation by upregulating the expres-
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sion of tight junction proteins and their mRNAs.74 Finally, a
recent study evaluated functional brain magnetic resonance
imaging changes and found that the therapeutic effects of elec-
troacupuncture and moxibustion in CD patients may involve
different modulation of the brain homeostatic afferent process-
ing network and default mode network, respectively.75
NONIMMUNE EFFECTS OF ACUPUNCTURE ON
IBD PATHOPHYSIOLOGY
Modulation of Microbiota
Current evidence suggests that gut microbial dysbio-
sis plays an important role in the pathogenesis of IBD.9, 10
Changes in the composition and metabolism of the microbi-
ota may result in enhanced immune responses, epithelial dys-
function, and increased mucosa permeability.76 Supporting
findings include decreases of Bifidobacterium, Lactobacillus,
and Fusobacterium species but increases of Bacteroides fragilis
and Escherichia coli in patients with IBD.77–80 Alterations in gut
microbiota have been associated with and are considered key
events in the inflammation underlying IBD.76, 81, 82
Several studies have assessed the effects of acupuncture
and/or moxibustion on the gut microbiota in animal models.
In rats with TNBS-induced colitis, moxibustion at acupoints
ST25 and RN6 increased Bifidobacterium and Lactobacillus
but decreased Escherichia coli and Bacteroides fragilis.83 The
shift in bacterial microbiota was accompanied by suppression
of TNF-α and IL-12 expression.83 Another study showed that
electroacupuncture (vs control) increased Lachnospiraceae
bacterium and Lactobacillus species and decreased Clostridium
bifermentans in colitic rats; these changes were associated with
improvement of a disease active index.84 A placebo controlled
study evaluated acupuncture at acupoints ST2, ST21, and ST36
vs nonacupoints (5 mm above each of the acupoints) in rats
with chronic atrophic gastritis and found partial reversal of
impaired gut microbiota metabolites such as dimethylamine, a
product of gut bacteria related to the pathogenesis of chronic
stomach inflammation.85 Finally, in a human obesity trial, acu-
puncture showed increased Lactobacillus and Bifidobacterium
species and decreased Bacteroides species and Clostridium per-
fringens.86 Although more studies of acupuncture effects on gut
microbiota in IBD are needed, gut microbiota modulation by
Inflamm Bowel Dis • Volume 25, Number 7, July 2019
acupuncture may be one of the beneficial mechanisms of action
of this form of therapy.
Modulation of GI Barrier Function
The GI epithelial barrier plays a central role in the
maintenance of gut immune homeostasis. The integrity of the
barrier depends on different epithelial components consist-
ing of innate immune responses, intestinal permeability, tight
junctions, epithelial cell integrity, and mucus production.11
Abnormalities of these components may contribute to the
pathogenesis of IBD.11
Acupuncture has been reported to restore gut barrier
function in multiple animal models of inflammation and in
patients with IBD. In a rodent model of ischemia/reperfusion
injury, electroacupuncture at acupoint ST36 showed protective
effects in decreasing local intestinal inflammation, reducing
barrier breakdown, alleviating permeability in the distal ileum,
and maintaining expression of the tight junction protein zonula
occludens-1 (ZO-1) via cholinergic pathways.87 Similarly, in
an ischemia/reperfusion injury model in rats, electroacupunc-
ture attenuated distortion of enteric glial cells (that maintain
normal barrier function) and increased expression of ZO-1
protein, along with reduction of intestinal permeability.88 In
TNBS-induced colitis rats, moxibustion at acupoints ST25 and
CV6 inhibited apoptosis of colonic epithelial cells and repaired
the colonic barrier via suppression of TNF-α and expression
of its receptor.62 There is 1 study in patients with CD showing
that acupuncture combined with moxibustion was superior to
mesalamine in attenuating intestinal inflammation and improv-
ing epithelial barrier repair by increasing expression of tight
junction proteins such as ZO-1, occluding, and claudin-1.74
POTENTIAL SYMPTOMATIC EFFECTS OF
ACUPUNCTURE IN IBD
Symptoms and quality of life of patients with IBD can
be significantly impacted by multiple factors, including vis-
ceral hypersensitivity, GI dysmotility, depression/anxiety, and
abdominal pain. We will review the role of acupuncture with
regard to these factors from an IBD-focused standpoint while
acknowledging that there is a broader literature regarding acu-
puncture in specific disease states such as irritable bowel syn-
drome and motility disorders that is beyond the scope of this
review.
