Acupuncture as a Therapeutic Intervention for Acute Gastrointestinal Injury (AGI): A Preliminary Study

Abstract

Acute gastrointestinal injury (AGI) is a significant factor contributing to increased mortality in patients receiving intensive care unit (ICU) care. Traditional Chinese medicine's acupuncture techniques offer an alternative approach to treating digestive disorders by controlling gastrointestinal secretion, improving gastrointestinal motility, and minimizing side effects. Transabdominal intestinal ultrasonography has proven effective in assessing gastrointestinal injury in critically ill patients. This study aims to evaluate the therapeutic effect of acupuncture in AGI patients using ultrasound. The main steps of the study include the syndrome-based selection of appropriate acupuncture points, including Hegu (LI4), Zhongwan (CV 12), Tianshu (ST 25), Zusanli (ST 36), Shangjuxu (ST 37), and Xiajuxu (ST 39), followed by a 30 min Deqi acupuncture session once a day for 1 week. The treatment's effectiveness is assessed by an experienced physician using abdominal gastrointestinal ultrasonography. This article provides a detailed account of how to standardize the use of acupuncture in treating gastrointestinal dysfunction in critically ill patients.

Introduction

Acute gastrointestinal injury (AGI) refers to the malfunctioning of the gastrointestinal (GI) tract in critically ill patients due to their acute illness¹. It is a significant contributor to acquired frailty, extended hospital stays, and higher fatality rates among patients receiving intensive care unit (ICU) care². Approximately 60% of ICU patients experience symptoms of AGI, and 40% develop AGI, with severe cases having a mortality rate of up to 33%³. AGI can arise or worsen as a result of multiple organ dysfunction syndrome (MODS) and systemic inflammatory response syndrome (SIRS). Inflammatory mediators released in response to injury, surgery, infection, and hemorrhage can lead to intestinal mucosal damage, translocation of gut microbiota⁴, loss of barrier function⁵, compromised immune defense system⁶, and secretory dysfunction⁷. The mortality rate increases with the severity of AGI, significantly surpassing that of non-AGI patients⁸.

While early bowel rest and traditional treatment plans aimed at increasing tissue perfusion and oxygen delivery are widely acknowledged, their effectiveness remains a subject of debate². There is currently no agreed-upon nutritional program for patients with severe AGI, which has a significant impact on patients' clinical outcomes. Therefore, alternative treatments must be explored to manage this condition. Acupuncture, a traditional Chinese medicine practice, has a rich history and extensive experience in treating serious illnesses. By controlling gastrointestinal motility, protecting the gastric mucosa, and reducing visceral sensitivity, acupuncture has shown potential in treating various digestive system disorders⁹. Numerous studies have demonstrated the safe and effective recovery of gastrointestinal function through acupuncture therapy^10,11,12.

Currently, few methods are available for monitoring gastrointestinal dysfunction in critically ill individuals¹³. Clinical assessment, although commonly used and often combined with gastric residual volume (GRV) measurement, is imperfect in evaluating overall GI function¹⁴ and lacks standardization in AGI investigations of critically ill patients. Recent research has shown that ultrasound (US) can facilitate quantification of tissue perfusion (US Doppler), intestinal peristalsis, colon diameter, and gastric emptying. Both GRV measurement and estimations based on CT imaging and gastric antrum diameter have demonstrated correlations¹⁵.

This study aims to validate the therapeutic impact of acupuncture in AGI patients based on previous research. The article provides a detailed account of the effective use of acupuncture in treating patients with severe AGI.

Protocol

Eligible volunteers provide written, informed consent prior to participating in the research. The protocol was carried out in accordance with the Declaration of Helsinki, approved by the Hospital of Chengdu University of Traditional Chinese Medicine's Medical Ethics Committee (ethics approval number: 2022KL-006).

