INTRODUCTION
Gastrointestinal diseases encompass various conditions, such as gastritis, enteritis, gastrointestinal bleeding, gastric ulcer, irritable bowel syndrome, functional gastrointestinal disorders, gastrointestinal cancer, and other organic and functional ailments. These diseases impact multiple systems, including metabolism, immunity, and neuroendocrine functions. With lifestyle changes and increased psychological stress in modern society, the global prevalence of gastrointestinal diseases is rising, posing a significant health concern[1]. This rise not only severely affects the physical and mental health of patients but also imposes a substantial social burden. The primary treatment modalities for these diseases include medical therapy, surgical interventions, and lifestyle modifications. However, due to the chronic and complex nature of these conditions, prolonged use of proton pump inhibitors, antibiotics, aminosalicylates, and other medications can cause disruptions in the intestinal flora and lead to hepatic and renal impairments[2-4]. Additionally, symptoms often relapse, persist, or worsen, leading to unsatisfactory treatment outcomes. While surgery can provide a rapid and visible therapeutic effect, it also involves significant risks of postoperative complications[5], stress responses[6], and challenges in perioperative rehabilitation[7], frequently encountered in clinical practice. Thus, exploring new treatment and management strategies is essential for improving the quality of life for patients suffering from gastrointestinal diseases.
Natural therapies encompass various modalities such as herbal medicine, homeopathy, acupuncture, and various physical therapies that leverage the healing properties of nature, often considered complementary and alternative with specific biological activities beneficial to humans[8]. These therapies primarily focus on regulating and restoring the homeostasis of the body’s internal environment, promoting self-repair mechanisms to treat diseases. As a prominent natural therapy, traditional Chinese medicine (TCM) boasts a unique theoretical framework and a rich history of practical application. TCM is effective in managing chronic diseases, particularly gastrointestinal disorders. It alleviates symptoms and plays a pivotal role in modulating the body’s internal environment and enhancing immune function, thereby offering a holistic treatment strategy that targets both symptoms and the root causes of conditions.
In addition to the remarkable results already achieved in the prevention and treatment of gastrointestinal medicine-related diseases such as functional dyspepsia[9], gastric ulcers[10], precancerous lesions[11], and tumor chemotherapy-related side effects[12], TCM has gradually been incorporated into the process of disease management in the perioperative, intraoperative, and postoperative phases of gastrointestinal surgery. Numerous studies are currently investigating integrating modern diagnostic and treatment technologies with TCM to develop a novel comprehensive treatment model for gastrointestinal diseases. The study published in recently by Zhou et al[13] experimentally validated the mechanisms through which the proprietary Chinese medicine Kangfuxin solution effectively mitigates esophageal stenosis caused by endoscopic submucosal dissection (ESD) by reducing excessive fibrotic repair of the esophagus post-ESD. The findings from the study revealed the scientific validity and efficacy of combining TCM with surgical gastrointestinal endoscopy in managing gastrointestinal diseases. However, TCM still encounters numerous challenges in clinical practice, including the lack of uniform treatment standards, incomplete elucidation of mechanisms of action, and difficulties in integration with modern medicine. Consequently, this paper aims to discuss the potential and challenges of TCM in the management of gastrointestinal diseases and to propose directions for future research.
THEORY AND PRACTICE OF TCM IN MANAGING GASTROINTESTINAL DISEASES
Restoration of internal environmental homeostasis is the core theory of TCM in managing gastrointestinal diseases
TCM boasts a long-standing history and a deep theoretical basis in preventing and treating gastrointestinal diseases. Central to TCM is the concept of Yin and Yang, the two fundamental forces believed to compose all phenomena. In TCM, the balance between Yin and Yang is essential for maintaining the homeostasis of the internal environment, and any imbalance may lead to disease development. Restoring this balance is thus a fundamental TCM strategy for disease prevention and treatment. Integral to this approach are several guiding theories: The Yin-yang theory, the Five Phase theory, and the concept of unity between nature and humanity. These theories are applied clinically through the concepts of qi, blood, and the functions of internal organs.
