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Prevention of Symptoms of Gastric Irritation (GERD) Using Two Herbal Formulas: An observational study.

Introduction

Acid-suppressive drugs are commonly used to treat gastric irritation and GERD. Concerns have been raised about the use of aluminium hydroxide-based antacids because orally ingested aluminium may be a contributing factor in the progression of Alzheimer's disease, (1) although more research needs to be undertaken to confirm this connection. Aluminium is neurotoxic (2) and should not be ingested in bolus amounts. Aluminium-based antacids can raise plasma aluminium (3) and can contribute to calcium and phosphorus depletion. In addition to these concerns, lowering of gastric acid may not be appropriate in many cases of gastric irritation and GERD and may enhance the progression of diseases such as osteoporosis and respiratory and other infections. (17) Promoting the integrity of the gastric mucosa is preferable in most instances.

A number of herbal remedies are commonly used to treat gastric irritation and GERD. These include:

Mentha piperita

Mentha piperita (peppermint) contains between 1-3% volatile oils, principally (-) menthol in combination with menthol stereoisomers such as (+)-isomenthol. Mentha piperita also contains the flavonoids luteolin and its 7-glucoside (cynaroside). Around 85 constituents have been identified in peppermint oil with a further 40 still under investigation (4). Peppermint's spasmolytic action is well documented. The volatile oils and flavonoids act locally causing smooth muscle relaxation, thereby reducing the symptoms of intestinal colic and abdominal pain. (4,5,6,7,8) Mentha piperita oil is the integral part of many digestive remedies, such as Gripe Water. This formula, based on peppermint and dill, is used for relief of the symptoms of mild colic and wind pains in infants.

High dosages of peppermint oil could lead to over-relaxation of the cardiac sphincter and may increase gastric reflux in some patients. Therefore, many peppermint oil preparations are enteric coated to prevent this occurrence. However, the amount of peppermint powder in the formulas was found to relieve symptoms without any reported side effects. The high mucilage content of the micro-pulverised slippery elm powder (4) in the formula prevents the peppermint oil from having any over-relaxation or irritant effect in the upper GIT via physical protection of the cardiac sphincter and gastric mucosa. Studies have shown that azulene, isolated from the oil, has both anti-ulcer and antiinflammatory action. (9)

Ulmus fulva

Ulmus fulva is the dried inner bark of the slippery elm tree. This tree is native to North America and its bark has been used in foods and recorded in folklore as a demulcent, emollient, nutritive and astringent. (4,5,6) The main water-soluble polysaccharide in slippery elm is the linear polymer of alternating D-galacturonic acid and L-rhamnose, residues of galactose or 3-0-methyl-galactose. It also contains small amounts of the tannins calcium oxalate and calcium. (4,5,6,7)

Slippery elm bark powder has a long history of soothing irritated gastrointestinal tract mucosa. It is indicated for the treatment of inflammation and ulceration of the gastrointestinal tract including colitis, gastritis, diarrhoea, gastric and duodenal ulcers, Crohn's disease and oesophagitis (4,10) Slippery elm has also been used as a soothing, nutritious food for patients with sensitive digestive systems during their convalescence. (4,7)

Skim milk powder

Skim milk powder is used to help stabilise the instant formula and to improve texture and taste. Cow's milk protein is also mucus forming and therefore soothing to inflamed gastric mucosa on ingestion. Milk protein in large amounts may increase gastric acid, however the amount used in the base of both formulas would have minimal effect on gastric acid levels. Also as the amount of skim milk powder in each dose is small most lactose intolerant individuals should not experience problems. Two lactose intolerant participants were included in the study and reported no problems with respect to lactose intolerance symptoms.

Liquorice

Glycyrrhiza gabra (liquorice) contains triterpene glycosides, principally glycyrrhiz(in)ic acid which occurs as a mixture of potassium and calcium salts known as glycyrrhizin, (4) and the flavanones liquiritigenin, its 4-0-gincoside liquirin, and galbrol. It also contains varying amounts of the minor saponins. (4,11)

Liquorice has broad spectrum antiinflammatory activity attributed to the steroid-like action of glycyrrhizin and liquiritin. (4,11) Liquorice's anti-ulcerous activity is thought to be related to its ability to increase the secretion of mucus by the gastric mucosa. (11) Carbenoxolone, a hemi-succinate ester of glycyrrhizic acid which has been synthetically produced from liquorice, also has this action. Carhenoxolone is widely used in the treatment of gastric and peptic ulcers. (11) Liquorice also has mild laxative and demulcent properties.

Glycyrrhizin is a mineralocorticoid which affects the sodium/potassium balance and can cause pseudoaldosteronism, leading to sodium retention, hypertension and oedema if taken in large amounts. (4,7,11) As there could be an adverse reaction to liquorice in certain individuals, DGL liquorice was used in the formulas.

