Clinical Search for Undiagnosed Mesenteric Phlebosclerosis at Outpatient Departments Specializing in Herbal (Kampo) Medicine

Safety of medicinal and edible herbs from fruit sources for human consumption: A systematic review

ETHNOPHARMACOLOGICAL RELEVANCE

Medicinal and edible herbs from fruit sources have been increasingly used in traditional Chinese medicine dietotherapy. There are no restrictions on who could consume the medicinal and edible fruits or on the dosage of consumption. However, their safety for human consumption has yet to be established.

AIM OF THE STUDY

This systematic review aimed to assess the safety of human consumption of 30 medicinal and edible fruits.

MATERIALS AND METHODS

Seven English and Chinese databases were searched up to May 31, 2023, to collect AE reports following human consumption of medicinal and edible fruits. Eligible reports should include details on the occurrence, symptoms, treatments, and outcomes of AEs. AEs that were life-threatening or caused death, permanent or severe disability/functional loss, or congenital abnormality/birth defects were classified as serious AEs (SAEs). The causality between the consumption of fruits and AEs was graded as one of four ranks: "certain", "probable", "possible", or "unlikely".

RESULTS

Thirty AE reports related to the consumption of medicinal and edible fruits were included, involving 12 species of fruits: Crataegi fructus, Gardeniae fructus, Mori fructus, Hippophae fructus, Cannabis fructus, Siraitiae fructus, Perillae fructus, Rubi fructus, Longan arillus, Anisi stellati fructus, Zanthoxyli pericarpium, and Lycii fructus. No AE reports were found for the remaining 18 species. A total of 97 AEs, featuring predominantly gastrointestinal symptoms, followed by allergic reactions and neuropsychiatric symptoms, were recorded. Thirty SAEs were noted, with Zanthoxyli pericarpium accounting for the most (14 cases), followed by Perillae fructus (7 cases), Anisi stellati fructus (6 cases), and Gardeniae fructus, Rubi fructus, and Mori fructus (1 case each). Mori fructus was associated with one death. All AEs were concordant with a causality to fruit consumption, judged to be "certain" for 37 cases, "probable" for 53 cases, and "possible" for 7 cases.

CONCLUSIONS

Our findings suggest that among medicinal and edible fruits, 12 species have AE reports with a causality ranging from "possible" to "definite". SAEs were not scarce. Most AEs may be associated with an excessive dose, prolonged consumption, or usage among infants or young children. No AE reports were found for the remaining 18 species.

A case of venous stasis colitis possibly caused by eplerenone

A 50-year-old man was referred to our hospital for colitis with abdominal pain and diarrhea that had persisted for more than 8 months. 9 months earlier, he had been treated for fulminant eosinophilic myocarditis. During steroid therapy, ulceration appeared in the esophagus, stomach and large intestine. The biopsy results showed cytomegalovirus (CMV) inclusion bodies, and the patient was diagnosed with CMV gastrocolitis and treated with ganciclovir. Colonoscopy 7 months earlier revealed ischemia-like segmental colitis 10 cm in length in the hepatic flexure without evidence of CMV infection. Colonoscopy after 1 month and 3 months showed no improvement. We suspected drug-induced focal ischemic colitis, and discontinued eplerenone. Colonoscopy 2 months after withdrawal of eplerenone showed improvement in colitis, and colonoscopy 8 months later showed ulcer healing. Venous disorders are cautioned as a known side effect of eplerenone, but this is the first report of venous stasis colitis thought to be caused by eplerenone.

Phosphoglyceride crystal deposition disease involving adnexa uteri: a case report with histogenetic consideration

We present a rare case of phosphoglyceride crystal deposition disease (PCDD), as a gynecologic disease, with reference to histogenesis of crystal deposition. An 84-year-old woman, who had undergone simple hysterectomy for uterine leiomyoma 44 years previously, presented with multiple masses in the bilateral adnexa and the pelvic wall. The bilateral adnexal tumors were resected. The masses histologically revealed a foreign-body granuloma composed of numerous tiny, radially arranged needle-like crystal lumps surrounded by multinucleated giant cells and macrophages. The crystals showed birefringence under polarized light and were positive for gold hydroxamic acid stain, and the tumor was thus diagnosed as PCDD. The masses revealed central cystic changes due to old hemorrhage, which contained crystal lumps without foreign-body reaction or birefringence. The present case demonstrated for the first time that phosphoglyceride crystals developed in old hemorrhagic foci, although it was not confirmed whether the old hemorrhagic foci were formed after hysterectomy or due to endometriosis.

