Acupoint catgut-embedding therapy as promising treatment for non-alcoholic fatty liver disease

Ali Etemadi Boroujeni

Ajand Medical Complex-Amadegah st, Isfahan 8145614544, Iran

Abstract

Objective: To investigate the effect of acupoint catgut-embedding therapy on non-alcoholic fatty liver disease (NAFLD).

Methods: Twenty-three participants were subjected to acupoint catgut-embedding therapy for 3 sessions. The second session was performed one month after the first session and the third session two months after the second session.Three months after the third session of catgut-embedding therapy, the patients were subjected to fibroscan analysis. A total of 20 acupoints were selected in three sessions. Same acupoints were selected for all the patients at the same session but different points were selected at different sessions.

Results: Of the 23 participants, 5 cases showed significant improvement and 8 cases showed moderate improvement as the steatosis stage was reduced by 1 or 2 degrees. The whole group showed significant improvements in terms of patient score, fat percentage, NAFLD steatosis stage, weight loss and abdominal circumference reduction after acupoint catgut-embedding therapy (all P<0.05).

Conclusion: The acupoint catgut-embedding therapy can significantly improve the important factors in patients with NAFLD.

Keywords: Embedding Therapy; Embedding, Thread; Acupoint Therapy; Weight Loss; Non-alcoholic Fatty Liver Disease

Non-alcoholic fatty liver disease (NAFLD) is progressively perceived as a reason for chronic liver disease, and frequently brings about the devastating outcomes of decompensated liver cirrhosis,hepatocellular carcinoma (HCC), liver transplantation,and death[1-2]. NAFLD is a rapidly growing disease in both developing and developed countries and what's more, is presumably the most widely recognized reason for abnormal liver function tests and liver transplantation around the world[3]. It is assessed to influence almost 30% of all inclusive community in Western nations[1]. NAFLD outbreak in Asian countries seems to be lower, but is expanding. The precise pathogenesis is not clear yet. However, several risk factors including obesity, advanced age, hyperlipidemia and insulin resistance have been proposed[4]. Many researches are being directed toward designing therapeutic strategies for NAFLD. Acupoint catgut-embedding therapy is one of the traditional methods used widely nowadays for treating many diseases such as obesity, epigastric pain, asthma,epilepsy, abdominal pain, facial paralysis, low back pain and leg pain successfully[5-6]. However, reports on the use of this method for treating NAFLD are very rare and limited mostly to China[7-8].

In current study we used acupoint catgut-embedding therapy for NAFLD in Iranian population. In previous reports liver enzymology and blood lipid test were used to assess the pattern of liver qi stagnation and spleen deficiency. Our report attempted to evaluate NAFLD steatosis stage before and after acupoint catgutembedding therapy via fibroscan analysis. Fibroscan is a specialized ultrasound machine which can be used alone to measure fibrosis (scarring) and steatosis (fatty change) in liver.

1 Clinical Materials

1.1 Diagnostic criteria

Meta-analysis of histologic data in viral hepatitis(METAVIR) score, fat percentage and NAFLD steatosis stage were analyzed before and after acupoint catgutembedding therapy using fibroscan 502 step 5 instruments (Ecosense, France) with controlled attenuation parameter (CAP).

1.2 Inclusion criteria

Inclusion criteria included the following: women and men between the ages of 18 and 65 years old with diagnosis of NAFLD confirmed by specialized gastroenterologist using an imaging examination(ultrasound, CT scan, MRI or MR spectroscopy)performed in the 6 months prior to enrolment. Not being under any drug treatment and willing to participate in the study were also considered as inclusion criteria. The research was conducted in accordance with the last update of Helsinki declaration.All selected participants signed the informed consent.

1.3 Exclusion criteria

Smokers or alcoholic participants, pregnant or breast-feeding women, and patients with previous acupuncture or drug treatment for NAFLD in the last 6 months; patients with congestive heart failure,uncontrolled diabetes mellitus, uncontrolled hypo- or hyper-thyroidism, chronic kidney disease, with creatinine clearance <60 mL/h and concomitant liver diseases such as autoimmune hepatitis, primary biliary cirrhosis, primary sclerosing cholangitis, alpha-1 antitrypsin deficiency were excluded; patients who failed to attend one or more sessions.