DGL deglycyrrhizinated liquorice

Studies have found that DGL can prevent the recurrence of gastric ulcer in animal models, without ill effects. Human studies have also found that DGL is as effective as cimetidine in the treatment of gastric ulcers. (12) The mechanism of DGL is unlike other anti-ulcer agents which usually act by reducing gastric acid secretion. DGL's mode of action emulates that of liquorice by increasing the secretion of mucus from the gastric mucosa, (11) improving mucus quality, coating the intestinal lining and improving the intestinal microcirculation. There have been several clinical studies that have shown DGL more effective than a placebo or Carbenoxolene in reducing the symptoms and size of gastric ulcers. (13,14,15,16) Both formulas were micropulverised to allow faster dispersion of the powder and mucilage onto the inflamed mucosa and for ease of dispersion in cold water.

The purpose of this observational study was to compare the efficacy of two herbal formulas in the reduction of the symptoms of GERD and some other gastrointestinal diseases without the need to substantially lower gastric acid.

Methods

Participants recruited from clients at my clinics in Yagoona, Penrith and Chatswood presented with one or more of the following: gastric reflux, unspecified burning sensations in the gastric area, confirmed gastric or duodenal ulcer, irritable bowel syndrome and Crohn's disease. All participants included in the study were suffering from one or more of the above complaints for more than 6 months. They were also taking one or more types of antacid in an endeavour to solve their problems, with limited success.

No participants who were included in and completed the study made any demonstrable changes to diet or lifestyle. Those taking Ranitidine and Cimetidine were excluded. Those suffering from Crohn's disease, whose management included sulfasalazine, and whose symptoms were still not under control were included, provided these symptoms had been stable for 6 months or more. Those taking prednisone were not included. All participants suffering from either ulcerative states or Crohn's disease agreed to undertake medical management if any of their symptoms worsened during the study.

The length of the study was 24 months. At the commencement of the study all other antacids were discontinued and only Formulas 1 or 2 were used.

Formula 1

The recommended dose of 12 grams contains:

* Micro pulverised Ulmus fulva powder 2,000mg

* mentha piperita oil 2.6mg

* in a base of skim milk powder, lecithin, maltodextrin and fructose

Formula 2

The recommended dose of 12 grams contains:

* micro-pulverised Ulmus fulva powder 2,000mg

* Mentha piperita oil 2.6mg

* D.G.L. liquorice 400mg

* in a base of skim milk powder, lecithin, maltodextrin and fructose

Dose: 12 grams (one scoop) in 100 to 250 ml of water up to three times daily or as required for pain: both formulas, being micro-pulverised, disperse in cold water instantly.

Evaluation of participants' improvement was by self-evaluation recorded on a questionnaire. This questionnaire, given at the start of the study, documented the perceived improvement or worsening of their condition, on a scale of 1-10 (Figure 1).

Results

A total of 59 people were recruited and 58 completed the study. The range of presenting complaints/symptoms among participants is shown in Figure 2.
Figure 2. Patient symptoms summary

Symptoms                        Patients
Irritable bowel                    7
Crohn's disease                    3 (*)
Gastric or duodenal ulcer         11 (*)
GERD, flatulence & dyspepsia      38
Total in Study                    58

(*) Participants taking Formula 2


The average quantity of formula taken daily was 12 grams in 150ml of water morning and night. The average number of times patients needed to take the formula weekly was averaged every 6 months. These results are reported in Figure 3.

A total of 52 out of 58 patients (89.7%) reported an improvement in their condition when taking either formula (see Figure 4). Fifty patients also reported that Formula 1 worked more quickly and with better results than over-the-counter antacids, ranitidine or slippery elm powder. However, 13 patients with medically confirmed ulcers and Crohn's disease reported better results with Formula 2.
Figure 4: Symptoms suffered and participants' perceived changes after
taking herbal formulas. Note that patients may be suffering from one or
more symptoms ((*)dropped out of study).

Condition        No in study     same    improved (1-10)   worse (1-10)
Reflux              38            2      36 (average 8)       1
Irritable bowel      7            -       7 (average 7)       -
Flatulence          28            1      26 (average 8)       1
Burning sensation   15            -      15 (average 9)       -
Gastric or
duodenal ulcer      11            3       7 (average 7)       1 (*)
Crohn's disease      3            -       3 (average 6)       -


Participants reported that the formulas gave almost instant relief from gastric pain (non-specific burning), flatulence, reflux pain and the symptoms of dyspepsia. Improvements reported by patients for specific conditions are shown in Figure 5.
Figure 5: Average improvement in symptoms reported by participants

Reflux          80
irr bowel       70
Flatulence      80
Burning         90
Ulcer           70
Cronn's         60


Discussion

This study supports the use of herbal formulas as an alternative treatment that may reduce the symptoms of gastrointestinal irritation (GERD) without the need to lower gastric acid and without the need for over-the-counter antacids.