1. Screening and diagnostics

1. Screen patients according to the inclusion and exclusion criteria with AGI in the initial phase of this study. Use the following diagnostic standards; class II-III on AGI as of the 2012 European Society for Intensive Care Medicine (ESICM)¹.
   1. AGI grade II (gastrointestinal dysfunction): the GI tract is unable to sufficiently complete digestion and absorption to meet the body's needs for nutrients and fluids. Regarding GI issues, the patient's overall condition has not changed.
   2. AGI grade III (gastrointestinal failure): the loss of GI function, in which case GI function is not restored despite interventions, and the overall state is not getting better.
2. Use the following inclusion criteria for this study. Add patients who match all of these requirements to the trial.
   1. Compliance with the diagnostic standards for AGI I-III grades.
   2. Informed consent to the treatment protocol described above.
3. Use the following exclusion criteria for this study. Exclude patients from the trial who met any of these requirements.
   1. An ICU stay of less than three days. These patients are unsuitable for acupuncture because they have damaged skin at the acupuncture site.
   2. Women who have childbearing needs within the previous 6 months, including those who are pregnant or breastfeeding. Also, patients whose life expectancy has been considerably reduced due to advanced malignant cancers.
   3. Patients with severe gastrointestinal conditions that prevent them from receiving routine therapy medications through the intestines, such as acute gastrointestinal hemorrhage, mechanical intestinal obstruction, major abdominal surgery, and abdominal compartment syndrome; patients whose unstable hemodynamics make it impossible to administer typical treatment medications orally.
   4. Individuals taking part in other clinical trials.
4. Obtain informed approval from those patients who satisfy the requirements and will thereafter be a part of the investigation. Ensure to get written informed permission before beginning any study procedures.

2. Patient grouping

1. Use a random number table by a non-affiliated third party to determine the random sequence number.
2. Create a card out of the random number sequence and insert it into the associated coded envelope.
3. Ask the patients who have been enrolled to choose an envelope at random. Assign odd numbers to the control group and even numbers to the treatment group, and number each patient corresponding to the random number.

3. Interventions

1. Start the intervention by an acupuncturist. After 24 hours, the groups are assigned. It is important to note that only acupuncture professionals with at least 1 year of clinical experience and a certificate as a physician are qualified to administer the treatments.
2. For the control group, administer standard care, including infection control, careful selection of antibiotics, correction of shock (maintaining intraperitoneal perfusion pressure > 60 mmHg), improvement of tissue perfusion and oxygen supply, elimination of factors that increase oxygen consumption as much as possible, early enteral nutrition, and protection of gastric mucosa. Additionally, treat symptoms such as diarrhea, abdominal distension, gastric retention, and vomiting.
3. For the treatment group, administer acupuncture according to standard medical practice.
   1. Prior to the procedure, prepare surgical masks and hats. Wash hands with a chlorine-containing disinfectant and dry them. Disinfect the hand that will hold the needle using an iodophor cotton swab.
   2. Prepare the patient by continuously monitoring their heart rate, blood pressure, respiratory rate, oxygen saturation, and changes in consciousness. Ask the patient to lie down in a supine position and fully expose the area for needle administration.
   3. Select the acupuncture points according to the WHO standard shown in Table 1, which include Zhongwan (CV 12), Tianshu (ST 25), Zusanli (ST 36), Hegu (LI 4), Shangjuxu (ST 37), and Xiajuxu (ST 39). Prior to acupuncture, clean the patient's skin using povidone-iodine cotton swabs.
   4. Use a disposable stainless-steel needle with a size of 0.30 mm x 40 mm. Hold the needle in the right hand and use the index and middle finger of the left hand to press the skin around the acupuncture point or hold the needle body to assist in its insertion.
   5. Rotate the needle in the right hand next to the nail surface of the left hand and insert the needle at the specified angle and depth. The penetration depth for Hegu is 0.5 cun, and for Zhongwan, Tianshu, Zusanli, Shangjuxu, and Xiajuxu, it is 1.5 cun. Keep all acupuncture directions perpendicular to the skin (90°). Leave the needle in place for 30 minutes.
   6. After the 30-minute treatment, remove the needle and gently press the needle hole with a sterile cotton swab. If there is any bleeding, continue to apply pressure for a few minutes until the bleeding stops.

