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Herbal medicines offer many potential ways to help people with gastroesophageal reflux disease (GERD), including by treating the underlying transient lower esophageal sphincter relaxations (TLESR), helping relieve symptoms, and reducing inflammation. Fumaria officinalis (fumitory-of-the-wall) and Chelidonium majus (celandine) are two among many cholagogues that empirically seem to be helpful. Another cholagogue, Artemisia asiatica (Asian wormwood), has been shown experimentally to reduce GERDrelated symptoms. Atropa belladonna (belladonna, deadly nightshade) and other anticholinergics may also correct TLESR. Demulcents, such as alginic acid, Ceratonia siliqua (carob), Ulmus rubra (slippery elm), Althaea officinalis (marshmallow), and Aloe vera (aloe) leaf gel can reduce acute symptoms and heal acid-damaged tissues. Inflammation modulators, such as deglycyrrhizinated licorice, Calendula officinalis (calendula), Curcuma longa (turmeric), Zingiber officinale (ginger), Rosmarinus officinalis (rosemary), and Symphytum officinale (comfrey) may also help with tissue repair and symptom control. Herbal medicine has much to offer patients with GERD but more clinical research is needed.
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Herbal medicines offer many potential ways to help people with
gastroesophageal reflux disease (GERD), including by treating
the underlying transient lower esophageal sphincter relaxations
(TLESR), helping relieve symptoms, and reducing inflammation.
Fumaria officinalis (fumitory-of-the-wall) and Chelidonium ma-
jus (celandine) are two among many cholagogues that empirically
seem to be helpful. Another cholagogue, Artemisia asiatica (Asian
wormwood), has been shown experimentally to reduce GERD-
related symptoms.
Atropa belladonna (belladonna, deadly nightshade) and other
anticholinergics may also correct TLESR. Demulcents, such as
alginic acid, Ceratonia siliqua (carob), Ulmus rubra (slippery elm),
Althaea officinalis (marshmallow), and Aloe vera (aloe) leaf gel
can reduce acute symptoms and heal acid-damaged tissues.
Inflammation modulators, such as deglycyrrhizinated lic-
orice, Calendula officinalis (calendula), Curcuma longa (tur-
meric), Zingiber officinale (ginger), Rosmarinus officinalis
(rosemary), and Symphytum officinale (comfrey) may also help
with tissue repair and symptom control. Herbal medicine has
much to offer patients with GERD but more clinical research
is needed.
Gastroesophageal reflux disease (GERD) encompasses two
conditions, nonerosive reflux and erosive esophagitis. Although,
historically, erosive esophagitis was considered an inevitable
consequence of nonerosive reflux, there is now fairly substantial
evidence that the two are distinct conditions and progression
from nonerosive reflux to erosive reflux to Barrett’s esophagus is
uncommon even without treatment.1 It was also once thought
that Barrett’s esophagus (or metaplastic transformation of the
esophageal lining into a type more similar to gastric epithelium)
ultimately transmuted into esophageal cancer. This outcome of
GERD in fact seems to be quite rare or represents a complete-
ly different disease that just happens to occur simultaneously
with GERD.2
Because the consequences of GERD are not as dire as once
thought, there is simply much less need to suppress gastric
acid completely. This, however, is the conventional treatment
for GERD, questionable though it is. Presently, proton-pump
inhibitors are the third most prescribed drugs in the United States,
generating more than $13 billion in sales each year.3
The negative effects of long-term acid suppression as a
treatment for GERD include increased risk of pneumonia, os-
teoporotic bone fracture, micronutrient malabsorption, gastric
and small-intestinal bacterial overgrowth, esophageal candidi-
asis, and food allergy.4–7 Moreover, it is well-documented that
acid-suppressing drugs do not fix the underlying problems in
GERD. When these drugs are withdrawn, symptoms almost
always return.8 This is an area where alternative, natural ap-
proaches can produce superior results if the focus is on ad-
dressing the causes of GERD and managing the symptoms
with more benign botanical agents. This article reviews the use
of those botanicals.