Mesenteric phlebosclerosis associated with the oral intake of Japanese traditional (Kampo) medicines containing Gardeniae Fructus

We report a case of mesenteric phlebosclerosis (MP) in a woman in her 50s who had been taking Kamishoyosan for 13 years. Colonoscopic findings 13 years after the start of oral administration were nonspecific, with decreased vascular permeability and redness of the mucosa. The extent of the lesion was initially from the cecum to the ascending colon but expanded over time to the transverse colon. In colon biopsies, there was a remarkable deposition of collagen fibers around the small vessels in the lamina propria of the cecum or the ascending colon over time, and the specific lesions expanded to the transverse colon. The deposition of collagen fibers around the vessels in the lamina propria was already present when the total oral dose of the Sanshishi component was low. In this valuable case of MP, changes after the start of oral administration of Kamishoyosan could be followed over time via endoscopy and biopsy.

Effectiveness and safety of Hwangryunhaedok-Tang (Huang-Lian-Jie-Du-Tang, Oren-Gedoku-to) for dyslipidemia: A protocol for a PRISMA-compliant systematic review and meta-analysis

BACKGROUND

Recent experimental and clinical studies have suggested that Hwangryunhaedok-tang (HHT), an herbal formula, could improve the lipid profiles in patients with dyslipidemia. This systematic review aimed to evaluate the effectiveness and safety of HHT monotherapy or adjunctive HHT therapy with conventional lipid-lowering drugs in managing dyslipidemia.

METHODS

Twelve English, Korean, Chinese, and Japanese databases were comprehensively searched from their inception to January 2020. Randomized controlled trials (RCTs) using HHT monotherapy or adjunctive HHT therapy for dyslipidemic patients were included. The primary outcome was the low-density lipoprotein cholesterol (LDL-C) level. Descriptive analyses of participant details, interventions, and outcomes were conducted and where appropriate data were available, a meta-analysis was performed and presented as a risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CIs). The risk of bias was assessed using the Cochrane risk of bias tool and the quality of evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.

RESULTS

Nine RCTs with 536 participants were included. In comparison with lipid-lowering drugs alone, HHT as an adjunctive therapy to lipid-lowering drugs or as a monotherapy showed significantly superior (MD -1.15 mmol/L, 95% CI -1.25 to -1.05) or inferior results (MD 0.23 mmol/L, 95% CI 0.09 to 0.38), respectively, for LDL-C levels. The incidence of adverse events was significantly lower when HHT was used in addition to lipid-lowering drugs, in comparison to that with lipid-lowering drugs alone. No serious adverse events were reported in the HHT group. Most included studies showed a high risk of performance bias and the quality of evidence was rated generally "low" because of the high risk of bias and inconsistency or imprecision of the meta-analysis results.

CONCLUSION

Current evidence suggests that HHT may be beneficial for patients with dyslipidemia and may reduce the adverse events associated with lipid-lowering drugs. However, due to the high risk of bias of the included studies and low quality of evidence for the main findings, no definitive conclusion could be reached. Further rigorous, high-quality, and placebo-controlled RCTs should be conducted to assess the efficacy of HHT.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42020164563.

Mesenteric Phlebosclerosis Associated with Herbal Medicine

Mesenteric phlebosclerosis (MP) associated with herbal medicine is rarely reported and its endoscopic and radiological features remain poorly described. An 81-year-old woman was admitted to our hospital for right lower abdominal pain and high-grade fever. Computed tomography (CT) revealed wall thickening, pericolic fat stranding, and linear calcifications extending from the cecum to the hepatic flexure of the colon. Ultrasonography (US) revealed wall thickening of the cecum and ascending colon. Colonoscopy (CS) revealed dark-purple edematous mucosa with erosion and ulcers from the cecum to the hepatic flexure of the colon. The patient was histopathologically diagnosed with MP, discontinued orengedokuto, and was treated with intravenous antibiotics for 1 week. Six months after treatment, US and CT revealed no significant changes, but CS showed improvement in dark-purple edematous mucosa with erosion and ulcers. To our knowledge, this report represents a valuable addition to the MP literature describing a rare case of MP associated with herbal medicine.

Adverse Events Associated with Ethical Kampo Formulations: Analysis of the Domestic Adverse-Event Data Reports of the Ministry of Health, Labor, and Welfare in Japan

Objectives

Traditional Japanese Kampo medicines have been integrated into the Japanese national health-care system. In Japan, the Ministry of Health, Labor, and Welfare's website discloses adverse drug-event data that have been obtained from medical personnel reports investigated by the Pharmaceutical and Medical Devices Agency. Using these data, we investigated adverse events associated with ethical Kampo formulations.

Methods

Reports of adverse events associated with ethical Kampo formulations from the domestic adverse-event data were obtained from July 30, 2003, to March 31, 2018. Adverse events were then categorized, and the relationships between categories of adverse events and crude drugs were analyzed.