The “Five Phase” theory categorizes natural and physiological phenomena into five elements: Wood, fire, earth, gold, and water, which interact in dynamic cycles of mutual support and control to maintain equilibrium. Imbalances in qi, blood, and organ functions are addressed through these interactions. For instance, the spleen (attributed to Earth and Yang) and the stomach (related to Yin) are interconnected; the spleen distributes essential nutrients and aids the upward movement of qi, while the stomach digests food and facilitates the downward movement of qi. Imbalances between these organs can be corrected by adjusting the elements based on their productive and controlling relationships - enhancing fire to support a deficient Earth element or reducing wood to temper excessive heat in the stomach. Moreover, treating gastrointestinal disorders in TCM also considers external factors such as climate and dietary habits, emphasizing the need for harmony between internal and external environments. Ultimately, TCM utilizes the four diagnostic methods - inspection, auscultation and olfaction, inquiry, and palpation - to identify deficiencies in qi, blood, fluids, organs, and meridians. Treatments, guided by the principles of the Yin-yang and “Five Phase” theories, may include herbal medicine, acupuncture, massage, and dietary modifications to restore and maintain balance within the body and between the individual and their environment.
Clinical practice of TCM in managing gastrointestinal diseases
Long-term clinical practice under the guidance of TCM theories - specifically the Yin-yang and "Five Phase" theories - has substantiated the effectiveness of natural therapies in restoring the body’s internal homeostasis. Therapies such as herbal medicine, acupuncture, massage, cupping, scraping therapy, and dietary modifications have shown significant clinical efficacy in both the prevention and treatment of gastrointestinal diseases, as well as in enhancing patients’ quality of life. Patients favor these treatment modalities due to their simplicity, efficacy, and cost-effectiveness.
Herbal therapy: Herbal therapy utilizes various parts of plants - including roots, stems, leaves, flowers, and fruits - to address imbalances in the body’s internal environment. The properties of the herbs (hot, cold, warm, and cool) are selected to match the patient’s specific symptoms to prevent and treat diseases. For example, patients with chronic gastritis and peptic ulcers often exhibit symptoms such as pale complexion, hoarse voice, shortness of breath, fatigue, reduced appetite, loose stools, and weak pulse. These symptoms typically indicate a deficiency of qi in the spleen and stomach. The treatment of choice in such cases is Sijunzi decoction, which aims to benefit qi and strengthen the spleen. This formula includes Ginseng (Panax ginseng C.A. Meyer), Rhizoma Atractylodis Macrocephalae (Atractylodes macrocephala Koidz), Poria (Poria cocos Wolf), and Glycyrrhiza (Glycyrrhiza uralensis Fisch.), and is recognized for its good clinical efficacy.
Modern research supports that Sijunzi decoction contains compounds, such as flavonoids, saponins, and polysaccharides, which have multiple beneficial effects. These compounds can regulate the secretion of digestive juices and gastrointestinal hormones, inhibit the progression of precancerous lesions, exert anti-tumor effects[14], and maintain intestinal homeostasis. This is achieved by regulating the intestinal microbiota and protecting the integrity of the intestinal barrier. Such mechanisms make Sijunzi decoction an effective treatment for gastrointestinal conditions, such as chronic atrophic gastritis[15] and ulcerative colitis[16].
Acupuncture, moxibustion, massage, cupping, and scraping therapies: Therapies guided by TCM principles focus on regulating qi and blood, dredging meridians, and balancing Yin and Yang to restore the body’s internal homeostasis. These therapies play a crucial role in preventing and treating gastrointestinal diseases and are essential components of TCM-based management strategies for such disorders. As previously mentioned, for patients with chronic gastritis and peptic ulcers who exhibit qi deficiency in the spleen and stomach, treatments such as acupuncture, moxibustion, massage, cupping, and scraping can be effective. These treatments involve selecting acupoints that benefit qi and tonify the spleen, such as Zusanli (ST36), Sanyinjiao (SP6), Pishu (BL20), and Weishu (BL21). These modalities have demonstrated significant clinical efficacy. Modern research supports that these therapies can regulate gastric acid secretion, enhance gastrointestinal peristalsis, and increase the secretion of digestion-related hormones[17], facilitating the self-repair of the internal environment. Consequently, they improve a range of chronic gastrointestinal symptoms and restore normal gastrointestinal function.