Irritable Bowel Syndrome/Visceral
Hypersensitivity
Many patients with IBD have superimposed irritable bowel
syndrome (IBS). One study of 62 CD and 44 UC patients showed
that IBS-like symptoms were common, with 59.7% of CD and
38.6% of UC patients having coexistent IBS.12 In a meta-analysis
of 13 studies containing 1703 patients, the prevalence of IBS was
39% in IBD, specifically 46% in CD and 36% in UC.89
Acupuncture in Inflammatory Bowel Disease
Acupuncture has been shown to be effective in ameliorat-
ing symptoms of IBS, possibly via inhibition of visceral hyper-
sensitivity. In 1 study, electroacupuncture at acupoints PC6 and
ST36 increased the threshold of rectal sensation to rectal dis-
tension in patients with diarrhea-predominant IBS.90 Another
study assessed 58 patients with IBS-related diarrhea who
received acupuncture 3 times a week for a period of 4 weeks
and found that acupuncture improved diarrhea and abdomi-
nal pain.91 Bao et al. performed a multicenter, randomized,
placebo-controlled trial for moxibustion at acupoints ST25
and ST36, with 3 treatment sessions per week for a period of
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6 weeks. They demonstrated that moxibustion treatment ame-
liorated symptoms score, quality of life, and Bristol stool form
scale in 104 patients with IBS-related diarrhea. In addition, a
meta-analysis of 17 randomized controlled trials involving a
total of 1333 patients confirmed similar results that acupunc-
ture improved abdominal pain and diarrhea in patients with
diarrhea-predominant IBS.92
GI Dysmotility
GI dysmotility can occur in patients with IBD and may
lead to symptoms mimicking those of IBD when IBD is in
remission or inflammation is subsiding. Ongoing symptoms in
such situations may be related to autonomic abnormalities in
patients.93 Evidence for GI dysmotility in IBD patients includes
the following: (1) delayed gastric emptying was reported in
about 30% of children with CD,14 was associated with higher
disease activity in IBD,15 and resulted in dyspeptic symptoms
in patients with inactive CD94; (2) small bowel motility func-
tions such as contractions and propagations were impaired in
CD16 and postproctocolectomy UC95–97 and were correlated
with inflammatory activity (measured by CRP and calprotectin
levels) during CD flares98; (3) colonic motility patterns of diar-
rhea in patients with UC were characterized by reduction of
colonic contractility,99, 100 acceleration of colonic transit,101 and
enhanced propulsive activity of the colon.100
Acupuncture has been extensively investigated in GI
dysmotility and has been shown to be effective in improving
multisegment dysmotility through modulation of autonomic
nervous system function from the esophagus to the colon.102
Although most GI functional studies involving acupuncture
were not performed in IBD or colitis models, the antidysmo-
tility properties of acupuncture may be an additional beneficial
target for ameliorating gut motor dysfunction in IBD. A few
examples of this include:
1. Delayed gastric emptying: Acupuncture is effective in accelerating
gastric emptying103–108 and in reducing nausea and vomiting.109, 110
Ouyang et al. reported that electroacupuncture at points PC6 and
ST36 increased gastric emptying via vagal mechanism in dogs.111
Similarly, acupuncture accelerated solid gastric emptying and
improved nausea and vomiting in comparison with control (non-
acupoints) patients with gastroparesis.107, 108 In another gastroparesis
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 et al
trial, TEA decreased visual stimuli–induced nausea symptoms and
gastric dysrhythmia, with a change of dominance from right to
left inferior frontal lobe activity.112 TEA was also reported to en-
hance gastric emptying in patients with functional dyspepsia.113
A meta-analysis showed that acupuncture improved delayed gastric
emptying and symptoms of nausea and vomiting in postoperative
gastroparesis.114
2. Small bowel motility: Limited clinical data are available on the
acupuncture effects on small intestinal motility as there is a lack
of noninvasive methods with which to measure intestinal motility.