Results

There were 4,232 reported adverse events associated with ethical Kampo formulations. The numbers of events by category were as follows: events related to liver injury, 1,193; lung injury, 1,177; pseudoaldosteronism, 889; mesenteric phlebosclerosis, 223; drug eruption, 185; and others, 565. Among events related to both liver injury and lung injury, approximately 70% were suspected to be induced by Kampo formulations containing Scutellariae Radix. The pseudoaldosteronism-related events, which are induced by Glycyrrhizae Radix, included several events related to muscle injury, heart failure, and arrhythmia. Events related to mesenteric phlebosclerosis, believed to be induced by long-term use of Kampo formulas containing Gardeniae Fructus, increased remarkably during the study period. Among the events related to drug eruption, approximately 35% were suspected to be induced by Kampo formulations containing Ephedrae Herba.

Conclusion

Kampo medicines may cause various adverse events. The present results provide valuable information regarding adverse events associated with Kampo medicines from the viewpoint of patient safety.

Possibility of Interstitial Lung Disease as a Phlebosclerotic Colitis Manifestation

Phlebosclerotic colitis presents with ischemic bowels and calcification of the mesenteric veins. Owing to its rarity, we have little information on the complications of this disease. Herein, we report on a 77-year-old woman with phlebosclerotic colitis and interstitial lung disease. She was diagnosed as having phlebosclerotic colitis by CT and colonoscopy. At the same time, chest CT also showed interstitial lung disease. After 4 years, she experienced exacerbation of interstitial lung disease. She recovered without treatment. The occurrence of interstitial lung disease may have been associated with her phlebosclerotic colitis.

Ascending colon cancer coincident with mesenteric phlebosclerosis associated with the long-term oral intake of Chinese herb containing gardenia fruit: A case report and literature review

Mesenteric phlebosclerosis is a recently discovered rare ischemic colon disease. The relationship between mesenteric phlebosclerosis and the use of herbal medicine containing gardenia fruit was recently reported. Although the relationship between colon cancer and mesenteric phlebosclerosis has not been described, some cases of colorectal cancer coincident with mesenteric phlebosclerosis have been reported. We treated a 63-year-old female who was diagnosed with ascending colon cancer coincident with mesenteric phlebosclerosis. She had been taking a Chinese herb containing gardenia fruit for over 18 years. The ascending colon cancer was clinically diagnosed as T2, N0, and M0 according to Japanese classification of colorectal carcinoma and the mesenteric phlebosclerosis had spread from the cecum to the descending colon. She underwent laparoscopic subtotal colectomy with en bloc removal of the regional lymph nodes, and both the ascending colon cancer and mesenteric phlebosclerosis were completely resected. The microscopic findings show that the tumor was well-differentiated tubular adenocarcinoma invading the muscular propria with no regional lymph node metastasis, and the mesenteric phlebosclerosis lesion was characterized by marked fibrous thickening of the venous walls with calcification, marked transmural fibrosis and deposition of the collagen in the mucosa, accompanied by macrophages within the vessel walls. In literature review, 10 cases with colorectal cancer coincident with mesenteric phlebosclerosis were reported. 9 of 10 cases (90%) had cancer in the right-side colon affected by mesenteric phlebosclerosis, and 5 of 10 cases (50%) were associated with the use of a Chinese herb containing gardenia fruit. It was recently demonstrated that genipin, which is a metabolite bio-transformed from gardenia fruit, possesses carcinogenesis. We speculate that genipin may be associated with not only the development of mesenteric phlebosclerosis but also carcinogenesis in the right-side colon. In conclusion, our findings suggest that the safety of gardenia fruit should be re-evaluated, and gastroenterologists should be aware that gardenia fruit may be risk factor for not only the development of mesenteric phlebosclerosis but also carcinogenesis in the proximal colon.

Total dosage of gardenia fruit used by patients with mesenteric phlebosclerosis

BACKGROUND

Mesenteric phlebosclerosis (MP) is a disease characterized by fibrotic change or calcification of the mesenteric vein. Recently, there has been an increase in case reports of MP related to herbal medicine usage. Long-term intake of gardenia fruit (GF) is suspected as a possible cause. However, many GF users do not develop this disease and the association between GF and MP remains unclear. In this study, we investigated for the first time the dosage of GF used by patients with and without MP.

METHODS

We used a medical chart review study design to assess the association between GF and MP. We reviewed patients with a history of intake of herbal medicines containing GF. Among these patients, we selected patients who were examined by colonoscopy and abdominal plain computed tomography (CT). We investigated the findings of colonoscopy, CT scan and histological examination. We assessed the total dosages of GF alongside the duration of ambulatory visit, the administration period of herbal medicine containing GF and pre-existing disease in order to compare MP cases and non-MP patients.

RESULTS

Ten MP cases and 42 non-MP patients were analyzed. We summarized clinical findings of MP cases. All MP cases used more GF than non-MP patients and were administered more than approximately 5,000 grams of GF in cumulative dosage.

CONCLUSIONS

This study indicated that excessive intake of GF contributes to and/or accelerates the development of MP suggesting that long-term usage of GF in excessive amounts increases the risk of MP.