Dietary therapy: Following TCM principles, adjustments to the diet can also regulate the body’s internal environment. In TCM, foods are categorized by their nature - cold, cool, warm, hot and their flavors - sweet, bitter, pungent, sour, salty - each corresponding to specific therapeutic effects. Targeted dietary adjustments can influence the balance of Yin and Yang, the flow of qi and blood, and organ function, thereby preventing and treating gastrointestinal diseases and enhancing the overall constitution. For patients with chronic gastritis and peptic ulcers deficient in the qi of the spleen and stomach, according to the cold-hot properties of food and herbal[18,19], sweet and warm foods such as jujube, mutton, cinnamon, and wolfberry can help tonify qi and strengthen the spleen and stomach.
Systemic mechanism of TCM in the management of gastrointestinal diseases
TCM exhibits a unique microscopic mechanism of action in preventing and treating gastrointestinal diseases through multi-target, multi-pathway system regulation, and biofeedback. This approach has seen considerable research advancements. Integrating network pharmacology, bioinformatics, multi-omics techniques[20], and topology in constructing a drug-target-disease systematic network is a prominent method. This network elucidates the targets and pathways of drug actions across various diseases, marking a significant shift in TCM from empirical practices to evidence-based medicine[21].
Research has identified that the polysaccharide, flavonoid, and saponin components in many natural medicines possess anti-inflammatory and antioxidant properties[22]. These components help mitigate the inflammatory response by scavenging free radicals, thereby reducing oxidative stress, minimizing gastrointestinal cell damage, and enhancing the immune functions of the microenvironment. For instance, salvia miltiorrhiza (Salvia miltiorrhiza Bunge) and safflower (Carthamus tinctorius L.) are known for activating blood circulation and removing blood stasis. Studies have shown that Danhong injection (a kind of Chinese patent drug) can improve gastric mucus secretion and reduce pepsin activity to maintain the integrity of gastric mucosal barrier[23]. These effects significantly improve gastrointestinal microcirculation by aiding the repair of damaged mucous membranes and alleviating inflammation-related discomfort. Moreover, Chinese herbal medicines such as Coptidis Rhizoma (Coptis chinensis Franch.), Scutellariae Radix (scutellaria baicalensis Georgi), and Honeysuckle (Lonicera japonica Thunb.) exhibit potent antibacterial properties that can suppress the proliferation of detrimental bacteria such as Helicobacter pylori, thereby improving the intestinal microecology[24]. Besides, it is worth noting that the complexity of Chinese medicinal components and targets often involves the modulation of multiple cellular signaling pathways. For example, components such as thujaplicin and luteolin can suppress the expression of pro-inflammatory cytokines, including tumor necrosis factor α and interleukin, by influencing nuclear factor kappa B, mitogen-activated protein kinase, and other signaling pathways, thereby reducing inflammatory responses[25-27]. Components such as quercetin and lignans may enhance the repair of intestinal epithelial cells by regulating apoptosis and proliferation[28]. For patients with low gastric acid production, herbs such as rheum officinale and capillary artemisia can improve gastrointestinal digestion, absorption, and metabolism by modulating the secretion of digestive juices such as gastric acid and bile.