The major pathophysiologic defect underlying GERD is
known as transient lower esophageal sphincter relaxations
(TLESR).9 Normally the lower esophageal sphincter (LES)
relaxes only during swallowing, but, in GERD, the LES re-
laxes inappropriately, albeit temporarily, at other times of the
day and night. Many factors are believed to contribute to
TLESR, including obesity, hiatal hernia, overeating, lying
down after eating, wearing tight clothing around the mid-
section, and smoking.4 Increasingly, medications that relax
or otherwise affect the LES also play a role, including an-
tihistamines, narcotic analgesics, calcium-channel blockers,
and bronchodilators.10
Often, patients who make dietary and lifestyle changes, in-
cluding elimination of likely causative agents, can eliminate
GERD symptoms. However, from a practical point of view,
many patients will not be able to make or sustain those changes
and will continue to experience symptoms. Herbal medicines
should then be added to help correct TLESR.
Herbs for Gastroesophageal
Reux Disease
Eric Yarnell, ND
and Kathy Abascal BS, JD, RH (AHG)
16.6ACT_pages.indd 344 12/15/10 3:20:19 PM
While treating 2 patients for gallbladder symptoms, one of
the authors (Dr. Yarnell) observed that cholagogue botanicals
also reduced and seemed to resolve these patients’ GERD
symptoms.* Cholagogues are herbs traditionally used to regu-
late gallbladder tone and activity; most notable for this activity
are Fumaria officinalis (fumitory-of-the-wall, fumitory) herb
and Chelidonium majus (celandine) herb.
No clinical work appears to have been published on the use
of these herbs for addressing GERD, but, logically, as these
herbs relax smooth muscle in the gallbladder, they might well
have a similar effect on smooth muscle in the LES. At least one
study has shown that the cholagogue herb Artemisia asiatica
(Asian wormwood), combined with the antiacid drug omepra-
zole, offset symptoms of reflux esophagitis and prevented its
occurrence in rats.11
Celandine is a potent herb that should only be used un-
der the care of a practitioner skilled in its use. There are
isolated reports of hepatotoxicity associated with celandine
use, but this problem has not yet definitively proven to be
caused by the herb.12,13 Because there are so few reports,
it is possible that the reported reactions were idiosyncratic
(meaning that this effect only occurs in a small fraction of
the population who are somehow susceptible and that there
is no inherent propensity of the herb to damage the liver).
Some preclinical work suggests that celandine can actually
be hepatoprotective.14,15
Anticholinergic Herbs
Atropa belladonna (belladonna, deadly nightshade) leaf and
root contain alkaloids that act as muscarinic receptor antago-
nists. This anticholinergic herb, and in particular atropine, has
been shown to decrease TLESR despite overall relaxation of
the LES, with a net reduction in reflux episodes in human tri-
als.16,17 The action of atropine is apparently in the brainstem
as opposed to a local action in the LES.18
Purified atropine tends to cause more adverse effects than
the whole herb, and, as a result, only whole-plant extracts are
recommended for people with GERD. A typical dose of a 1:5
tincture of belladonna leaf is 8–10 drops with each meal. Mild
dry mouth may occur but is not a reason to modify dosing. In
contrast, blurred vision or confusion that develops after taking
the herb can be signs of overdose. If these symptoms occur, the
herb should be withdrawn until the symptoms resolve. It can
then be readministered at half the prior dose.
Demulcent herbs and herbal compounds are frequently
used to offset symptoms in patients with reflux. These rem-
edies are particularly attractive because of their extremely low
toxicity. They are also safe and fairly well-studied, even in in-
fants with reflux. Demulcents are believed to help because they
reduce inflammation and form a temporary protective barrier
against inflammation.
The algal polysaccharide known as alginic acid, combined
with antacids, has been confirmed to relieve reflux symptoms
and esophagitis in infants and children. The dose used was 1–2
mL/kg per day.19
Ceratonia siliqua (carob) pod powder is a flavorful demul-
cent with a taste reminiscent of chocolate. Its pods grow on a
tree in the Fabaceae family. Carob is frequently administered
mixed with applesauce. One study found a combination of
carob, alginic acid, and antacids helpful and completely safe
for relieving GERD symptoms in adults.20 Carob (350 mg)
mixed with cow’s milk has repeatedly helped reduce reflux in
infants.21,22 However, in the authors’ opinion, cow’s milk is
not optimal for most infants, and a better practice would be
to add carob to other bases such as applesauce, breast milk,
or rice gruel.
