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Ulcerative Colitis : Treatment
   
Western Medicine Chinese Medicine

The goals of treatment of ulcerative colitis are to induce and maintain remission of symptoms and inflammation of the inner lining of colon. Treatment options are determined according to the extent of the inflammation and the severity of the disease.

5-Aminosalicylic Acid (5-ASA)
The majority of patients with ulcerative colitis have mild or moderate disease with inflammation involving areas close the rectum. In these patients, rectally administered preparation of 5-aminosalicylic acid (5-ASA) is the best treatment option. Rectal preparation of 5-ASA is available as an enema, foam, gel, or suppository, which are equally effective. For patients who prefer oral therapy, sulfasalazine and 5-ASA derivatives (mesalamine, olsalazine, and balsalazide) are also effective in the treatment of mild to moderate ulcerative colitis, although rectal preparations have higher remission and improvement rates.

Sulfasalazine is less effective than corticosteroids for active disease and its major role in the management of ulcerative colitis is to maintain remission once the active inflammation has resolved. However, side effects from sulfasalazine such as headache, nausea, and vomiting can be severe. Rash and infertility in males are also commonly reported with sulfasalazine therapy.

Mesalamine, olsalazine, and balsalazide have been developed to minimize adverse effects seen with sulfasalazine therapy. These new 5-ASA derivatives are shown to be as effective as sulfasalazine in both treating active ulcerative colitis and maintaining remission with fewer side effects.

Corticosteroids
For patients whose symptoms are inadequately controlled with 5-ASA, corticosteroids are used in active disease.

Hydrocortisone is available as an enema, suppository, or foam for rectal administration. For patients with severe ulcerative colitis, oral corticosteroid is used. Prednisone and cortisone are commonly used oral corticosteroids for severe ulcerative colitis but prolonged use can cause many long-term side effects, including osteoporosis and cataract. For patients with severe disease requiring hospitalization, intravenous corticosteroid is also available.

Although corticosteroids deliver fast and reliable remissions of the active ulcerative colitis, these drugs do not change the underlying disease course and they were shown to be ineffective in maintaining long-term remission with continued use. Therefore, corticosteroids should be used to treat active disease and should be used to maintain remission of the disease.

Immunosuppressive Agents
Immunosuppressive agents are often used to allow reduction or elimination of corticosteroids and also to maintain corticosteroid-induced remissions of the disease. The immunosuppressive agents used in ulcerative colitis include azathioprine (AZA), 6-mercaptopurine, and cyclosporine.

Azathioprine and 6-mercaptopurine are most widely used immunosuppressive agents used in ulcerative colitis. These drugs are especially useful in patients who are having repeated relapses from their disease once corticosteroids have been discontinued. It may take up to 6 months for these drugs to achieve a therapeutic effect. Both azathioprine and 6-mercaptopurine are associated with minimal side effects which include nausea, fever, and diarrhea. Pancreatitis and liver dysfunction can also occur and rare occurrence of bone marrow suppression with these drug warrant regular monitoring of blood counts.

Cyclosporine is used for patients hospitalized with severe ulcerative colitis who do not respond to high doses of intravenous corticosteroid s . Although oral formulation of the drug is available, only intravenous administration of cyclosporine has been shown to provide favorable effects in severe ulcerative colitis. It has much faster onset of therapeutic efficacy compared to azathioprine and 6-mercaptopurine, but is not found to be as effective in maintaining remission. Unlike azathioprine and 6-mercaptopurine, cyclosporine is not associated with bone marrow suppression but can cause kidney toxicity.

Surgery
In patient with ulcerative colitis, surgery is performed to remove the colon in the following situations:

Severe attacks not responding to medical treatment
Perforation or dilatation of the colon during a severe attack
Cancer due to ulcerative colitis

TCM believes that the major pathologies of ulcerative colitis include spleen and stomach dysfunctions, intestinal turbid accumulations, and blood and qi disturbances . Therefore, TCM treatment strategies are to restore organ functioning, eliminate turbid accumulations and harmonize the flows of qi and blood.

In clinical applications, if individuals have obvious pus, mucus or bloody loose bowels, physicians will focus on clearing pathogens like damp-heat or damp-cold, so as to improve the bowel environment. Afterwards, tonifying methods are employed to overcome the internal weakness and promote a longer remission period.

Prescriptions according to syndrome differentiation

Damp-heat in the large intestine
Therapeutic aim: Clearing damp-heat, harmonizing blood and qi.
Sample prescription: Modified Peony Decoction (Shao Yao Tang)

In the prescription, the peony root and angelica root enrich the blood; the betel nut, costus root and rhubarb promote qi flow, the thread rhizome and skullcap root clear damp-heat and detoxify. The whole combination resolves the pathogenic accumulation in the large intestine, enabling the bowel to resume its normal transmission process.

Peony root

Damp-cold in the spleen
Therapeutic aim: warming and dissolving dampness, harmonizing blood and qi
Sample prescription: Modified Weiling Decoction (Wei Ling Tang)

In the prescription, the atractylodes rhizome and root enhance fluid metabolism in the spleen; the magnolia bark and tangerine peel regulate qi flow to dispel damp-cold; the poria, water-plantain root and chu-ling induce urination; cassia bark and ginger promote warmth to expel coldness. The whole combination enables the intestinal functions to perform normally by enhancing spleen functioning and dispelling damp-cold pathogens.

Qi and Blood stagnation
Therapeutic aim: regulating blood and qi flows to arrest diarrhea and pain.
Sample prescription : Modified Decoction for Removing Blood Stasis in the Lower Abdomen (Shao Fu Zhu Yu Tang)

In the prescription, the cattail pollen, angelica, lovage and squirrel feces nourish blood and promote tissue regeneration; the corydalis rhizome, peony root and myrrh promote blood and qi flows to arrest pain; the fennel, ginger and cassia bark warm the meridian to dispel blood stasis. The whole combination improves the circulation in the large intestine so as to arrest diarrhea and pain.