The influence of Chinese medicine on the gut microbiota is a critical aspect in treating gastrointestinal diseases. Identifying the brain-gut-microbe axis has expanded research beyond traditional gastrointestinal physiology into a new era of interdisciplinary and multisystem integration[29,30]. This development represents a significant theoretical intersection between TCM principles and modern medical science. Modern research has demonstrated that TCM can alleviate chronic stress-induced gastrointestinal dysfunction by regulating the brain-gut-microbe axis, thereby affecting immune responses and neuroendocrine signaling in intestinal endothelial cells[31]. Additionally, TCM enhances the diversity of the intestinal flora and increases the proportion of probiotics, improving the intestinal environment, strengthening the intestinal barrier function, and boosting autoimmunity[32].
Furthermore, in the surgical treatment of gastrointestinal diseases, which typically includes diagnostic, therapeutic, and palliative procedures, the recovery of gastrointestinal function is paramount for the rapid perioperative recovery of patients. During the perioperative period, TCM has proven effective in promoting postoperative rehabilitation. For instance, Cao et al[33] conducted a prospective, multi-center, randomized, controlled study evaluating the efficacy and safety of hot compresses with Yikou-Sizi powder at the Shenque acupoint combined with rapid rehabilitation techniques in patients undergoing laparoscopic colorectal cancer surgery, yielding positive results. Postoperative acupuncture treatments have also been shown to alleviate pain in patients with gastrointestinal tumors by regulating qi and blood flow, potentially reducing the duration of postoperative intestinal obstructions and enhancing intestinal function in cancer patients[34]. Notably, as the use of digestive endoscopy in diagnosing, treating, and monitoring gastrointestinal diseases has become more prevalent, the integration of TCM with digestive endoscopy in treating these conditions is also gaining traction. Zhou et al[13] experimentally explored the mechanism of action of the proprietary Chinese medicine, Kangfuxin solution, in attenuating esophageal stenosis following ESD. The endoscopy was performed to assess esophageal repair and expression of fibrosis markers in cells 21 days after the pigs underwent whole-week ESD and Kangfuxin treatment. In vitro, their results also demonstrated that Kangfuxin treatment effectively inhibited pEsF hyperactivation through a transforming growth factor-β1/Smad2/3-dependent mechanism in the transforming growth factor-β1-induced fibrotic microenvironment, thereby regulating fibrotic function. The findings indicated that TCM could promote mucosal recovery post-surgery. For gastrointestinal diseases such as gastroesophageal reflux disease, peptic ulcer, and inflammatory bowel disease - conditions that often experience recurrent episodes and are inadequately managed with conservative internal medicine alone, a personalized TCM treatment plan, combined with precise and minimally invasive gastrointestinal endoscopy, can significantly enhance therapeutic efficacy, improve patient quality of life, and shorten the treatment duration. The above studies reflect the complementarity and synergy of TCM and modern medical technology, demonstrates the diversification and innovation direction of medical development, and promotes the optimization of gastrointestinal disease diagnosis and treatment.
CHALLENGES FACED BY TCM IN MANAGING GASTROINTESTINAL DISEASES
Standardization and quality control of TCM treatment and medicinal materials
The standardization and quality control of Chinese medicine pose significant challenges in clinical care today. Firstly, the diverse sources of TCM raw materials and variations in herb cultivation, collection, and processing can lead to inconsistencies in the quality and efficacy of the treatments. Additionally, the absence of unified standards and norms for drug testing and quality evaluation complicates the standardization of active ingredients, dosages, usage methods, and safety of Chinese medicines, affecting patient compliance and therapeutic outcomes. Establishing a comprehensive standardized quality control system, such as Good Manufacturing Practice and other quality systems, is crucial to enhance the monitoring and evaluation of Chinese medicine quality.
Secondly, while the development of diagnostic and therapeutic pathways and guidelines for treating gastrointestinal diseases with TCM has shown some success, a systematic and comprehensive evaluation system to measure the efficacy of TCM has yet to be established. This gap makes it challenging to keep pace with advancements in medical research and limits the broader adoption and application of TCM. The focus now is on standardizing, modularizing, and systematically integrating TCM with existing clinical diagnosis and treatment modes without compromising the distinct advantages of TCM’s personalized and precise approach to treatment. This integration is pivotal in refining clinical pathways and formulating diagnostic and treatment plans.
