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Herbal Treatment of Peptic Ulcer: Guilty or Innocent

  • Al-Azhar University, Assiut, Egypt
Herbal Treatment of Peptic Ulcer:
Guilty or Innocent
Khaled A. Abdel-Sater
1,2Department of Physiology, Faculty of Medicine for Boys
1Al-Azhar University Assiut branch, Assiut
2King Abdul-Aziz University Rabigh branch, Rabigh
1. Introduction
Normally there is a balance between the protective factors (e.g. mucus, bicarbonate,
prostaglandins, nitric oxide and normal blood flow) and aggressive factors (e.g. acid plus
pepsin, active oxidants, leukotrienes, endothelins, bile or exogenous factors including
nonsteroidal anti-inflammatory drugs). Peptic ulcer develops when aggressive factors
overcome the protective mechanisms (Borrelli & Izzo, 2000). Helicobacter pylori, nonsteroidal
anti-inflammatory drugs and acid-pepsin hypersecretion are the major factors that disrupt
this equilibrium. There is other type classified as idiopathic and may be related to defective
mucosal defence mechanisms due to tobacco use, psychological stress (stress gastritis), rapid
gastric emptying or genetics (Calam & Baron, 2001).
Drug treatment of peptic ulcers is targeted at either counteracting aggressive factors or
stimulating the mucosal defences (Tepperman & Jacobson, 1994). The ideal aims of
treatment of peptic ulcer disease are to relieve pain, heal the ulcer and delay ulcer
recurrence (Borrelli & Izzo, 2000).
2. Aim of the work
The aims of this chapter are to review data about their herbs current usage by patients with
peptic ulcer, evidence for their efficacy, the mechanisms by which they might act, and,
lastly, their adverse effects on the body.
3. Herbal treatment of peptic ulcer
Tyler defines herbal medicines as “crude drugs of vegetable origin utilized for the treatment
of disease states, often of a chronic nature, or to attain or maintain a condition of improved
health (Tyler, 1994).
In spite of the progress in conventional chemistry and pharmacology in producing effective
drugs, the herbal medicine might provide a source of treatment by many people in the
world. In many cultures herbal knowledge was said to have been handed down from the
gods. Herbs had been used by all cultures throughout history because patients are often
Peptic Ulcer Disease
unaware of the potential problems caused by herbal medicines. In addition, their physicians
commonly lack knowledge about these compounds. This factor results in the perception by
physicians that herbal drugs are ineffective placebos that can simply be ignored. Some
physicians view use of these products as a threat to their paternalistic role and sternly
admonish their patients or angrily label them as being crazy (Crone & Wise, 1998).
3.1 Examples of herbs used in treatment of peptic ulcer
Solanum nigrum (family: Solanaceae) commonly known as black nightshade, deadly
nightshade, sunberry, makoy, fragrant tomato, duscle, Hound's berry , petty Morel , wonder
berry, popolo or wonder cherry. It is effective in treatment of peptic ulcers. The raw juice of
its leaves is given either separately or in conjunction with other beneficial juices (Akhtar &
Munir, 1989).
A condensed tannin, polyflavonoid tannin, catechol-type tannin non-hydrolyzable tannin or
flavolan has been isolated and their anti-peptic and anti-ulcer activity confirmed
experimentally (Vasconcelos et al., 2010). When a low concentration of tannin is applied to
the mucosa, only the outermost layer is tanned, becoming less permeable and affording an
increased protection to the subjacent layers against the action of bacteria, chemical irritation,
and, to a certain extent, against mechanical irritation. Tannins may promote a mechanic
barrier that protects the stomach from ulcer formation and facilitates ulcer healing (Borrelli
& Izzo, 2000).
Saponins (family: Sapindaceae) are so-called because of their soap-like effect, which is due
to their surfactant properties. Saponins isolated from the rhizome of panax japonicas, the
fruit of kochia scoparia (which contain approximately 20% of saponins) some oleanolic acid
oligoglycosides extracted from P. japonicas, K. scoparia and a methanol extract of P.
japonicus rhizome have been demonstrated to possess gastro-protective properties
(Matsuda et al., 1998).
