Efficacy and safety of Xiangsha Liujunzi granules for functional dyspepsia: A multi-center randomized double-blind placebo-controlled clinical study

AIM

To assess the efficacy and safety of a Chinese herbal medicine (CHM), Xiangsha Liujunzi granules, in the treatment of patients with functional dyspepsia (FD).

METHODS

We performed a randomized, double-blind, placebo-controlled trial with patients from three centers. Two hundred and sixteen subjects diagnosed with FD according to ROME III criteria and confirmed by upper gastrointestinal endoscopy and spleen-deficiency and Qi-stagnation syndrome were selected to receive Xiangsha Liujunzi granules or placebo for 4 wk in a 2:1 ratio by blocked randomization. The subjects also received follow-up after the 4-wk intervention. Herbal or placebo granules were dissolved in 300 mL of water. Participants in both groups were administered 130 mL (45 °C) three times a day. Participants were evaluated prior to and following 4 wk of the intervention in terms of changes in the postprandial discomfort severity scale (PDSS) score, clinical global impression (CGI) scale score, hospital anxiety and depression scale (HADS) score, traditional Chinese medicine symptoms score (SS), scores of various domains of the 36-item short form health survey (SF-36), gastric emptying (GE) and any observed adverse effects.

RESULTS

Compared with the placebo group, patients in the CHM group showed significant improvements in the scores of PDSS, HADS, SS, SF-36 and CGI scale (P < 0.05 or P < 0.01). They also showed the amelioration in the GE rates of the proximal stomach and distal stomach (P < 0.05 or P < 0.01).

CONCLUSION

Xiangsha Liujunzi granules offered significant symptomatic improvement in patients with FD.

Shen-ling-bai-zhu-san, a spleen-tonifying Chinese herbal formula, alleviates lactose-induced chronic diarrhea in rats

ETHNOPHARMACOLOGICAL RELEVANCE

Shen-ling-bai-zhu-san (SLBZS) was firstly documented in ancient Chinese medical works "Tai Ping Hui Min He Ji Ju Fang" in Song-dynasty. It has been widely used for treating gastrointestinal disorders such as diarrhea with poor appetite for about 900 years. The present study is to observe the effects of SLBZS on high lactose diet-induced chronic diarrhea.

MATERIALS AND METHODS

Rats were subjected to a high lactose diet to induce chronic diarrhea, which were then administrated with SLBZS or smecta. General symptom, body weight, food consumption, water intake and fecal fluid content were recorded every day. The intestinal absorption function was determined by d-xylose uptake assay. The ultrastructures of intestine segments including jejunum, ileum, proximal and distal colon were observed by transmission electron microscopy. Additionally, sodium transport proteins including γ-epithelial sodium channel (ENAC-γ) and sodium/potassium-transporting ATPase subunit alpha-1 (ATP1A1) in distal colon were detected by immunohistochemistry and western blotting.

RESULTS

Diarrheal rats produced watery or loose, sticky feces, and presented inactiveness and grouping. A high lactose diet caused a significant decline in body weight, serum d-xylose level as well as food consumption rather than water intake. In contrast, general symptoms were improved to a certain extent and body weight loss was alleviated in the rats treated by SLBZS for one week. Fecal fluid content in diarrheal rats treated by SLBZS presented a gradual decrease trend with about 55% in the end, which was significantly less than the model group with about 81%. Meanwhile, SLBZS significantly improved the serum d-xylose level and reversed abnormal changes of tight junctions and microvilli in intestine. Additionally, SLBZS significantly modulated the abnormal expressions of ENAC-γ and ATP1A1 in distal colon of diarrheal rats.

CONCLUSIONS

These findings suggested that SLBZS exhibited ameliorating effects against lactose-induced diarrhea, which might be attributed to its modulations on intestinal absorption function as well as mucosal ultrastructure.

Irritable bowel syndrome: Epidemiology, overlap disorders, pathophysiology and treatment

Irritable bowel syndrome (IBS) is a common chronic gastrointestinal disease with a significant impact on patients' quality of life and a high socioeconomic burden. And the understanding of IBS has changed since the release of the Rome IV diagnosis in 2016. With the upcoming Rome V revision, it is necessary to review the results of IBS research in recent years. In this review of IBS, we can highlight future concerns by reviewing the results of IBS research on epidemiology, overlap disorders, pathophysiology, and treatment over the past decade and summarizing the latest research.