*is information was derived from notes used in Dr. Yarnell’s medi-
cal practice.
Atropa belladonna (belladonna, deadly nightshade). Drawing © 2010 by
Kathy Abascal, BS, JD, RH (AHG).
Calendula officinalis (calendula).
16.6ACT_pages.indd 345 12/15/10 3:20:28 PM
Other common demulcents used to treat GERD are Ul-
mus rubra (slippery elm) bark, Althaea officinalis (marshmal-
low) leaf and root, and Aloe vera (aloe) leaf gel. Slippery elm
and marshmallow are generally made into cold infusions, or
powder is added to water to make a gruel. The usual adult
dose is 5–10 g with each meal. Because of the progressive
destruction of slippery elm by Dutch elm disease, marsh-
mallow or aloe gel may be the best choices from an eco-
logic perspective. The usual dose of aloe gel is 1–3 oz with
each meal.
Inammation Modulators
Patients with erosive esophagitis also frequently benefit
from the addition of herbs that decrease inflammation and
promote healing. All the demulcents mentioned above fit
this bill, as do a host of other herbs. There is surprisingly
little research on these herbs, despite the fact that they are
such obvious choices. Only Glycyrrhiza glabra (licorice) root
has been established to be helpful, in its deglycyrrhizinated
form.23 However, Calendula officinalis (calendula) flower,
Curcuma longa (turmeric) rhizome, Zingiber officinale (gin-
ger) rhizome, Rosmarinus officinalis (rosemary) leaf, Symphy-
tum officinale (comfrey) leaf, and many other herbs will prob-
ably prove to be equally efficacious.
A multifaceted herbal approach can help both treat un-
derlying causes of GERD as well as managing symptoms,
helping many patients reduce or avoid long-term use of an-
tiacid drugs. Cholagogues and anticholinergics may help re-
duce or eliminate TLESR, the base abnormalities in GERD
patients, especially if these herbs combined with lifestyle
changes. Demulcents and inflammation-modulators can
help relieve acute symptoms and heal damaged tissues.
These approaches need to be studied better to determine
optimal doses and specific herbs, and to clarify when and if
antiacid drugs are needed in conjunction with herbs. In the
meantime, there is a significant ability—and opportunity—
to improve the status of patients with GERD through the
use of botanical medicines. n
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increases the risk of acute gastroenteritis and community-acquired pneumonia
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induced by greater celandine (Chelidonium majus). Acta Gastroenterol Belg
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(Chelidonium majus). Scand J Gastroenterol 2003;38:565–568.
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experimental hepatic tissue injury. Phytother Res 1996;10:354-356.
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gastro-oesophageal reflux and transient lower oesophageal sphincter relax-
ations in patients with gastro-oesophageal reflux disease. Gut 1998;43:12–16.
17. Mittal RK, Holloway R, Dent J. Effect of atropine on the frequency of
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alginate in the treatment of regurgitation in infants [in French]. Ann Pediatr
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20. Greally P, Hampton FJ, MacFadyen UM, Simpson H. Gaviscon and Car-
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Eric Yarnell, ND, is chief medical officer of Northwest Naturopathic Urology,
in Seattle, Washington, and is a faculty member at Bastyr University in Ken-
more, Washington. Kathy Abascal, BS, JD, RH (AHG), is executive director
of the Botanical Medicine Academy in Vashon, Washington.
To order reprints of this article, e-mail Karen Ballen at:
or call (914) 740-2100.
16.6ACT_pages.indd 346 12/15/10 3:20:31 PM
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... In a separate animal study, Chinese honeysuckle (Lonicerae flos) extract demonstrated dosedependent attenuation of acute esophagitis following foregut ligation in rats, but again, it is difficult to extrapolate these findings clinically [51]. Belladonna, the plant from which atropine was derived, is sometimes used as a tincture by naturopathic practitioners to treat GERD [52]. While there is experimental evidence to suggest that atropine might reduce reflux burden by inhibiting transient relaxations of the lower esophageal sphincter, the botanical extract has not been studied and is certainly associated with the risk of anticholinergic side effects [53]. ...