Licorice or glycyrrhiza glabra (family: Leguminosae) also known as lacrisse (German),
licorice root, liquorice, reglisse (French), regolizia (Italian), suessholz, sweet licorice, sweet
wood. It is one of the most widely used medicinal plants in the world, commonly used in
European, Arabian and Asian traditional medicine systems. Licorice is very effective in the
treatment of stomach ulcers. It soothes the irritation of the inner lining of the stomach
caused due to excessive acids. Its root is taken, dried and then soaked overnight in water.
This is taken in an infusion with rice gruel. This is such an effective treatment that it is used
in conventional allopathic medicine also (Hayashi & Sudo, 2009).
Plants containing mucilages traditionally used in several countries in the treatment of
gastric ulcer include althaea officinalis (marshmallow), cetraria islandica (Iceland moss),
malva sylvestris (common mallow), matricaria chamomilla (chamomile) and aloe species
(Capasso & Grandolini, 1999). Myrrh (meaning bitter), an oleo-gum-resin obtained from
commiphora molmol, contains up to 60% gum and up to 40% resin (Newall et al., 1996).
Myrrh pre-treatment produced a dose-dependent protection against the ulcerogenic effects
of different necrotizing agents (Al-Harbi et al., 1997). The protective effect of myrrh is
attributed to its effect on mucus production or increase in nucleic acid and non-protein
sulphydryl concentration, which appears to be mediated through its free-radical scavenging,
thyroid-stimulating and prostaglandin- inducing properties. Also aloe seems to be able to
speed wound healing by improving blood circulation through the area and preventing cell
death around a wound (Borrelli & Izzo, 2000).
Herbal Treatment of Peptic Ulcer: Guilty or Innocent
3.2 Potential benefits and mechanism of action
Experimental studies have demonstrated that the herbs have gastroprotective activity
against gastric mucosal injury induced by ethanol (Souza et al., 2007), ischemia reperfusion
(El-Abhar et al., 2002), indomethacin (Souza et al., 2007), alcohol toxicity (Kanter et al., 2005)
or stress (Khaled, 2009) in rat.
The mechanism of herb-induced gastroprotection varies according to the nature and
chemical constituents of the herbs. The main functions including; inhibition of acid plus
pepsin secretion (Baggio et al ., 2007), cytoprotective (by enhancement of epidermal growth
factor content in gastric juice, nitric oxide and H+, K+-ATPase inhibitory activity in gastric
tissue, PGE2 in plasma, inhibition of endothelin in plasma, an increase in mucosal thickness
(Fan et al., 2007) and mucus content in the gastric mucosa) (Kamath et al., 2008), bactericidal
activity, inhibition of the growth and activity of helicobacter pylori (Mahady et al., 2002) and
antioxidant activities (and the ability to scavenge reactive oxygen species) (Souza et al.,
2007), isolated or in combination, are responsible for gastric mucosal protection (Zaidi, et al.,
2009). Moreover, plantextract- induced gastroprotection is probably related to the enhancing
effect on NOS inhibitor expression, gastric microcirculation (Al Mofleh, 2010). Herbs could
protect the gastric mucosa by increasing the bioavailability of arachidonic acid, resulting in
biosynthesis of the cytoprotective prostaglandins in the stomach (Tsuji et al., 1990).
Moreover, herbs have also been reported to produce a marked inhibition on the release of
leukotrienes, which cause mucosal tissue injury and hypoxemia (Mansour, 1990).
3.3 Risks of herbal treatment of peptic ulcer
It is important to acknowledge that all conventional drugs have potential toxicities.