A Combination of Peppermint Oil and Caraway Oil for the Treatment of Functional Dyspepsia: A Systematic Review and Meta-Analysis

A combination of peppermint oil and caraway oil (POCO) with its unique properties has been shown clinical benefits for FD. However, the potent statistical data to confirm its effects are lacking. This meta-analysis thus aimed at evaluating the efficacy and safety of POCO compared with placebo in treating patients with FD. We searched CENTRAL, PubMed, EMBASE (Ovid), Web of Science, Google Scholar, China National Knowledge Infrastructure database, Wanfang, and VIP databases for randomized clinical trials (RCTs) up to June 2019. Dichotomous data were shown as a risk ratio (RR) with 95% confidence intervals (CIs). All data were analyzed by Review Manager 5.2 software. The search identified 382 citations, and 5 RCTs (578 participants) were included. POCO showed a statistically significant effect in global improvement of FD symptoms (RR for not much or very much improvement 0.59, 95% CI: 0.49 to 0.71, P < 0.00001, I 2 36%, NNT 3) and improvement in epigastric pain (RR 1.61, 95% CI: 1.28 to 2.03, P < 0.0001, I 2 0%, NNT 3). There were no significant differences in the total number of adverse events between POCO and placebo (NNH 40). In conclusion, this is the first meta-analysis to assess the effects of POCO in FD. POCO is an effective and safe short-term treatment for FD. However, current findings are based on smaller sample sizes and low/very low quality of the evidence. More well-designed RCTs with large sample sizes of FD patients are required.

The Effect of Tong-Xie-Yao-Fang on Intestinal Mucosal Mast Cells in Postinfectious Irritable Bowel Syndrome Rats

Objective. To investigate the effects of Tong-Xie-Yao-Fang (TXYF) on intestinal mucosal mast cells in rats with postinfectious irritable bowel syndrome (PI-IBS). Design. PI-IBS rat models were established using a multistimulation paradigm. Then, rats were treated with TXYF intragastrically at doses of 2.5, 5.0, and 10.0 g·kg-1·d-1 for 14 days, respectively. Intestinal sensitivity was assessed based on abdominal withdrawal reflex (AWR) scores and fecal water content (FWC). Mast cell counts and the immunofluorescence of tryptase and c-Fos in intestinal mucosa were measured; and serum IL-1β, TNF-α, and histamine levels were determined. Results. AWR reactivity and FWC which were significantly increased could be observed in PI-IBS rats. Remarkably increased mast cell activation ratio in intestinal mucosa, together with increased serum TNF-α and histamine levels, could also be seen in PI-IBS rats; furthermore, PI-IBS-induced changes in mast cell activation and level of serum TNF-α and histamine could be reversed by TXYF treatment. Meanwhile, tryptase and c-Fos expression were also downregulated. Conclusion. TXYF improves PI-IBS symptoms by alleviating behavioral hyperalgesia and antidiarrhea, the underlying mechanism of which involves the inhibitory effects of TXYF on activating mucosal mast cells, downregulating tryptase and c-Fos expression, and reducing serum TNF-α and histamine levels.

Tojapride prevents CaSR-mediated NLRP3 inflammasome activation in oesophageal epithelium irritated by acidic bile salts

Impairment of the oesophageal epithelium in patients with reflux oesophagitis (RE) is a cytokine-mediated injury rather than a chemical burn. The present study was conducted to explore CaSR/NLRP3 inflammasome pathway activation and cytokines IL-1β and IL-18 release in oesophageal epithelia injured by refluxates and the effects of Tojapride on that signal regulation. Using a modified RE rat model with Tojapride administration and Tojapride-pretreated SV40-immortalized human oesophageal epithelial cells (HET-1A) exposed to acidic bile salts pretreated with Tojapride, we evaluated the therapeutic effects of Tojapride on oesophageal epithelial barrier function, the expression of CaSR/NLRP3 inflammasome pathway-related proteins and the release of downstream cytokines in response to acidic bile salt irritation. In vivo, Tojapride treatment ameliorated the general condition and pathological lesions of the oesophageal epithelium in modified RE rats. In addition, Tojapride effectively blocked the CaSR-mediated NLRP3 inflammasome activation in modified RE rats. In vitro, Tojapride treatment can reverse the harmful effect of acidic bile salts, which reduced transepithelial electrical resistance (TEER), up-regulated the CaSR-mediated NLRP3 inflammasome pathway and increased caspase-1 activity, LDH release and cytokines secretion. Taken together, these data show that Tojapride can prevent CaSR-mediated NLRP3 inflammasome activation and alleviate oesophageal epithelial injury induced by acidic bile salt exposure.

Clinical study on post evaluation after listing of Qizhi Weitong granules: Study protocol clinical trial (SPIRIT compliant)

BACKGROUND

Functional dyspepsia (FD) is a highly prevalent functional gastrointestinal disorder which brings a significant impact on patients' quality of life. Although there are many available treatments to alleviate dyspepsia symptoms, most of them are far from satisfactory. Traditional Chinese medicine (TCM) has shown good potential in the treatment of FD, especially in terms of improving symptoms and adverse effects of Western medicine. Qizhi Weitong granule (QZWTG), a TCM preparation, has been utilized in treating FD for a long time and has achieved good clinical results. However, the existing evidence of its efficacy and mechanism of action is insufficient. Hence, the purpose of this study is to evaluate the efficacy and safety of QZWTG in the treatment of FD.