... Honey has been posited as a potential reflux remedy as well on the basis of previously demonstrated antioxidant effects as well as its native properties of viscosity and density that lead to prolonged mucosal contact, but these presumptive mechanisms remain speculative [54]. Anecdotal reports suggest benefit with a wide range of other herbal products, including individual components of the compound preparations discussed above (e.g., chamomile and angelica root) and others (e.g., ginger root, marshmallow root, rosemary leaf, turmeric, and aloe), though to our knowledge, the use of these particular botanical interventions for reflux remains formally unstudied [52,55]. ...
Full-text available
Purpose of Review Popular remedies are of ongoing interest to patients experiencing common esophageal symptoms, particularly as typical pharmacologic interventions have been subject to increased scrutiny. Herein we summarize the available data regarding potential risks and benefits of several such remedies. Recent Findings With emphasis on reflux and non-cardiac chest pain, research is ongoing into the clinical utility and diverse physiologic mechanisms underlying a variety of complementary and alternative modalities, including dietary manipulation, apple cider vinegar, melatonin, acupuncture, and various herbal products (rikkunshito, STW 5, slippery elm, licorice, and peppermint oil, among others). Summary A substantial gap persists between anecdotal and empirical understandings of the majority of non-pharmacologic remedies for esophageal symptoms. This landscape of popular treatments nevertheless raises several interesting mechanistic hypotheses and compelling opportunities for future research.
... On the other hand, studies in mice demonstrated that E. dysenterica leaf extract protected the gastric mucosa against lesions induced by ethanol and chloric acid by inhibiting the production of chloric acid and presenting antioxidant properties and endogenous sulphydryl (SH)-containing compounds, which induce the elimination of free radicals. In addition, synergism can exist between antioxidant properties and SH-bearing molecules, as the extract can increase the bioavailability of endogenous SH groups [81]. ...
Full-text available
The fruit and leaves of Eugenia dysenterica DC., locally known as cagaita, are rich in antioxidant glycosylated quercetin derivatives and phenolic compounds that have beneficial effects on diabetes mellitus, hypertension and general inflammation. We conducted a literature search to investigate the nutraceutical potentials of these phenolic compounds for treating obesity, diabetes mellitus and intestinal inflammatory disease. The phenolic compounds in E. dysenterica have demonstrated effects on carbohydrate metabolism, which can prevent the development of these chronic diseases and reduce LDL (low-density lipoprotein) cholesterol and hypertension. E. dysenterica also improves intestinal motility and microbiota and protects gastric mucosa, thereby preventing inflammation. However, studies are necessary to identify the mechanism by which E. dysenterica nutraceutical compounds act on such pathological processes to support future research.
... Besides conventional intervention, complementary and alternative medicine (CAM) has introduced many approaches for this disorder (8). As well, new investigations have introduced various methods such as natural approaches, lifestyle modification, and herbal medicine for the management of GERD symptoms (9)(10)(11). The traditional Persian medicine (TPM), which dates back to thousands of years ago, consists of the assemblage of whole knowledge applied in diagnosis, prevention, and treatment of diseases in Iran from ancient times until now (12)(13)(14)(15)(16)(17)(18). ...
Full-text available
Background: Gastro-esophageal reflux disease (GERD) is one of the most widespread gastrointestinal disorders. In addition, there is increasing evidence that not all patients respond to its current remedies. Objectives: The aim of this pilot study was to investigate the effect of “Satureja hortensis L.” on improving the symptoms of mild to moderate GERD in adults. Methods: In this double-blind, randomized, controlled, clinical trial, we evaluated the efficacy of “Satureja hortensis L.” compared to placebo in the symptoms of GERD in fifty-eight adultswith GERD who referred to Hazrat Rasool-e-Akram hospital in Tehran, Iran, in 2015. In order to assess GERD symptoms, a standardized questionnaire of frequency scale (FSSG) was used before and after the intervention. Results: Regarding within-group changes, a significant decrease was observed in FSSG, dysmotility-like symptoms and acid reflux related scores in both groups of the study after the intervention compared to baseline (P < 0.001). Regarding between-group analysis, no significant differences were observed between the two groups in terms of FSSG total scores (0.05 < P). Conclusions: According to the results of the current study, Satureja hortensis L. with the dose of 500mgthree times per day failed to improve the symptoms of GERD in adults compared to placebo. The significant reductions in the GERD scores in both groups seem to be related to the lifestyle modification that was prescribed to both groups.