However, in contrast to herbal products, conventional drugs undergo trials and
postapproval surveillance that define these toxicities, giving practitioners data on that to
weigh risks and benefits of treatment. The therapeutic window and dosage are also defined,
as are the constituents of the medicine. Because of rigorous quality control, each pill has the
same ingredients as another. Adverse reactions to herbal medicines are probably
underrecognized and underreported (D’Arcy et al., 1991). Herbal medicines can produce
unwanted side effects, toxicity and herbal drug interaction caused by their pharmacologic
A-Side-effects and toxicity of herbal therapy
i. Direct side-effects and toxicity of herbal therapy
Nausea, diarrhea, and skin reactions are common side effects of a wide variety of herbal
medicines (tannins, mucilages, saponins and solanum nigrum). Also there is a serious side
effects of herbal remedies on the liver (tannins and Licorice) include liver injury, acute and
chronic hepatitis, hepatic failure and possibly hepatic tumours (Chandler, 1987). While most
of the adverse effects on the digestive tube are self-limiting and relatively trivial, the same is
not true of herb-induced hepatotoxicity, in which fatalities have been reported with
alarming frequency (Chitturi & Farrell, 2000). More serious side effects of herbal medicines
may include hypertension, heart failure (licorice), anaphylaxis (matricaria chamomilla), and
lupus-like symptoms (D’Arcy et al., 1991). Ventricular arrhythmias, intravascular hemolysis,
hemorrhage, renal failure, and pulmonary hypertension have all been linked to the active
chemical components found in herbal remedies (Larrey et al., 1992). Psychoactive effects in
several herbal medicines have produced behavioural, cognitive, mania and emotional
Peptic Ulcer Disease
disturbances (Capwell, 1995). Most of these herbs are not recommended for woman with
pregnancy or breast feeding (Roulet et al., 1988).
Black nightshade is UNSAFE. It contains a toxic chemical called solanin. At higher doses, it
can cause severe poisoning. Signs of poisoning include irregular heartbeat, trouble
breathing, dizziness, drowsiness, twitching of the arms and legs, cramps, diarrhea,
paralysis, trembling, paralysis, coma, and death (Duke, 1985).
In sensitive individuals, a large intake of tannins may cause bowel irritation, kidney
irritation, liver damage, irritation of the stomach and gastrointestinal pain. A correlation has
been made between esophogeal or nasal cancer in humans and regular consumption of
certain herbs with high tannin concentrations (Lewis, 1977). Tannins interfere with iron
absorption through a complex formation with iron when it is in the gastrointestinal lumen
which decreases the bioavailability of iron. There is an important difference in the way in
which the phenolic compounds interact with different hydroxylation patterns (gallic acid,
catechin, chlorogenic acid) and the effect on iron absorption. The content of the iron-binding
galloyl groups may be the major determinant of the inhibitory effect of phenolic
compounds. However, condensed tannins do not interfere with iron absorption (Brune et
al., 1989).
Saponins are harmful if swallowed or inhaled. They cause irritation to skin, eyes and
respiratory tract. Symptoms include redness, itching, and pain. Saponin inhalation causes
sneezing and may irritate the respiratory tract. They cause haemolysis of RBC’s if reach the
blood. Frequent ingestion of small amounts of saponin results in chronic githagism (a
disease, similar to lathyrism, that results in pain, burning and prickling sensations in lower
extremities, and increasing paralysis) (Hostettmann and Marston, 2005).
Excessive consumption of licorice is known to be toxic to the cardiovascular system and
may produce oedema (van Uum, 2005). Comparative studies of pregnant women suggest
that licorice can also adversely affect both IQ and behaviour traits of offspring (De Smet,
2002). In large amounts, licorice containing glycyrrhizin can cause high blood pressure, salt
and water retention, and low potassium levels, which could lead to heart failure
(Blumenthal et al., 2000).
Mucilage side effects include bloating, abdominal pain, flatulence and oesophageal
obstruction. Matricaria chamomilla (chamomile) causes symptoms of an allergic reaction
such as rash, itching, swelling, dizziness and trouble breathing (Andres et al., 2009).
Althaea officinalis is generally regarded as safe. However, the potential for marshmallow to
cause allergic reactions or low blood sugar, genotoxicity, carcinogenicity and/or
reproductive and developmental toxicity has been noted anecdotally (Büechi et al., 2005).
Taking aloe by mouth is unsafe, especially at high doses. There is some concern that some of
the chemicals found in aloe latex might cause cancer. Additionally, aloe latex is hard on the
kidneys and could lead to serious kidney disease and even death (Poppenga, 2002).
ii. Indirect Side-Effects and Toxicity of Herbal Therapy
The use of herbal therapy may be complicated by several indirect adverse effects. People
initially consulting herbal practitioners may suffer from misdiagnosis and consequent delay
in obtaining effective conventional treatment (Angell & Kassirer, 1998). Others may delay or
forego appropriate conventional options in favour of ineffective unconventional ones. When
expectations of alternative therapy are high, failure to obtain relief from symptoms,
particularly if treatment has been expensive, could also be construed as an adverse effect
(Langmead & Rampton, 2001).