METHODS

This study is a multicenter, randomized, double-blinded, double-placebo, positive drug parallel controlled clinical study. The experiment will be carried out in 8 hospitals at the same time, and a total of 384 cases of participants will be randomly assigned to the experimental group and the control group (n = 192). The experimental group will be given QZWTG and Mosapride citrate tablet placebo, and the control group will be given QZWTG placebo and Mosapride citrate tablet. After 4 weeks of intervention and 2 weeks of follow-up, the efficacy and safety of QZWTG in patients with FD will be observed. The primary outcomes are the change in the main symptom score. The secondary outcomes include TCM syndrome evaluation, the change of the Hamilton anxiety scale and the Hamilton depression scale, and advanced events. This study will explore the biological mechanism of QZWTG in the treatment of FD through the results of blood and urine metabolomics.

DISCUSSION

This trial will provide first-hand evidence on whether QZWTG is noninferior to Mosapride citrate tablet. There will be a new option for the treatment of FD if noninferiority is set up. In addition, the efficacy and safety of QZWTG in the treatment of FD will be evaluated, and the mechanism of QZWTG in the treatment of FD will be explored through the metabolomics of blood and urine. On the other hand, as far as we know, this study may be the largest trial of efficacy and safety of QZWTG in the treatment of FD, which has important application value.

Histamine H2 antagonists for functional dyspepsia: A protocol for a systematic review and meta-analysis

BACKGROUND

Functional dyspepsia (FD) is a prevalent gastrointestinal disorder. Histamine H2 antagonists (H2RAs) are the pharmacological treatment option for FD, but no potent evidence has been found for the efficacy of these drugs in the condition. Therefore, this systematic review protocol aims to examine the efficacy and safety of H2RAs in the treatment of FD.

METHODS

We will perform a systematic search in the following electronic databases: the Cochrane Central Register of Controlled Trials (to October 2019), MEDLINE (OvidSP; to October 2019), EMBASE (OvidSP; to October 2019). Only randomized clinical trials (RCTs) comparing any H2RA with placebo for the treatment of FD will be included. The primary outcome will be an improvement in global symptoms of dyspepsia. Study selection, data extraction, and study quality will be performed by 2 independent reviewers. Dichotomous data will be presented as a risk ratio (RR) with 95% confidence intervals (CI), and continuous data as mean difference (MD) or standardized MD (SMD) with 95% CI. RevMan v.5.3 software will be used for all statistical analyses.

RESULTS

This study will provide a high-quality synthesis to examine the role of H2RAs in FD as reflected by the improvement of global symptoms of dyspepsia, quality of life scores, and adverse events.

CONCLUSION

This systematic review will provide updated evidence to judge whether H2RAs are of benefit in FD.

Herbal placebo response in clinical trials on irritable bowel syndrome: a systematic review and meta-analysis

AIM OF THE STUDY

To systematically evaluate the herbal placebo response in randomized controlled trials (RCTs) of herbal medicine on irritable bowel syndrome (IBS).

MATERIALS AND METHODS

We searched for RCTs with herbal placebo groups for IBS in PubMed, EMBASE, the Cochrane Library, the China National Knowledge Infrastructure (CNKI), the Wan Fang database and Sinomed database from 31 January 1994 to November 2023, and the quality of the literature was evaluated by the Cochrane risk of bias assessment criteria. The primary outcome indicators were response rate, abdominal pain and stool improvement rate, which were analyzed by single-group rate meta-analysis. Secondary outcomes were analyzed in subgroups based on diagnostic criteria, duration of treatment, subtype, research locations, placebo form, and presence of herbal ingredients to look for factors affecting respond rate.

RESULTS

The study included 24 papers, involving a total of 2,596 patients. Of these, 1151 IBS patients were treated with the herbal placebo. The placebo response rate in IBS patients in the herbal placebo group was 37% (P < 0.01,I2 = 75%). A total of 287 patients in five studies were given the herbal placebo, and the improvement rate of abdominal pain was 29% (P = 0.83, I2 = 0%). Four studies enrolled a total of 212 patients with IBS who received herbal placebo, and the stool improvement rate was 46% (P = 0.02 < 0.05, I2 = 71%). The research locations and treatment duration were sources of heterogeneity (P < 0.05).