1.4 Statistical methods

All statistical analyses were based on theSuggested Statistical Reporting Guidelines for Clinical Trials Data[9].SPSS version 25 statistical software was used for data processing. The quantitative variables were expressed using the mean ± standard deviation (±s) or median(lower quartile, upper quartile) [M (QL, QU)] and qualitative variables were expressed as frequency.Pairedt-test was used to compare quantitative variables expressed as (±s). Also, Wilcoxon signed-rank test was used to compare the qualitative variables and quantitative variables expressed as [M (QL, QU)].α=0.05 andP<0.05 were statistically considered significant.

1.5 General data

The current study was designed as a pre-post clinical study. Patients were recruited at the private acupuncture clinic (Jivar Clinic) of Dr. Ali Etemadi Boroujeni. Twenty-three patients including 16 females and 7 males were included.

2 Treatment Method

Patients were subjected to acupoint catgutembedding therapy for 3 sessions. The second session was performed one month after the first session and the third session two months after the second session.Three months after the third session of acupoint catgutembedding therapy, patients were subjected to fibroscan analysis. Selected acupoints for treatment in all patients were fixed at the same session but different between sessions. A total of 20 acupoints were selected in three sessions. In the first session, Yaoyangguan(GV 3), Danshu (BL 19), Sanjiaoshu (BL 22), Zhizheng(SI 7), Tianjing (TE 10) and Yanglingquan (GB 34) were selected. In the second session, Shaohai (HT 3), Qimen(LR 14), Huangshu (KI 16), Xinshu (BL 15), Ganshu(BL 18) and Shenshu (BL 23) were selected. In the third session, the key acupoints were Zusanli (ST 36),Yinlingquan (SP 9), Pishu (BL 20), Ganshu (BL 18), Geshu(BL 17), Qihai (CV 6), Zhongwan (CV 12) and Guanyuan(CV 4). The needle used in our study is shown in Figure 1.

Figure 1. The needle used in this study

3 Results

3.1 Evaluation criteria

Patient score, METAVIR score, fat percentage and NAFLD steatosis stage were analyzed by fibroscan technique before and after acupoint catgut-embedding treatment.

3.2 Tolerance and general effects

All treatments were very well-tolerated, and none of the patients suspended the therapy due to adverse side-effects. Moreover, patients who suffered from problems such as back pain, neck pain, and migraine were cured during the treatment of fatty liver. Due to the lack of advice and compliance with the diet, the weight loss process was not satisfactory in some patients who did not follow the particular diet. Data before and after treatment can be seen in Table 1.

According to statistical analysis, even though for some patients weight loss process was not satisfactory but totally the weight and abdominal circumference reductions after treatment were significant.

Table 1. Comparison of general data of the included patients before and after treatment

In our study three patients with F3 METAVIR score were scored F2 after treatment and two patients with F3 were scored F0 after treatment, showing significant improvement. Two patients with F2 also showed improvement after treatment (F0). Although the rest did not show any significant positive change, but their overall METAVIR score remained unchanged or stable after treatment.

3.3 Therapeutic results

The relevant results are presented in Table 2 and Table 3. As Table 2 and Table 3 show, the whole group showed significant improvements in terms of mean patient score, fat percentage, NAFLD steatosis stage,weight loss and abdominal circumference reduction after acupoint catgut-embedding therapy (allP<0.05).

3.4 Patient fibroscan results

One of our female patients, 38 years old, referred to our clinic due to severe stress and ovarian cyst.Fibroscan analysis showed NAFLD, grade 3 with patient score: 342. Treatment was done through the 3 sessions of acupoint catgut-embedding therapy as described in the method. After intervention, the fatty liver was completely treated, patient score was reduced to 207 and the patient lost weight from 64 kg to 58 kg.According to the patient, the patient's stress was relieved and the ovarian cyst also improved. The patient’s fibroscan results before and after treatment are shown in Figure 2.

Table 2. Comparison of mean variables studied before and after acupoint catgut-embedding treatment ( ±s)

Table 2. Comparison of mean variables studied before and after acupoint catgut-embedding treatment ( ±s)

Variable n Before treatment After treatment Difference between before and after treatment P-value Weight (kg) 23 94.47±20.05 89.50±20.30 -4.96±4.40 <0.001 Abdominal circumference (cm) 23 119.00±16.10 112.10±15.07 -6.80±4.21 <0.001

Table 3. Comparison of mean variables studied before and after acupoint catgut-embedding treatment [M (QL, QU)]

Figure 2. A patient’s fibroscan result

4 Discussion

NAFLD is a worldwide disease, not only because of wrong diets and obesity, but in part due to insulin resistance, finally leading to accumulation of free fatty acids and triglycerides in liver[10]. NAFLD patients are at increased risk of liver-related mortality as well as kidney- and cardiovascular-related mortality, and today it has become the main reason for liver transplantation[4,11]. Current treatment for NAFLD is based mostly on dietary and exercise interventions that have been shown to be effective. However, compliance with new lifestyle modifications is very hard, and thus making new treatment strategies a necessary option[10,12]. The incidence of NAFLD in Western countries is estimated to be 20%-30% and 5%-18% in Asia[1].