Herbal Treatment of Peptic Ulcer: Guilty or Innocent
B-Drug–herb Interactions
A pharmacodynamic interaction occurs when substances act at the same receptor, site of action
or physiologic system. Pharmacodynamic interactions result in an antagonistic or additive
drug effect (Anastasio et al., 2000). A drug or substance that accentuates or interferes with the
absorption, distribution and elimination of a second drug or substance produces a
pharmacokinetic interaction. This mechanism is the most frequent cause of adverse
interactions, commonly caused by altered drug elimination. Induction of elimination can result
in a decreased therapeutic benefit whereas inhibition of drug elimination can produce
excessively increased dose related toxicity (Nicole & Mitchell, 2003).
Saponins and mucilage can interfere with the absorption of other medicines within the gut if
they are taken at the same time (Mohammed, 2009).
Several medications may cause potentially negative drug interactions with licorice. Some of
these medications include blood pressure medications (beta blockers, calcium channel
blockers, and nervous system inhibitors), certain diuretics (such as bumetanide,
chlorothiazide, chlorthalidone, ethacrynic acid, furosemide, hydrochlorothiazide,
metolazone and torsemide), hypoglycemics and corticosteroids (D’Arcy et al., 1991). These
licorice drug interactions can result in serious problems, such as low blood potassium and
low blood calcium (Blumenthal et al., 2000). Licorice should not be taken concurrently with
corticosteroid treatment (Poppenga, 2002). Concurrent use of furosemide may potentiate
development of acute renal failure. Potassium loss due to other drugs, e.g. thiazide
diuretics, can be increased. With potassium loss, sensitivity to digitalis glycosides increases
(D’Arcy et al., 1991). Licorice should not be administered in conjunction with
spironolactone or amiloride (Poppenga, 2002).
It is mentioned in some literature sources (Barnes et al. 2002, Poppenga, 2002) that
absorption of concomitantly administered medicines can be delayed due to mucilage
protecting layer. Potential risks of chamomile include interference with warfarin and infant
botulism in very young children (Biancoa et al., 2008). Aloe may increase K + loss and
potentiate cardiac glycosides and antiarrhythmic agents such as quinidine. Increased K +
loss when used with other drugs, such as diuretics, with similar effect on K +. Laxative
effect may reduce absorption of other drugs (Poppenga, 2002).
4. Conclusion
Herbal medicine is prescribed by the herbalists symptomatically—based on signs and
symptoms alone—rather than as a result of a full understanding of the underlying disease.
Proper diagnosis is totally absent. As any plant, medicinal herbs contain many chemicals
that are subjected to change with changing conditions of the environment, especially
storage. The discriminate and proper use of some herbal products is safe and may provide
some therapeutic benefits, but the indiscriminate or excessive use of herbs can be unsafe and
even dangerous (Borrelli & Izzo, 2000).
There is an urgent need for further scientific assessment of the potential benefits and
dangers of the huge range of herbal medications available. Herbal preparations used for
medicinal purposes should require licensing by an independent national body in order to
improve their quality and safety, and to ensure that claims of efficacy are validated by
randomized controlled trials.
The general public, as well as pharmacists, general practitioners and hospital doctors,
should be aware, particularly, of the risks associated with the use of herbal remedies,
Peptic Ulcer Disease
whether on their own or in combination with other herbal or conventional medicines. The
incorporation of a short course on alternative and complementary therapy in medical school
curricula would help achieve this end.
Lastly, because of the potential for side effects, toxic reactions, and unwanted drug-drug
interactions, it is essential for physicians to ascertain if their patients are taking herbal
medications. So if you are thinking about using herbal medicine it would be a good idea to
check with your physician about possible adverse reactions and interactions with
medications you may be taking before starting (D’Arcy et al., 1991).
IF YOU NEED ONE WORD “Do not take herbs internally except under the supervision of a
qualified professional”.
Herbs you're guilty until proven innocent by researchers!