CONCLUSION

There is a significant herbal placebo response in patients with IBS. Different research locations and treatment durations are major sources of heterogeneity that may affect IBS patient response rates. The addition of a low dose of herbal ingredients when simulating an herbal placebo does not exaggerate the therapeutic effect of the placebo. There is a lack of uniformity and standardization in the preparation and evaluation of herbal placebos.

Cerebral cortex changes in FD, IBS, and GERD: A Mendelian randomization study

BACKGROUND

Prospective and cross-sectional studies have reported an association between functional gastrointestinal disorders and anxiety and depression. However, the causal relationship remains uncertain. To clarify this, we utilized Mendelian randomization (MR) to assess the causal effects of common gastrointestinal disorders on cortical structures.

METHODS

Genome-wide association study (GWAS) data was gathered for functional dyspepsia (FD), irritable bowel syndrome (IBS), and gastroesophageal reflux disease (GERD) from European populations numbering 329,262, 16,792, and 602,604, respectively. GWAS cerebral cortical architecture data for cortical thickness (TH) and surface area (SA) were obtained from 51,665 MRI scans. MR was used to analyze the casual relationship between FD, IBS, GERD, and cortical structures. Inverse-variance weighted, weighted median, and MR-Egger tests were performed as assessment indicators. We also evaluated heterogeneity and pleiotropy.

RESULTS

FD significantly decreases the TH in the rostral anterior cingulate cortex (βTH = -0.022 mm; 95%CI: -0.035 mm to -0.009 mm2; PTH = 6.89 × 10-4), and IBS significantly decreases the SA of the pars triangularis (βSA = -21.91 mm2; 95%CI: -32.99 mm to -10.83 mm2; PSA = 1.06 × 10-4), precuneus (βSA = -47.53 mm2; 95%CI: -73.57 mm to-21.48 mm2; PSA = 3.48 × 10-4) and superior frontal regions (βSA = -78.70 mm2; 95%CI: -122.61 mm to -34.78 mm2; PSA = 4.4 × 10-4). At the local functional level, GERD significantly increases the SA of the inferior temporal region (βSA = -113.58 mm2, 95%CI: -113.58 mm to -39.01 mm2, PSA = 6.05 × 10-5).

CONCLUSIONS

FD, IBS and GERD can affect the cerebral cortex architecture through the brain-gut axis, potentially increasing the risks of mental illness and cognitive impairment.

Endoplasmic reticulum stress in gut inflammation: Implications for ulcerative colitis and Crohn's disease

Eukaryotic cells contain the endoplasmic reticulum (ER), a prevalent and intricate membranous structural system. During the development of inflammatory bowel disease (IBD), the stress on the ER and the start of the unfolded protein response are very important. Some chemicals, including 4μ8C, small molecule agonists of X-box binding protein 1, and ISRIB, work on the inositol-requiring enzyme 1, turn on transcription factor 6, and activate protein kinase RNA-like ER kinase pathways. This may help ease the symptoms of IBD. Researchers investigating the gut microbiota have discovered a correlation between ER stress and it. This suggests that changing the gut microbiota could help make new medicines for IBD. This study looks at how ER stress works and how it contributes to the emergence of IBD. It also talks about its possible clinical importance as a therapeutic target and looks into new ways to treat this condition.

Comparative Analysis of Gastroesophageal Reflux Disease Animal Model Methods: A Data Mining of the Past Decade

PURPOSE

The differences in the animal model construction of different subtypes of gastroesophageal reflux disease (GERD) have not been clearly demonstrated at present. We aim to reveal the characteristics and differences between them.

METHODS

The literature related to GERD animal model construction in the past decade was searched and data on animal strains, modeling modes, modeling cycles, and detection indices were extracted, and the results were presented by using descriptive statistical methods of frequency and relative frequency.

RESULTS

88 papers finally met the criteria. Sprague-Dawley (68.25%) rats were most often used to induce reflux esophagitis (RE), whereas Swiss mice (50.00%) and C57BL/6 mice (57.89%) for non-erosive reflux disease (NERD) and Barrett's esophagus (BE), respectively. RE and NERD were most frequently constructed using fore-stomach-glandular transition ligation together with pyloric insufficiency (37.68%, 50.00%), yet their median modeling cycles were 14 and 7 days, respectively. BE was most frequently constructed using L2-IL-1β transgenic mice (27.27%), and the median modeling cycle over 270 days. Determining esophageal mucosal permeability was common in NERD, while finding intestinal chemotaxis markers, squamous epithelium, and columnar epithelium was common in BE. In animal models of RE, researchers tended to look for markers associated with the inflammatory response and oxidative stress.

CONCLUSIONS

The induction methods vary among the animal models of GERD's three subtypes. Inflammatory stimulation is crucial for inducing RE and BE, differing in modeling cycle. In contrast, Visceral hypersensitivity draws more attention in NERD animal models, reflecting researchers' thoughts on distinct pathogenesis.