... Usually, lesions are induced in the antrum or Studies of aloe vera in rats have therefore focused on glandular lesions. However, aloe vera has also been used to treat other ulcerative lesions of the gastrointestinal tract, including oral ulcers [31,32], radiation-induced mucositis [33] and gastroesophageal reflux disease [34]. ...
Background: Anecdotally, aloe vera is used to treat gastric ulceration, although no studies have yet investigated its efficacy in horses. Objectives: To test the hypothesis that aloe vera would be non-inferior to omeprazole for the treatment of equine gastric ulcer syndrome (EGUS). Study design: Randomised, blinded clinical trial. Methods: Forty horses with grade ≥2 lesions of the squamous and/or glandular mucosa were randomly assigned to one of 2 groups. Horses received either aloe vera inner leaf gel (17.6 mg/kg bwt) twice daily or omeprazole (4 mg/kg) once daily for approximately 28 days, after which a repeat gastroscopic examination was performed to determine disease resolution. Horses with persistent lesions were offered a further 28 days of treatment with omeprazole (4 mg/kg bwt once daily) and were re-examined on completion of treatment. Results: Efficacy analyses were based on 39 horses that completed the trial. Equine squamous gastric disease (ESGD) was observed in 38 horses and improvement and healing rates were 56% and 17% respectively for aloe vera and 85% and 75% respectively for omeprazole. Healing was less likely to occur in horses with prolonged gastric emptying. Equine glandular gastric disease (EGGD) was less common than ESGD (n = 14) and numbers were too small to perform meaningful statistical analyses. The hypothesis that aloe vera would be non-inferior to omeprazole was not supported. Main limitations: No placebo control group was included. Limited numbers to be able to comment on efficacy of aloe vera for treatment of EGGD. Conclusions: Treatment with aloe vera was inferior to treatment with omeprazole. This article is protected by copyright. All rights reserved.
... 17 We have previously written about fumitory as an herb incidentally noted to address gastroesophageal reflux (GERD) in patients simultaneously being treated for gallbladder dysfunction. 18 A relative from India, F. indica (pitpapra) has been shown to be a calcium-channel blocking spasmolytic and a spasmogenic agent in atropinized guinea pig ileum. 19 This tends to confirm the amphoteric nature of fumitory on the gallbladder and indicate that the mechanism of action is not a simple spasmolytic action. ...
It is essential to be aware of the advances in the nutritional aspects of cancer for oncology practitioners. Unlike the popular myth, the term “Cachexia” more effectively defines the present status in oncology patients rather than “cancer-related malnutrition” (CRM). The consensus guidelines recommend the usage of management algorithm, staging of the CRM involving screening for the nutritional risk and also devising a management strategy consistent with a phenotype and the staging. There should be an inclusion of preventive measures for the CRM in the management algorithm like pharmacological and non-pharmacological interventions aiming both anabolic and the anti-catabolic measures as well as repeated checking of the status of Nutrition. At present, the multimodal mechanism is the optimum method to battle catabolic resulting in CRM. This method should be simultaneously given with anticancer treatments and involve pharmaconutrients, nutritional intervention and the multiple target drug treatments and physical activity. This article provides the practitioners with an awareness of the recent development in the area of nutritional care and as well as defined guidelines to regulate cancer therapy during treatment. This book chapter thus gives insightful guidelines pointing on crucial aspects of Nutrition for cancer treatment.