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The aim of this study was to assess the effects of hypothyroidism on the development of acute cold restraint stress gastritis in rats and protective effect of Nigella sativa at the beginning of the acute cold restraint stress. 60 rats were randomly divided into six groups; the control (groups I), surgically thyroidectomized group (group II), acute cold restraint stressed group (group III), surgically thyroidectomized plus stressed group (group IV), Nigella sativa oil group (group V) and surgically thyroidectomized plus stressed plus Nigella sativa oil group (group VI). Volume of gastric juice, number and size of ulcer, gastric malonaldehyde, gastric glutathione, gastric protein and serum thyroxine (T4) were measured. Significant increases both of number of gastric ulcer and malonaldehyde while decreases both of glutathione and protein levels in rats in groups III and IV in comparison with control group. While, insignificant increase were observed between control and both of groups II and VI. In rats, low thyroid hormone level increase stress gastritis, and this effect can be decreased by treatment with Nigella sativa.
Negli ultimi anni la fitoterapia si è arricchita di un certo numero di prodotti vegetali che in commercio possono trovarsi come specialità medicinali, farmaci da banco, prodotti galenici o semplicemente come prodotti erboristici. L’intento di questo aggiornamento della seconda edizione di Fitofarmacia è quello di mettere a disposizione di medici, farmacisti ed erboristi, nonchè agli studenti uno strumento moderno, ma anche semplice, che possa fornire informazioni essenziali e scientificamente provate sul corretto impiego dei prodotti fitoterapici.La nuova edizione risulta notevolmente ampliata in tutte le sue parti, sia per la stesura di nuovi capitoli e appendici, sia per il rifacimento di alcuni capitoli che richiedevano un aggiornamento ed una trattazione più approfondita; include inoltre numerose figure di piante medicinali e schemi che sintetizzano in modo semplice, ma nel contempo esauriente, i meccanismi d’azione di numerose droghe vegetali, riassumendo così in chiave moderna, alla luce dei progressi realizzati nel campo della farmacologia, antichi concetti di fitoterapia.
Licorice is the root and stolon of the Glycyrrhiza plant, which belongs to the family Leguminosae. The licorice plant is an important medicinal herb, and the constituent-glycyrrhizin-is widely used as a natural sweetener and also as a pharmaceutical agent because of its anti-inflammatory and hepatoprotective properties. Licorice is also an indispensable ingredient of traditional Japanese Kampo medicines. Furthermore, licorice extracts are used as cosmetics, food additives, tobacco flavors, and confectionery foods. In this article, we review the importance of licorice and its related products.
A Practical, Authoritative CompendiumThis handbook catalogs 365 species of herbs having medicinal or folk medicinal uses, presenting whatever useful information has been documented on their toxicity and utility in humans and ani-mals. Plants from all over the world - from common cultivars to rare species - are included in these 700 pages. The toxicity of these species varies, but the safety of each has been formally or informally questioned by the Food and Drug Administration, National Cancer Institute, Department of Agriculture, Drug Enforcement Administra-tion, or Herb Trade Association. Easy-to-Locate Facts and FiguresDesigned to enable fast access to important information, this hand-book presents information in both catalog and tabular forms. In the catalog section, plants are presented alphabetically by scientific name. (The index permits you to locate an herb by its common name.) A detailed sketch of the chief identifying features accompa-nies most catalog entries. For each species the following information, as available, is presented and referenced: Family and colloquial namesChemical contentUses and applications - present and historicalProcessing, distribution, and economic potentialToxicological agents and degree of toxicityPoison symptoms in humans and animalsTreatment and antidotes References to original literature Five Tables of Accessible DataGiven a plant species, you can easily determine its toxins; or, given a toxin, you can discover which plants contain it. These and other data are presented in convenient tabular formats as appendixes to the handbook. Other information contained in these tables include toxicity ranking and other toxicity data (as applicable), such as mode of contact, organs affected, and lethal dose; and proximate analyses of selected foods. These tables are titled: Medicinal Herbs: Toxicity Ranking and PricelistToxins: Their Toxicity and Distribution in Plant GeneraHigh Plant Genera and Their ToxinsPharmacologically Active PhytochemicalsProximate Analyses of Conventional Plant Foods
Interaction between foods and drugs can have profound influence on the success of drug treatment and on the side effect profiles of many drugs. The clinical significance of drug-food interactions can be variable. Drug-food interactions can lead to a loss of therapeutic efficacy or toxic effects of drug therapy. Generally, the effect of food on drugs results in a reduction in the drug's bioavailability; however, food can also alter drug clearance. Some foods greatly affect drug therapy, resulting in serious side effects, toxicity, or therapeutic failure. In some instances, the interaction may have a beneficial effect by increasing drug efficacy or diminishing potential side effects. Pharmacists in every practice setting need to be vigilant in monitoring for potential drug-food interactions and advising patients regarding foods or beverages to avoid when taking certain medications. It is imperative for pharmacists to keep up-to-date on potential drug-food interactions of medications, especially today's new drugs, so that they may counsel properly to the patients.