Insufficient in-depth research on mechanisms of TCM in managing gastrointestinal diseases
Despite the significant outcomes achieved by TCM in managing gastrointestinal diseases, research into its mechanisms of action remains relatively insufficient. The scientific basis and international recognition of TCM are not yet universally established. Chinese herbal medicines are often administered in compound formulas with intricate compositions, making it time-consuming and challenging to identify their active ingredients and mechanisms of action. Furthermore, the pharmacological effects of TCM compound decoctions are not merely cumulative of their components but represent a complex multi-target, multi-pathway pharmacotoxicological network. It is thus simplistic and inaccurate to deduce the action mechanisms of the overall formula solely based on the effects of individual components or TCM alone. Variations in decoction times, preparation processes, and application methods can lead to differences in the compositions, mechanisms of action, and effectiveness in disease treatment of the same drug formula.
TCM’s treatment based on syndrome differentiation mirrors the precision treatment in modern medicine and is a distinctive feature. For instance, patients diagnosed with gastritis may receive varying types and dosages of medicines within TCM formulations. Even for the same patient, the prescribed treatments can change during different stages of the disease, and the experience and prescriptions of individual practitioners vary significantly. These variations make it challenging to establish standardized and uniform diagnostic and treatment criteria, conduct large-scale clinical research, and validate evidence-based data. Similar challenges are faced in researching the mechanisms of other TCM treatments, such as acupuncture, moxibustion, and cupping, which hinder the in-depth exploration of TCM’s mechanisms in managing gastrointestinal diseases.
Challenging integration of TCM and modern medicine
Although some progress has been made in managing gastrointestinal diseases by combining Chinese and Western medicine[35,36], integrating TCM and modern medicine is a complex and challenging process. Effectively merging these two systems to form a complementary and comprehensive diagnostic and treatment program remains an urgent issue. Modern medicine focuses primarily on disease identification, emphasizing organic lesions and employing scientific theories and tools. It elucidates the causes, pathogenesis, and pathological changes of local tissues and organs through physical, biochemical, and other multifaceted testing indices, providing quantitative and qualitative data. For example, Western medicine classifies and types gastrointestinal diseases based on etiology, anatomy, and pathology, employing names such as gastroenteritis, gastric ulcer, Helicobacter pylori infection, and gastrointestinal tumors. It utilizes modern scientific and technological means to select treatments and medications, including genetic testing, molecular markers, and pathological analysis.
Conversely, TCM uses diagnostic methods, such as inspection, listening and smelling examinations, inquiry, and palpation to gather information about the patient’s symptoms, signs, and overall condition. Rooted in the basic theories of TCM and aligned with the principles of Yin and Yang and the five elements, it postulates that disorders in any part of the body can influence the gastrointestinal system. As two distinct medical systems with differing theoretical foundations, diagnostic methods, and treatment principles, the complete integration of TCM and Western medicine still has a considerable distance to traverse.
FUTURE DIRECTIONS OF TCM IN MANAGING GASTROINTESTINAL DISEASES
Strengthen the basic and evidence-based research of TCM in managing gastrointestinal diseases
With the rapid advancement of science and technology, multi-omics, artificial intelligence, bioinformatics, and network pharmacology have become powerful tools for researching TCM. These technologies aid researchers in better understanding the chemical compositions and biological activities of TCM and in revealing its mechanisms of action in treating gastrointestinal diseases[19]. They also help clarify the mutual regulation relationships between TCM therapeutic targets at the levels of human genes, proteins, and even more microscopic dimensions. For instance, Gan et al[37] provided a modern scientific interpretation of TCM therapeutic principles from the complex networks and systems perspective. They constructed a topological relationship on the network of human protein interactions based on herbal targets and symptom associations, incorporating real clinical data to validate the network medical framework, thereby proposing innovative research paradigms and directions for pharmacological studies of TCM. Moreover, it is crucial to conduct larger-scale, high-quality, multi-center, randomized controlled studies to enhance the level of evidence-based evidence for TCM. These studies are vital for validating the efficacy and safety of TCM across different populations and regions and play a significant role in improving the scientific validity, effectiveness, and reproducibility of the studies. They can also provide theoretical references for the broad application of TCM in clinical practice and the exploration and development of new drugs.