4. Ultrasonic analysis

1. Perform abdominal ultrasound on the first day before treatment and the seventh day after treatment.
2. Ask the patient to lie on the bed on their back.
3. Scan the abdomen using an ultrasonic machine and choose a convex array probe with a skilled intensivists. The scan should include the colon, ileum, jejunum, and gastric antrum.
4. In the short-axis view of the stomach antrum, locate the abdominal aorta in the lower portion of the screen and keep the angle annular.
5. Position the convex array ultrasonic probe longitudinally on the midline beneath the xiphoid process with the probe mark pointed toward the head. This position is referred to as the stomach antrum. Measure the greatest antrum diameters (D1 and D2) using two vertical lines and average them over three subsequent measurements to determine the antrum area.
   Antrum area = π x (D1 x D2)/4
6. At the same time, observe the frequency of stomach movements per minute.
7. For the ileum section, use a convex array ultrasound probe to scan the right lower abdomen in a clockwise direction. Measure the thickness of the intestinal wall and the maximal diameter of the small intestine.
8. For the colon section, position the convex array ultrasound probe along the course of the colon on either the left or right side of the abdomen and scan vertically or horizontally from top to bottom. Measure the thickness of the intestinal wall and the largest diameter of the colon.

Representative Results

General information
In this clinical study, a total of 15 patients were observed, and ultimately, 10 patients successfully completed the 7-day trial process, with 5 patients in the treatment group and 5 patients in the control group. Comprehensive trial data were collected from all patients and included in the final analysis. The mean age of the enrolled patients was 60.50 years, with 3 males in each group.

To compare between the treatment group and the control group, an independent sample t-test was conducted, while a paired sample t-test was used to compare within each group before and after treatment. Data analysis and image rendering were performed using GraphPad Prism. Statistical significance was considered where a p-value of less than 0.05.

A comparison of ultrasound data between the two groups after 7 days of treatment is shown in Table 2 and Figure 1. The treatment group exhibited a significant decrease in the gastric antrum area, small intestine diameter, colon diameter, and colon wall thickness compared to the control group (P < 0.05). Additionally, the treatment group showed an increase in the frequency of gastric peristalsis (P < 0.05).

Comparison of ultrasound data before and after treatment in the treatment group after 7 days of treatment is shown in Table 3. Significant improvements were observed in the gastric antrum area, gastric peristalsis frequency, small bowel wall thickness, colon diameter, and thickness (P < 0.05).

Figure 1: Ultrasound images before and after acupuncture treatment. (A) This figure shows the jejunum before acupuncture treatment. (B) This figure shows the jejunum after acupuncture treatment (red arrow). Please click here to view a larger version of this figure.

Acupoint	Location
Hegu (LI4)	on the dorsum of the hand radial to the midpoint of the second metacarpal bone.
Shangjuxu (ST37)	6 cun directly below Dubi (ST35), and one finger-breadth lateral to the anterior border of the tibia.
Tianshu (ST25)	On the upper abdomen, 2 cun lateral to the center of the umbilicus.
Xiajuxu (ST39)	9 cun directly below Dubi (ST35), and one finger-breadth lateral to the anterior border of the tibia.
Zhongwan (CV12)	On the upper abdomen, 4 cun above the navel.
Zusanli (ST36)	On the anterior aspect of the leg, on the line connecting ST35 and ST41, 3 cun inferior to ST35, locate on the tibialis anterior muscle.

Table 1: Acupuncture point location.

group	GAD	GAA	GPF	SID	SIWT	CD	CWT
	(cm)	(cm2)	(times/min)	(cm)	(mm)	(cm)	(mm)
Treatment group(n=5)	3.27±0.70	6.15±1.33	3.00±0.71	2.52±0.25	1.46±0.65	2.62±0.74	2.10±0.60
Control group(n=5)	3.84±0.93	8.54±1.85	1.40±0.55	2.96±0.25	2.06±0.65	4.69±0.84	3.35±0.77
T	1.082	2.337	-4	2.749	1.442	4.152	2.849
P	0.311	0.048	0.004	0.025	0.187	0.003	0.021