Previous studies have indicated a pivotal role of reactive oxygen species in the pathomechanism of gastric ulcer. Recent studies demonstrated that thymoquinone (TQ) had an antioxidant effect on injuries caused by various toxic agents in different experimental models. The present study was planned to test whether TQ, the main constituent of the volatile oil of Nigella sativa seeds, was capable to exert beneficial effects on acute gastric ulcer model in rats. We examined antiulcerative and antioxidant effects of TQ on ethanol (EtOH)-induced gastric lesions in rats. The data we collected showed that gastric ulcer caused by absolute EtOH induction resulted in an increase in lipid peroxidation, represented by malondialdehyde level as well as by superoxide dismutase level, an antioxidant enzyme, whereas it resulted in a decrease in glutathione content in rat stomach tissue. Thymoquinone (20 mg/kg) administration reduced the ulcer index and the malondialdehyde level, and reversed the glutathione depletion. However, it did not statistically change the high superoxide dismutase activity induced by EtOH. These results suggest that TQ could inhibit the development of EtOH-induced gastric ulcer, and gastroprotective action of TQ might be in part dependent on its antioxidant property.
Mouriri pusa, popularly known as "manapuçá" or "jaboticaba do mato", is a plant from Brazilian cerrado that has been found to be commonly used in the treatment of gastrointestinal disturbs in its native region. The present work was carried out to investigate the effect of tannins (TF) and flavonoids (FF) fractions from Mouriri pusa leaves methanolic extract on the prevention and cicatrisation process of gastric ulcers, and also evaluate possible toxic effects. The following protocols were taken in rats: acute assay, in which ulcers were induced by oral ethanol after pre-treatment with the fractions; and 14 days treatment assay, in which ulcers were treated for 14 days after induction by local injection of acetic acid. In the acute model, treatment with either, TF (25mg/kg) or FF (50mg/kg), was able to reduce lesion area, showing gastroprotective effect. In addition, FF proved itself anti-inflammatory by reducing COX-2 levels. In acetic acid model, both fractions exhibited larger ulcers' regenerative mucosa, indicating cicatrisation enhancement. FF group also showed augmented cell proliferation, anti-inflammatory action and enhanced angiogenesis as well as increased mucus secretion. Moreover, concerning the toxicity parameters analyzed, no alteration in the fractions groups was observed. Tannins and flavonoids from Mouriri pusa provide beneficial effects against gastric ulcers with relative safety.
Spices and herbal remedies have been used since ancient times to treat a variety of disorders. It has been experimentally demonstrated that spices, herbs, and their extracts possess antimicrobial, anti-inflammatory, antirheumatic, lipid-lowering, hepatoprotective, nephroprotective, antimutagenic and anticancer activities, besides their gastroprotective and anti-ulcer activities. Despite a number of reports on the toxicity of herbs and spices, they are generally accepted as safer alternatives to conventional therapy against gastric ulcers. To this end, it is also believed, that excessive consumption of spices may favor the pathogenesis of gastric and duodenal ulcer and some studies have substantiated this common perception. Based on various in vivo experiments and clinical studies, on the effects of spices and herbs on gastric ulcers, it has indeed been shown that certain spices do possess remarkable anti-ulcer properties mediated by antisecretory, cytoprotective, antioxidant, and anti-Helicobacter pylori effects and mechanisms regulated by nitric oxide, prostaglandins, non-protein sulfhydryl molecules and epidermal growth factor expression. Accordingly, their consumption may attenuate and help prevent peptic ulcer disease. In the present review, the beneficial effects of spices and herbal nutritive components on the gastric mucosa are discussed against the paradigm of their deleterious potential.