| |
|
|
CASE REPORT
Treatment
Of Small Bowel
Obstruction With Acupuncture
Martha M. Grout, MD
ABSTRACT
Obstruction is the most common surgical condition of the small bowel.
Acupuncture may offer an effective, inexpensive, and more rapid treatment
of this condition than standard medical therapy alone. Two patients
were treated for small bowel obstruction with acupuncture in addition
to standard therapy. Both recovered more rapidly than would be anticipated
with allopathic treatment alone.
KEY WORDS
Small Bowel Obstruction, Acupuncture, Alternative Medicine, Complementary
Medicine
INTRODUCTION
Obstruction is the most common surgical condition of the small bowel,
often occurring as a consequence of scarring within the abdominal cavity,
secondary to a prior surgical procedure. Standard treatment for patients
includes placement of a nasogastric tube, use of intravenous fluid replacement,
and early surgical exploration if the obstruction cannot be relieved
expeditiously by medical means.1 Patients are frequently hospitalized
for 5 or more days and require surgical intervention for definitive
treatment. The overall mortality rate is between 20% and 70% for strangulating
obstruction, and as low as 5%-8% for non-strangulating obstruction.2
One article suggests that non-operative therapy of up to 5 days' duration
can be safely attempted for patients who present with postoperative
small bowel obstruction, with 73% resolution of the obstruction and
no significant increase in mortality. In that experience, the obstruction
resolved within a mean of 22 hours and a maximum of 5 days.3
CASE REPORTS
Case 1
A 27-year-old man presented to the emergency department of Phoenix (Arizona)
Memorial Hospital with complaints of severe cramping abdominal pain,
distension, nausea, and vomiting for 1 day. Five years previously, the
patient had a ruptured appendix. Vital signs were within normal limits,
as were complete blood cell count, electrolytes, amylase, prothrombin
time, and partial thromboplastin time. Plain radiography of the abdomen
showed marked small bowel obstruction with multiple air-fluid levels.
The patient was treated with standard medical management, including
intravenous fluids and nasogastric tube insertion.
In addition, after the standard medical management had been initiated,
acupuncture treatment was performed using the points CV 12 Zhonguan
and ST 36 Zusanli bilaterally.4 Hwato 25-mm needles were used for 20 minutes. The points were chosen to stimulate
the correct functioning of the digestive system overall, using CV 12
Zhonguan, the functional Mu point for SP, and ST 36 Zusanli, recommended
for treatment of counterflow Qi,5 which accurately describes small bowel
obstruction. No further needles were used because the treating physician
was concerned that stimulation of the small bowel directly, e.g., with
CV 4, the Mu point of the small bowel, might lead to increased bowel
motility against a closed obstruction with subsequent perforation.
The patient was admitted to the hospital and received no further acupuncture
treatments. Within 6 hours, he began to pass flatus and his abdomen
became much softer. The admitting surgeons expressed surprise that his
system began to function so soon. The patient was discharged from the
hospital after 3 days.
Case 2
A 65-year-old woman presented to the emergency department of John C.
Lincoln Hospital in Deer Valley (Phoenix, Arizona) with complaint of
severe cramping abdominal pain and vomiting. Sixteen years previously,
she had a colostomy placed due to carcinoma of the large bowel. She
had experienced frequent bowel obstructions with surgical revision of
the colostomy 4 times. The patient had symptoms of obstruction about
every 6 weeks during the previous 4 years. Radiography never showed
the typical air-fluid levels, probably because the patient always came
to the hospital within a few hours of onset of her discomfort. She had
symptoms suggestive of early small bowel obstruction, including cessation
of functioning of her colostomy, severe cramping pain, and copious vomiting
of feculent bile-stained liquid. The patient was always hospitalized,
with nasogastric tube and intravenous fluids, for 2 or 3 days. She would
return to work 3 or 4 days later.
On this occasion, the patient presented with typical symptoms of obstruction.
She was treated with the standard nasogastric tube and intravenous therapy.
In addition, after the medical management was initiated, she received
acupuncture treatment using the points CV 12 Zhonguan, ST 25 Tianshu,
CV 4 Guanyuan, ST 36 Zusanli, and PC 6 Neiguan. Hwato 25-mm needles
were used and left in place for 20 minutes. The points were chosen to
stimulate the correct functioning of the intestinal system. In this
case, the treating physician was bolder in the choice of points since
the patient had a history of multiple similar episodes, many of which
had been treated without operative intervention. CV 12 Zhonguan and
ST 36 Zusanli were chosen for the same rationale as in the first patient.
In addition, CV 4 Guanyuan, the front Mu point of SI, was chosen to
stimulate the small intestine, and ST 25 Tianshu, the front Mu point
of LI, was chosen to stimulate functioning of the colostomy. PC 6 Neiguan
was chosen to treat the patient's severe nausea and vomiting. The needles
were manually tonified to achieve de Qi and then left in neutral position
for 20 minutes. She received no further acupuncture treatments while
in the hospital. Within 3 hours, the patient's colostomy began to function,
she ingested oral fluids, and was released feeling well. She returned
to work the next day, rather than 3-4 days later as had happened after
previous episodes. Ten weeks after treatment, no further hospitalizations
had occurred. Six weeks after her first acupuncture treatment, she had
an 8-hour episode of abdominal pain; the patient was treated with an
ear tack at the LI point with complete resolution of symptoms.