Liver stagnation and spleen weakness
Therapeutic aim: soothing liver, invigorating spleen, expelling dampness, arresting diarrhea.
Sample prescription: Modified Essential Formula for Diarrhea with Pain (Tong Xie Yao Fang)

In the prescription, the atractylodes root invigorates the spleen; the peony root works on the liver; the tangerine peel regulates qi flow and expels dampness; the ledebouriella root assists the above herbs to work properly. The whole combination invigorates the spleen and expels dampness to arrest diarrhea, soothes the liver and regulates qi to arrest pain.

Spleen qi deficiency
Therapeutic aim: Replenishing qi, invigorating spleen, consolidating intestines to arrest diarrhea.
Sample prescription: Modified Powder of Ginseng, Poria & Atractylodes (Shen Ling Bai Shu San)

In the prescription, the ginseng, atractylodes root and poria are the main ingredients to replenish qi and invigorate the spleen; the hyacinth bean, coix seed, lotus seed and yam enhance the water metabolism of the spleen which helps to drain dampness and arrest diarrhea; the amomum fruit promotes the digestive process; the balloonflower regulate the water passages and the liquorice acts as a buffer.

Spleen and kidney deficiencies
Therapeutic aim: warming and tonifying the spleen and kidney, consolidating the intestine to arrest diarrhea.
Sample prescription: Modified Immortal Organ-Nourishing Decoction (Zhen Ren Yang Zang Tang)

In the prescription, the poppy capsule is used in high dosage to consolidate the intestine and arrest diarrhea; cassia bark warms the kidney and spleen; both herbs are the main ingredients. The nutmeg and myrobalan fruit provide warming to arrest diarrhea; the ginseng and atractylodes root replenish qi; the angelica and peony root replenish blood; the costus root and liquorice root act as buffer.

Herbal enemas

An enema is the procedure of introducing liquids into the rectum and colon via the anus. Herbal enemas help improve problems affecting the lining of the bowel such as abrasions, edema, ulcers and bleeding, therefore effectively relieving the intestinal symptoms.

Herbal enemas for ulcerative colitis must be carried out in medical or hospital environments. Before the procedure is undertaken, the lower bowel must be cleaned properly; drip a warm herbal preparation slowly into the colon; let the liquid be retained for at least 4 hours so as to obtain the full herbal effects. Do once a day for ten days, and then rest for 4 days before repeating the treatment. Patients usually feel an improvement after 3 courses. Selection of herbs is based on individual cases, below are some suggested ingredients:

Clearing damp-heat accumulation

bai tou weng

Chinese pulsatilla root

Radix Pulsatillae

ye ju hua

wild chrysanthemum

Flos Chrysanthemi Indici

pu gong ying

dandelion

Herba Taraxaci

huang lian

golden thread rhizome

Rhizoma
Coptidis

bai jiang cao

patrinia

Herbal Patriniae


Removing blood and qi stagnation

dan pi

peony tree root bark

Crotex Moutan Radicis

huang qin

baical skullcap root 

Radix Scutellariae

huai hua

pagoda tree flower

Flos Sophorae

san chi

notoginseng

Radix
Notoginseng

da huang

Chinese rhubarb

Radix et Rhizoma Rhei


Soothing liver and invigorating spleen

bai ji

common bletilla tuber

Rhizoma
Bletillae

chai hu

bupleurum root

Radix Bupleuri

bai shao

white peony root

Radix Paeoniae Alba

yu jin

turmeric root tuber

Radix Curcumae

wu yao

lindera root

Radix Linderae


Tonifying spleen and stomach

huang qi

astragalus

Radix Astragali

dang shen

pilose asiabell root

Radix Codonopsis Pilosulae

bai shu

largehead atractylodes root

Rhizoma Atractylodis Macrocephalae

chen pi

dried tangerine peel

Pericarpium Citri Reticulatae

dang gui

angelica root

Radix Angelicae Sinensis


Pilose asiabell root

Acupoint therapies

Stimulation of acupoints not only enhances the immune modulation effect, but also mobilizes the innate healing power inside the body. For the localized problems like inflammation, ulcers, muscular spasms and sluggish flow, acupuncture and moxibustion are particular effective and thus facilitate structural recovery.

Suggested acupuncture methods:
Major points: navel's four-point (one-thumb-width apart from the navel, located in three, six, nine & twelve o'clock), tian-shu, guan-yuan & qi-hai;
Assist points: da-chang-shu, zhang-qiang, pi-shu, wei-shu, zu-san-li & san-yin-jiao.

When applying, first punch the four-point needle in 0.3-0.5 cm deep and rotate for about 30 seconds, stimulate the four locations in a clockwise sequence, no needle retention; then select one more major point and 2-3 assist points for stimulation, retain the needles on the locations for 15-20 minutes, moxa cones can be attached for heating during this time. Do this once daily or every two days, ten times is one course.

Moxibustion can also be used to boost the weakened systems, particularly for individuals with chronic symptoms. Below are suggested protocols:
Major points: zhong-wan, tian-shu, guan-yuan & shang-ju-xu;
Assist points: pi-shu, shen-shu, da-chang-shu, zu-san-li, tai-xi, tai-chong, san-yin-jiao & zhong-iv-shu.

Each time, select 1-2 major points and heat for 30-40 minutes; while select 2-3 assist points and heat for 15-20 minutes. Do this once daily or every two days, 15-20 times is one course.

Acupoints for UC