Giving full play to the unique advantages of TCM in the diagnosis and treatment of gastrointestinal diseases
The concept aligns with its principles of treating diseases before their onset, preventing the progression of existing diseases, and preventing the recurrence of diseases post-healing. This approach is consistent with the management process of gastrointestinal diseases. Combining modern medicine’s concept of three-level prevention with TCM’s theory of curing future diseases involves, firstly, prevention by analyzing the genetic information, lifestyle habits, and pathological characteristics of high-risk groups and gastrointestinal disease patients. Additionally, by incorporating evidence obtained from TCM’s four diagnostics, personalized health management profiles can be established, providing characteristic interventions of combined traditional Chinese and Western medicine to prevent diseases from arising and progressing. In terms of treatment, the holistic concept of TCM is merged with the precise diagnostic and treatment methods of modern medicine, enhancing their synergy, improving clinical efficacy, and reducing the toxic and side effects caused by Western medicine[38,39]. In the rehabilitation stage, natural therapies of TCM, such as herbal tonics, acupuncture, massage, dietary therapy, and emotional therapy, are widely used in the perioperative rehabilitation of gastrointestinal diseases and post-healing rehabilitation. These therapies regulate the balance of the patient’s internal environment and prevent disease recurrence, thereby ensuring TCM’s positive impact throughout the prevention, treatment, and rehabilitation stages of gastrointestinal disease management.
Strengthen policy support and public awareness
Policy support is crucial for the development of TCM, providing a robust foundation for its innovation and dissemination. To enhance the standardization, modernization, and internationalization of TCM in managing gastrointestinal diseases, it is necessary to establish and refine the development policy and management systems for integrating traditional Chinese and Western medicine. This approach aims to create an innovative medical model for managing gastrointestinal diseases collaboratively using TCM and Western medicine. Governments and international medical organizations should increase funding for TCM research and support policies favorable to its development, thereby promoting international research on its basic theories and clinical applications in gastrointestinal disease management. These efforts should also extend to strictly regulating the clinical diagnosis and treatment practices of integrated TCM and Western medicine. Such measures are instrumental in promoting, developing, and improving technical standards, guidelines, and quantitative evaluation systems specific to TCM’s role in gastrointestinal disease management.
Further, establishing international cooperation and exchanges with research institutions, universities, and hospitals can facilitate joint clinical trials, effectiveness evaluations, and scientific research exchanges on TCM therapies. These collaborations are essential for enhancing high-quality, evidence-based medicine evidence, which can reveal the micro-mechanisms of TCM in managing gastrointestinal diseases and aid in garnering recognition from international bodies such as the World Health Organization. Moreover, encouraging the growth and innovation of TCM enterprises, focusing on optimizing TCM-related technology and product development, and further standardizing the quality evaluation and control systems from a market perspective will elevate the overall level of the modern TCM industry[40]. Strengthening the construction of scientific research and teaching institutions, setting up international TCM education exchange programs, updating TCM research progress in real-time, and continuously improving the integrated diagnostic and treatment plans for gastrointestinal diseases are also vital. These initiatives aim to cultivate international medical talents proficient in TCM and promote modernization and internationalization.
In terms of raising public awareness, enhancing public understanding and acceptance of TCM is equally important. Activities such as public lectures, community events, and widespread publicity through TV, social media, and online platforms can effectively disseminate TCM knowledge. Publishing scientific research results, successful case studies, and actual data on TCM efficacy can improve public understanding of TCM theories and awareness of its applications in daily health management, thus creating a favorable social environment. Additionally, establishing TCM treatment centers worldwide can provide professional gastrointestinal disease treatment services, helping the public better understand TCM’s role in disease management and further promoting its internationalization.