Since the 1960s, laryngopharyngeal reflux (LPR) has been hypothesized as reflux of gastric contents through the upper and lower esophageal sphincter (LES) into the larynx and pharynx (Francis and Vaezi, Clin Gastroenterol Hepatol, 13:1560–1566, 2015). A lax LES or increased pressure through a normal LES has often been considered a factor in LPR, resulting in reflux of acidic or nonacidic nature. Concurrent gastroesophageal reflux disease (GERD) is usually not present. This was first noted by Koufman with 81% of pH-documented LPR patients showing normal esophagoscopy (Koufman, Laryngoscope, 101:1–78, 1991). General symptoms of LPR include hoarseness of the voice, sore throat, chronic cough, globus sensation, dysphagia, sinusitis, and symptoms of asthma. LPR diagnosis via laryngoscopy is subjective and controversial at best with concern for overdiagnosis. Based on its assumed etiology, LPR treatment is based largely on the same standard of care used for GERD with very little in the way of prevention or LPR-specific treatments.
Full-text available
Proton pump inhibitors (PPIs) can cause diarrhea, enteric infections, and alter the gastrointestinal bacterial population by suppressing the gastric acid barrier. Among patients that received long term PPI treatment, we evaluated the incidence of small intestinal bacterial overgrowth (SIBO; assessed by glucose hydrogen breath test [GHBT]), the risk factors for development of PPI-related SIBO and its clinical manifestations, and the eradication rate of SIBO after treatment with rifaximin. GHBTs were given to 450 consecutive patients (200 with gastroesophageal reflux disease who received PPIs for a median of 36 months; 200 with irritable bowel syndrome [IBS], in absence of PPI treatment for at least 3 years; and 50 healthy control subjects that had not received PPI for at least 10 years). Each subject was given a symptoms questionnaire. SIBO was detected in 50% of patients using PPIs, 24.5% of patients with IBS, and 6% of healthy control subjects; there was a statistically significant difference between patients using PPIs and those with IBS or healthy control subjects (P < .001). The prevalence of SIBO increased after 1 year of treatment with PPI. The eradication rate of SIBO was 87% in the PPI group and 91% in the IBS group. SIBO, assessed by GHBT, occurs significantly more frequently among long term PPI users than patients with IBS or control subjects. High dose therapy with rifaximin eradicated 87%-91% of cases of SIBO in patients who continued PPI therapy.
The eagerly anticipated second edition of this popular textbook has finally arrived, with copious updates and additional insights based on Dr. Yarnell's extensive clinical practice, teaching experiences, and delineation of advances in medical research over the past ten years. Students of any medical orientation studying gastroenterology for the first time will find this new edition gives them a superior advantage in approaching this complicated system. The comprehensive material provided for each area gives the reader an in-depth understanding of how the gastrointestinal system works and how to approach its many complexities and pathologies from a holistic and integrated perspective. Practitioners looking for rapid review, quick reminders, or new tips also find much that benefits them in Natural Approach to Gastroenterology 2nd edition. Natural and conventional information are included. Its ease of use, strong organization, clear writing, clinical usefulness, and many research references will provide the busy clinician with an invaluable resource. Rich in diagrams, algorithms, tables, and extensively indexed for rapid access of material, the book is appropriate in the clinic or the classroom.
A staggering 113.4 million prescriptions for proton pump inhibitors (PPIs) are filled each year, making this class of drugs, at $13.9 billion in sales, the third highest seller in the United States.1 These medications are effective for treatment of erosive and ulcerative esophagitis, Barrett esophagus, Zollinger-Ellison syndrome, and gastroesophageal reflux disease (GERD), as well as for short-term treatment of ulcer disease, as part of a combination regimen for Helicobacter pylori eradication and for prevention of ulcers due to nonsteroidal anti-inflammatory drugs.2 However, these indications do not account for more than a hundred million prescriptions. So it should come as no surprise that PPIs have been shown to be overprescribed3; between 53% and 69% of PPI prescriptions are for inappropriate indications.2,4,5
Abstract The efficacy of an alcohol extract of Chelidonium majus as an antihepatotoxic agent was tested on rats with CC14-induced hepatic injury. CCl4 (1 ml/kg; twice a week) and extract (125 mg/kg/day) were administered simultaneously. The parameters studied to assess liver damage were. plasma ALAT, ASAT. AIP, LDH, bilirubin, cholesterol and liver histology. Significant protection toward CC14-induced elevation of plasma enzymes, changes in bilirubin, cholesterol. and microscopic liver damage was observed. These results indicate the hepatoprotective action of the extract.