DISCUSSION
A MEDLINE search revealed no literature on the treatment of small bowel
obstruction using acupuncture as a modality of therapy. Both surgical
and non-surgical interventions are advocated for treatment of this disease,
depending on the clinical presentation and the cause of the obstruction.3,6,7
Patients with small bowel obstruction can have severe fluid and electrolyte
imbalance, with potentially life-threatening dehydration. Edema of the
bowel wall, strangulation, and perforation can occur if the condition
is not relieved, progressing to peritonitis and sepsis. Many patients
require surgical intervention, with lysis of adhesions, or even bowel
resection if strangulation has occurred. Mean length of hospitalization
in 1 study was 15.3 days.4 Mortality is reported to range from 5%-75%
depending on the cause of the obstruction. Patients with intestinal
adhesions have the lowest mortality, and those with neoplasm and/or
advanced age, the highest.
Research of the available translated literature from China showed 1
article8 that addressed small bowel obstruction secondary to intestinal
adhesions. Twenty-three cases were reported, all of which had at least
1 abdominal surgery. These cases were treated according to TCM principles
of invigorating stagnant Blood (caused by the surgery), resolving Phlegm
(accumulation of which resulted in intestinal adhesions), and regulating
the flow of Qi (which, when rebellious, causes vomiting). This author
used different points, depending on whether the pain was experienced
in the epigastrium, the hypochondrium, or the lower abdomen. In addition
to the points mentioned above, SP 10 Xuehai was used to remove accumulation
of stagnant Blood, ST 40 Fonglong to resolve Phlegm, and ST 23 Taiyi
to regulate the function of Qi (this point also transforms Phlegm and
calms the spirit).4 For pain in the hypochondrium, LR 3 Xinjian, ST
28 Shuidao, and ST 29 Guilai were used to soothe the Liver, normalize
the Gallbladder, and regulate the channels. For lower abdominal pain,
CV 6 Qihai and CV 4 Guanyuan were used to warm the Middle Heater and
regulate the flow of Qi.
The 2 patients described herein both had remarkably short courses of
hospitalization: 3 days for the first, 4 hours for the second. Both
patients had more rapid resolution of their symptoms than would have
been expected from standard medical measures alone. Two successful treatments
could easily be interpreted as coincidence or following the natural,
though shortened, course of the disease. However, the results in these
2 cases are sufficiently striking as to suggest that acupuncture might
play a role in the treatment of small bowel obstruction. It would be
interesting to see results of acupuncture treatment of a larger series
of patients, and perhaps eventually undertake a clinical trial, if results
of acupuncture seem to be promising in the larger series of patients.
It might also be possible to demonstrate clinical significance if there
were several reports of patients similarly treated for small bowel obstruction
with results similar to those herein described.
CONCLUSION
These 2 case reports suggest an area for future study in the treatment
of small bowel obstruction. Any treatment that could contribute to shorter
hospitalization and less morbidity would be of value in the ongoing
care of patients with this clinical condition. If acupuncture does prove
effective in shortening the course of hospitalization and reducing morbidity
due to small bowel obstruction, an additional modality of therapy can
be added to the armamentarium of treatments for small bowel obstruction.
In addition, cost savings may be significant.
REFERENCES
1. Lawrence PF, Bell RM, Dayton MT, eds. Essentials of General Surgery.
Baltimore, MD: Williams & Wilkins; 1988:198.
2. Fauci AS, Braunwald E, et al, eds. Harrison's Principles of Internal
Medicine. 14th ed [CD-ROM]. New York, NY: McGraw-Hill; 2000.
3. Seror D, Feigin E, Szold A, et al. How conservatively can postoperative
small bowel obstruction be treated? Am J Surg. 1993;165:121-125.
4. Deadman P, Al-Khafaji M, Baker K. A Manual of Acupuncture. Hove,
England: Journal of Chinese Medicine Publications; 1998.
5. Flaws B, trans. Classic of Difficulties. Boulder, CO: Blue Poppy
Press; 1999:123.
6. Asbun HJ, Pempinello C, Halasz NA. Small bowel obstruction and its
management. Int Surg. 1989;74:23-27.
7. Bizer LS, Liebling RW, Delaney HM, Gliedman ML. Small bowel obstruction:
the role of nonoperative treatment in simple intestinal obstruction
and predictive criteria for strangulation obstruction. Surgery. 1981;89:407-413.
8. Chunming L, trans. Treatment of 23 cases of post operative intestinal
adhesion by warmed needle and cupping. Shanghai J Acupuncture Moxibustion.
1999:19-20.
AUTHOR INFORMATION
Dr Martha M. Grout is a Board-certified Emergency
Physician, practicing in the Emergency Department of John C. Lincoln
Hospital, Deer Valley, in Phoenix, Arizona. She is a Fellow of the American
College of Emergency Physicians, and a member of the American Holistic
Medical Association. Dr Grout is a Clinical Instructor for the UCLA
Medical Acupuncture for Physicians Program. She uses acupuncture in
her emergency medicine and private practices.
Martha M. Grout,
MD, MD(H)
6137 E Mescal St
Scottsdale, AZ 85254-5419
Phone: 480-348-9394
Fax: 480-951-5930
E-mail: drmartha@worldnet.att.net
|
|
|
|