In dogs, acupuncture at ST36 increases intestinal contractions,115
intestinal transit,115 and the number of intestinal movements,116
whereas acupuncture at ST25 inhibits jejunal motility117, 118 and at
BL27 it decreases the number of intestinal movements.116 Similar
results were also found in mice,119 rats,106 and rabbits,120 showing
that acupuncture at ST36 and SP6 increased intestinal contractions
and transit. A randomized trial reported that acupuncture reduced
postoperative ileus and accelerated bowel recovery after colorectal
cancer resection.121
3. Colonic motility: Studies have demonstrated dual effects (inhibitory
and excitatory) of acupuncture in altering colonic motility, simi-
lar to its effects on small intestinal motility. Acupuncture at ST25
inhibits colonic motility in mice,118 suppresses colonic contrac-
tions at GV1 in dogs, and decreases acceleration in colonic transit
induced by stress in rats.105 However, acupuncture at ST36 and ST37
excites colonic motility in mice118, 122 and restores rectal distension–
induced impairment in both colonic contractions and transit.123 In a
multicenter, randomized, sham-controlled trial, 1075 patients with
chronic severe functional constipation received 28 sessions of acu-
puncture at acupoints or sham acupuncture at nonacupoints over
8 weeks. Results showed increased spontaneous bowel movements
during weeks 1–8 in the acupuncture group.124
Depression/Anxiety
The incidence of depression and/or anxiety in patients with
IBD is approximately 20% to 30%, which is higher than that of
general population.18–20 It has been reported that symptoms of
depression and anxiety are associated with disease activity and an
increased risk for onset of IBD.19, 20 Acupuncture has been increas-
ingly used for treatment of psychiatric disorders such as depres-
sion and anxiety.125, 126 The World Health Organization states
that acupuncture is safe and effective for treating depression and
anxiety.127 A meta-analysis of 207 clinical trials of acupuncture
for treatment of depression demonstrated that acupuncture had
similar efficacy to antidepressants in improving clinical response
and symptom severity of major depression and was superior to
antidepressants in the management of poststroke depression.126
Abdominal Pain
Abdominal pain occurs in up to 70% of IBD patients with
active disease128, 129 and in 20%–50% of those in remission.129, 130
Common causes include ongoing inflammation, neuropathy, and
GI dysmotility.131 Approximately 25% of outpatients with IBD
use narcotics on a chronic basis without supporting evidence
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Inflamm Bowel Dis • Volume 25, Number 7, July 2019
that they are effective.132–135 Instead, chronic use of narcotics can
potentially worsen disease activity and pain, induce constipation,
and increase risk of infection and mortality.136–138
Acupuncture is safe and cost-effective and has been show
to alleviate numerous types of painful conditions of inflam-
matory, neuropathic, and/or visceral origin.139–142 Studies have
demonstrated that mechanisms of analgesia by acupuncture
include modulation of various neurotransmitters, neuropep-
tides, and cytokines through peripheral, spinal, and supraspi-
nal pathways.143–145 A recent meta-analysis of 39 randomized
controlled trials focused on nonpharmacological treatments
Downloaded from https://academic.oup.com/ibdjournal/article/25/7/1129/5238704 by guest on 03 October 2021
to reduce pain after knee arthroplasty showed that electrother-
apy and acupuncture reduced and delayed opioid consumption
and that acupuncture outperformed cryotherapy, continuous
passive motion, and preoperative exercise.146 Acupuncture has
also been reported to decrease opioid use in other conditions,
including cardiac,147 thoracic,148 and brain surgeries.149 In 2017,
McDonald and Janz published the largest and most comprehen-
sive meta-analysis for acupuncture so far. The analysis consisted
of more than 1000 randomized controlled trials and showed the
effectiveness of acupuncture, with the strongest evidence for
treating various types of pain, including back pain, neck pain,
shoulder pain, chronic headache, and osteoarthritis.150
CONCLUSIONS
In this review, we have introduced the history and meth-
odology of acupuncture, summarized the mechanisms of
action of acupuncture, and provided an overview of acupunc-
ture effects in animal models and human IBD. Acupuncture
is a safe, cost-effective, noninvasive, and widely available non-
pharmacological therapy option for managing various disor-
ders. Further well-done studies are needed, but, based on the
collective evidence derived from studies published to date,
acupuncture has a potential role as an adjunctive therapy for
managing IBD. Through vagal control of immune response,
acupuncture improves disease activity and inflammation in
IBD. Acupuncture also has nonimmune effects that could
positively modulate the gut microbiota and improve GI bar-
rier function in IBD. In addition, for symptom management,
acupuncture has therapeutic potential for IBS/visceral hyper-
sensitivity, GI dysmotility, depression/anxiety, and pain, which
frequently occur with IBD.
With specific regard to the applications of acupuncture
in IBD, further studies are needed to better define efficacy,
especially given the heterogeneous and multifactorial aspects
of these diseases and placebo effects. As such studies are done,
standardization of acupuncture methodology and of study
design and outcome measurements will be essential. However,
with increasing research, expanding applications of acupunc-
ture to various conditions, and the publication of high-qual-
ity acupuncture trials in top Western journals,146, 151–153 the time
is ripe to further evaluate the full therapeutic potential of this
treatment approach in the management of IBD.
Inflamm Bowel Dis • Volume 25, Number 7, July 2019
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