Hepatic tissue recovery in albino rat, after 3 weeks simultaneous administration of carbon tetrachloride (1 mL/kg b.wt) with different doses of Chelidonium majus was studied. Fibrotic change was prevented with both doses, while near normal tissue condition with microsteatosis and few necrotic cells was noted with the high dose.
Gastro-oesophageal reflux disease (GORD) - reflux of stomach contents +/- bile into the oesophagus causing symptoms such as heartburn and acid reflux - is a common relapsing and remitting disease which often requires long-term maintenance therapy. Patients with GORD may have oesophagitis (inflammation of the oesophagus) or a normal endoscopy (endoscopy negative reflux disease or ENRD). To assess the effects of continuous maintenance therapy in adults with GORD (both ENRD and healed oesophagitis). We searched Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 2, 2003), MEDLINE (1966 to 2003), EMBASE (1980 to 2003), CINAHL (1982-2003), and the National Research Register (Issue 2, 2003) and reference lists of articles. We also contacted manufacturers and researchers in the field. Randomised controlled studies comparing PPIs, H2RAs, prokinetics, sucralfate and combinations either in comparison to another treatment regimen or to placebo in adults with reflux oesophagitis and ENRD. One author extracted data from included trials and a second author carried out an unblinded check. Two authors independently assessed trial quality. Study authors were contacted for additional information. Maintenance of patients with healed oesophagitis: For a healing dose of PPI (generally the standard dose given by the manufacturer) versus placebo, the relative risk (RR) for oesophagitis relapse was 0.26 (95% confidence interval (CI) 0.19 to 0.36); versus H2RAs the RR was 0.36 (95% CI 0.28 to 0.46) and versus maintenance PPIs the RR was 0.63 (95% CI 0.55 to 0.73). However overall adverse effects were also more common and headaches were more common when comparing healing PPIs to H2RAs.For a maintenance dose of PPI (half of the standard dose) versus placebo, the RR for oesophagitis relapse was 0.46 (95% CI 0.38 to 0.57) and versus H2RAs the RR was 0.57 (95% CI 0.47 to 0.69). Overall adverse effects were more common.H2RAs were of marginal help but beneficial for symptomatic relief. Prokinetics and sucralfate were also more effective than placebo.For ENRD patients: Limited data with one RCT showed benefit for omeprazole 10 mg once daily over placebo (RR 0.4; 95% CI 0.29 to 0.53). The findings in this review support the long-term treatment of oesophagitis to prevent relapse, both endoscopically and symptomatically. Healing doses of PPIs are more effective than all other therapies, although there is an increase in overall adverse effects compared to placebo, and headache occurrence compared to H2RAs. H2RAs prevent relapse more effectively than placebo, demonstrating a role for PPI-intolerant patients. Prokinetics and sucralfate both show benefit over placebo, but the former is no longer licenced. There is only limited data for ENRD.
A double-blind controlled trial was carried out in 37 patients with oesophagitis, confirmed endoscopically and histologically, to compare the efficacy of treatment with a carbenoxolone/alginate antaacid combination with that of the alginate antacid compound used alone. The total daily dosage of carbenoxolone was 100 mg. During the 8-week-period of the trial patients were seen every 2 weeks and endoscoped at 4 and 8 weeks. Response to treatment was assessed symptomatically and endoscopically using 6-point grading scales, and multiple oesophageal biopsies were taken at each endoscopy. The addition of carbenoxolone to the alginate antacid compound was shown to enhance symptomatic relief and to increase healing of oesophagitis and oesophageal ulceration significantly. No serious side-effects were reported in either group. Although there were a number of biochemical or clinical abnormalities recorded, none required any alteration in treatment.
An open multicenter study was performed to assess the efficacy and safety of alginic acid in two different dosages in 76 pediatric patients with gastroesophageal reflux confirmed by pH monitoring. Among the 69 patients in whom endoscopy was carried out before treatment, 18 had erythematous esophagitis and 5 had erosive esophagitis. Irrespective of the dosage used, the frequency of regurgitation and vomiting decreased significantly (p < 0.00001 and p = 0.01, respectively). Clinical and biochemical tolerance were outstanding and no adverse effects were recorded. On the basis of these data, the recommended dosage is 1 to 2 ml/kg/day in divided doses after meals.