In traditional Chinese medicine, acupuncture therapy has been used for the treatment of several diseases[5-6].Successful application of this method has been reported for back pain, headache, neurological disease and migraine[13-14]. Treatment of NAFLD patients with acupuncture requires a long time between 6 and 24 months, which is very effective. Due to the large number of acupuncture sessions (at least 2 sessions per week) and the lack of patient collaboration, the alternative method of acupoint catgut-embedding therapy seems to be more appropriate. In previous studies, the positive effect of acupoint catgutembedding therapy on NAFLD was proved using liver enzymology and blood lipid test[7-8]. In their studies,acupoint catgut-embedding therapy reduced the levels of alanine aminotransferase, aspartate aminotransferase, total cholesterol, triglyceride and relieved the severity of fatty liver more significantly compared with oral drug treatment. In this study, almost all of the patients except one had normal liver enzymes in their tests, indicating that liver enzymes alone shouldn’t be the exact criteria for liver function testing. So, I decided to use the fibroscan technique in my study to evaluate liver fibrosis.

For the rest factors including fat percentage, patient score and NAFLD steatosis stage, significant positive improvements were observed. Steatosis stage in 14 patients was improved very significantly: 4 patients (S3 to S1), 4 patients (S3 to S2), 2 patients (S3 to S0), 3 patients (S2 to S0) and 1 patient (S2 to S1). In patients with concomitant fibrosis and steatosis, fibrosis was initially treated during the 6-month treatment process and after fibrosis treatment; fatty liver was improved significantly, with a significant decrease in patient score during this period. However, the present study did not include a continuation of treatment for these patients over another 6-month period.

The treatment of patients with fatty liver in this study was based on a specific pattern that has been employed at each stage: to reconstruct specific pathways of the meridians as embodied.

The treatment started with the Taiyang and Shaoyang Meridians. Danshu (BL 19, the Back-Shu point of gall bladder), Sanjiaoshu [BL 22, the Back-Shu point of the three Jiao (energizer)], Zhizheng (SI 7), Tianjing (TE 10)and Yanglingquan (GB 34) were selected.

In the second step, the liver was selected as the target organ. For treatment of liver, one should work on the son-organ (heart) and mother-organ (kidney) of liver according to five-element theory, which means we selected acupoints of the Heart and Kidney Meridians at the second stage, namely Shaohai (HT 3), Qimen (LR 14),Huangshu (KI 16), Xinshu (BL 15), Ganshu (BL 18) and Shenshu (BL 23).

At the third stage, in addition to liver, removing the phlegm was stressed, and the key acupoints in this session were Zusanli (ST 36), Yinlingquan (SP 9), Pishu(BL 20, the Back-Shu point of spleen), Ganshu (BL 18,the Back-Shu point of liver), Geshu (BL 17) and Guanyuan (CV 4, the Front-Mu point of small intestine).The better effects of acupoint catgut-embedding therapy may depend on the persistent stimulation to these acupoints.

It has been mentioned that the mixed outcomes of proteolytic enzymes and macrophage reaction against the absorbable surgical thread can also enhance and amplify the acupoint stimulation for duration of 18-21 d,which is attributed to the slight inflammation in subcutaneous tissue.

One of the most important causes of fatty liver disease is stress, which partly explains why many patients with fatty liver are not overweight. Due to the tremendous effect of acupuncture treatment on stress,this group of patients lost a large percentage of their liver fat without a specific diet or weight loss. However,weight loss and abdominal circumference reduction were also positively affected in our study.

5 Conclusion

In conclusion, this report showed that acupoint catgut-embedding therapy can be applied very successfully for NAFLD patients with no harms but positively affecting patient score, fat percentage,METAVIR score, NAFLD steatosis stage, weight and abdominal circumference. Therefore, it is worth promoting clinically.

Conflict of Interest

There is no potential conflict of interest in this article.

Acknowledgments

This work was done by author and personal finances.The author would like to thank the personnel of Jivar Clinic for their help.

Statement of Informed Consent

Informed consent was obtained from each individual participant included in this study.

Author’s contribution

All the work was done by the author.

Received: 8 June 2020/Accepted: 26 November 2020