Table 2: Comparison of ultrasound data between the two groups after 7 days of treatment. Abbreviations: GAD = gastric antrum diameter, GAA = gastric antrum area, GFP = gastric peristalsis frequency, SID = small intestine diameter, SIWT = small intestine wall thickness, CD = colon diameter, CWT = colon wall thickness.

group	GAD	GAA	GPF	SID	SIWT	CD	CWT
	(cm)	(cm2)	(times/min)	(cm)	(mm)	(cm)	(mm)
pre-Treatment (n=5)	5.03±1.48	10.65±3.06	1.00±0.71	2.56±1.03	2.74±0.44	3.43±0.67	3.39±0.92
post-Treatment (n=5)	3.27±0.70	6.15±1.33	3.00±0.71	2.52±0.25	1.46±0.65	2.62±0.74	2.10±0.60
T	2.135	3.134	-3.162	0.068	4.411	3.527	2.836
P	0.1	0.035	0.034	0.949	0.012	0.024	0.047

Table 3: Comparison of ultrasound data before and after treatment in the Treatment groups. Abbreviations: GAD = gastric antrum diameter, GAA = gastric antrum area, GFP = gastric peristalsis frequency, SID = small intestine diameter, SIWT = small intestine wall thickness, CD = colon diameter, CWT = colon wall thickness.

Discussion

Critically ill patients often experience acute gastrointestinal injury (AGI), which encompasses delayed gastric emptying, abnormal intestinal motility patterns, and compromised intestinal barrier integrity¹⁶. The grading of AGI assists in identifying the severity of gastrointestinal dysfunction and serves as a strong predictor of mortality among severely ill patients¹⁷. Transabdominal intestinal ultrasonography has been established as an effective method for assessing gastrointestinal injury in critically ill patients¹⁸. Acupuncture, as a form of external traditional Chinese medicine, stimulates acupuncture points, clears meridian blockages, regulates the flow of qi and blood, nourishes the body, and possesses antimicrobial properties. Acupuncture has been recognized as a suitable supplementary treatment for gastrointestinal dysfunction disorders⁹, with minimal side effects¹⁹, and it has been shown to have a favorable regulatory effect on gastrointestinal motility disorders^20.

Although acupuncture is a relatively safe traditional Chinese medicine therapy, certain precautions should be observed during the procedure. Firstly, the correct acupuncture points should be selected based on the patient's condition and treatment goals. Secondly, it is crucial to ensure clean hands and the use of sterile needles before performing acupuncture procedures to prevent the risk of infection and cross-contamination. Thirdly, caution should be exercised to avoid bending or damaging needles during use, as this can cause harm to both the operator and the patient. Fourthly, given that abdominal acupoints are included in this study protocol, it is important to minimize the risk of injury to abdominal organs and major blood vessels. Finally, close observation of the patient's response is necessary. If any abnormal reactions like discomfort or pain occur, the treatment approach should be adjusted or discontinued.

This study presents several strengths as there are limited studies on acupuncture in patients with severe AGI. However, it also has some limitations. Firstly, this was a small controlled study, and the sample size needs to be expanded for further investigation. Secondly, due to the relatively short duration of the intervention (only 7 days), clinically significant results might not have been observed. Nevertheless, we remain optimistic that this experiment will contribute to understanding the effectiveness of acupuncture in the treatment of severe AGI and provide reliable evidence.

In the future, as more clinical studies related to acupuncture and moxibustion emerge, it is expected that more clinicians will choose acupuncture as a treatment option for gastrointestinal dysfunction in critically ill patients.

Materials

Name	Company	Catalog Number	Comments
Cotton swab	Chengdu Zhongxin Sanitary Materials Co., Ltd.	20220415	For hemostasis
Iodophor cotton swab	Zhejiang Baikal Health Technology Co., Ltd.	20220601	For disinfection of acupuncture points
Portable Color Doppler Ultrasound System	Mindray	M9	Assess gastrointestinal function.
Sterile Acupuncture Needles	Changchun Aikang Medical Equipment Corporation	20172270314	For acupuncture
TM-100 medical ultrasonic couplant	Tianjin Xiyuan Temple Factory	20190618	For air isolation during ultrasonography