This is important given that the use of antacid medications and acid-suppressive drugs that include proton pump inhibitors (PPI) or H2-receptor antagonist that result in a reduction of gastric acid are associated with an increase in osteoporosis, hip fractures, cardiac-events, iron deficiency and Clostridium difficile infection. Also, long-term PPI use has been associated with an increased risk of all-cause mortality in two cohorts of institutionalized older persons. (18)

Although the results of this study are promising, conclusions of causality cannot be drawn from a small observational study and further larger studies are needed to confirm these results.

Given the positive results reported for the reduction in symptoms of gastric and/or duodenal ulcers further studies need to be undertaken to determine whether Formula 2 inhibits or affects Helicobacter pylori.

Conclusion

The results showed that the both herbal formulas were associated with significant improvement in symptoms of gastric and intestinal irritation and that these improvements were consistently reported as better than commonly used antacids. A herbal formula designed to soothe and protect the gastric mucosa may be a better alternative than acid-suppressive drugs for some people suffering with gastric irritation and GERD.

REFERENCES

(1.) Martin CN et al. Graphical relation between Alzheimer's disease and aluminium in drinking water. Lancet. 1989; 1(8629); 59-62.

(2.) Kruck TPA, McLachlan DR. Mechanisms of aluminium neuotoxicity: relevance to human disease. In: Sigel H, editor. Metal ions in biological systems: Vol xxiv, Aluminium and its role in biology. New York: Marcel Dekker; 1988. p. 285-315.

(3.) Puntis JWI et al. Raised plasma aluminium in an infant on antacid. Lancet. 1989; 2:923.

(4.) British Herbal Medical Association. British Herbal Compendium Volume 1. Bristol: British Herbal Medicine Association, 1992.

(5.) Mills S. The A-Z of Modern Herbalism. London: Thorsons, 1989.

(6.) British Herbal Medicine Association. British Herbal Pharmacopoeia. Bristol: British Herbal Medicine Association, 1983.

(7.) Reynolds JEF (ed). Martindale: The Extra Pharmacopoeia (28th edition). London: The Pharmaceutical Press, 1982.

(8.) Rees WDWetal. Treating Irritable Bowel Syndrome with Peppermint Oil. Brithish Medical Journal. 1979; 2; 835.

(9.) Leung AY. Encyclopedia of Common Natural Ingredients Used in Food. Dugs and Cosmetics. New York: John Wiley & Sons Inc, 1980.

(10.) Setright RT. Crohn's disease. Get Well: An A-Z of Natural Medicine for Everyday Illness. Atrand Pub, 1990.

(11.) Hikino H. Recent Research on Oriental Medicinal Plants. In: Wagner H, Farnsworth NR (eds). Economic and Medicinal Plant Research Vol. 1. London: Academic Press, 1985.

(12.) Morgan AG et al. Comparison between cimetidine and Cauii-S in the treatment of gastric ulceration and subsequent maintenance therapy. Gut. 1982; 23: 545-51.

(13.) Turpie AGG et al. Clinical trial of deglycyrrhizinated liquorice in gastric ulcer, Gut. 1969; 10: 299-303.

(14.) Wilson JAC. Drugs for Gastric Ulceration. British Journal of Clinical Practice. 1972; 26; 563.

(15.) Tewari SN, Wilson AK. Deglycyrrhizinated liquorice in duodenal ulcer. Practitioner. 1973; 210(260); 820-3.

(16.) Kassir ZA. Endoscopic controlled trial of four drug regimens in the treatment of chronic duodenal ulceration, Irish Medical Journals. 1985; 78: 153-6.

(17.) Chun-Sick E et al. Use of acid-suppressive drugs and the risk of pneumonia; a systematic review and meta-analysis. Canadian Medical Association Journal. 2011; 183(3): 310-319.

(18.) Bell JS et al. Use of proton pump inhibitors and mortality among institutionalized older people. Archives of Internal Medicine. 2010; S170(17):1604-1605.

Russell Setright is an accredited Naturopath, Medical Herbalist, Nutritionist, Remedial Therapist and Emergency Medical Technician and an educator in natural medicine, Advanced Life Support, First Aid, Emergency Critical Care and Rescue. Russell is a member of ATMS, AREMT, ACRRM, and the Australian Medical Writers' Association. He was registered in the Northern Territory under the Health Practitioners and Allied Professionals Registration Act in 1986 and was the Editor in Chief of the Journal of Health Sciences, and is naturopathic consultant to Blackmores Ltd. Russell is also the author of the Get Well books.
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Title Annotation:ARTICLE
Author:Setright, Russell
Publication:Journal of the Australian Traditional-Medicine Society
Article Type:Report
Date:Dec 22, 2017
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