Chinese Journal of Physiology 56(5): 253-262, 2013 253 DOI: 10.4077/CJP.2013.BAB127 Herbal Haemorrhoidal Cream for Haemorrhoids Ebru Gurel1, Savas Ustunova1, Bulent Ergin1, Nur Tan2, Metin Caner3, Osman Tortum4, and Cihan Demirci-Tansel1 1Department of Biology, Faculty of Science 2Department of Pharmacognosy, Faculty of Pharmacy 3Department of Internal Medicine, Cerrahpasa Medicine Faculty and 4Department of General Surgery, Cerrahpasa Medicine Faculty, University of Istanbul Istanbul, Turkey Abstract Although hemorrhoids are one of the most common diseases in the world, the exact etiology underlying the development of hemorrhoids is not clear. Many different ointments are currently used to treat hemorrhoids; however, there is little evidence of the efficacy of these treatments to support their use. The aim of this study was to compare different herbal creams used for the treatment of hemorrhoids. Twenty-eight male Wistar albino rats, 6-8 weeks old and weighing 160-180 g, were used in this study as 1-control, 2-croton oil, 3-croton oil+fig leaves+artichoke leaves+walnut husks and 4-croton oil+fig leaves+artichoke leaves+walnut husks+horse chestnut fruit. After 3 days of croton oil application, rats were treated with 0.1 ml of cream or saline twice a day for 15 days by syringe. Tissue and blood samples were collected for histological, immunohistochemical and biochemical studies. Statistical significance was determined using one-way ANOVA followed by Tukey’s multiple comparison tests. Croton oil administration resulted in severe inflammation. The third group showed partial improvement in inflammation; however, the greatest degree of improvement was seen in the fourth group, and some recovered areas were observed. Myeloperoxidase immunoreactivity was found to be decreased in the third and fourth groups compared to the second group. Additionally, biochemical analyses (Myeloperoxidase, Malondyaldehyde, nitrate/nitrite and nitrotyrosine levels and Superoxide Dismutase activity) were in agreement with the histological and immunohistochemical results. In conclusion, croton oil causes inflammation in the anal area and results in hemorrhoids. Treatment with our herbal hemorrhoid creams demonstrated anti-inflammatory and anti-oxidant effects in this model. Key Words: croton oil, hemorrhoid, herbal cream, myeloperoxidase, rat Introduction swelling, called hemorrhoids. The exact mechanism underlying these changes that lead to the formation Hemorrhoids are normal vascular structures in of hemorrhoids is not clear*. Hemorrhoids usually the anal canal that aid in stool control (4, 25). There present with itching, rectal pain, or rectal bleeding is a network of small veins within the inner lining of (25). In most cases, symptoms will resolve within a the anus and lower rectum. These veins occasionally few days. The symptoms of pathological hemorrhoids become wider and engorged with more blood than depend on their type. External hemorrhoids are usual. These engorged veins and the overlying tissue painful, while internal hemorrhoids usually are not may then develop into one or more small areas of painful unless they become thrombosed or necrotic Corresponding author: Ebru Gurel, Ph.D., Department of Biology, Faculty of Science, University of Istanbul, 34134 Vezneciler, Istanbul- Turkey. Tel: +90 212 455 58 42, Fax: +90 212 528 05 27, E-mail: [email protected] Received: May 23, 2012; Revised (Final Version): October 3, 2012; Accepted: October 17, 2012. ©2013 by The Chinese Physiological Society and Airiti Press Inc. ISSN : 0304-4920. http://www.cps.org.tw *http://www.patient.co.uk/health/Haemorrhoids-(Piles).htm [20 June 2011] 254 Gurel, Ustunova, Ergin, Tan, Caner, Tortum and Demirci-Tansel Table 1. The general ingredients used in herbal hemorrhoid creams I. Base Liquid (30-33%) a) Active Ingredients (60% of I) b) Assisting Ingredients (30% of I) Very Desirable Ingredients (60% of b), Less Important Ingredients (30% of b), Least Important Ingredients (10% of b) c) Helping Ingredients (10% of I) II. Vegetable Oils (30-33%) a) Most Important Oils (70% of II) Storax Oil, Cade Oil, Balsam Apples, Nigella Sativa Oil b) Less Important Oils (24% of II) Sesame Oil, Cocoa Oil, Ricine Oil, Almond Oil, Olive Oil c) Least Important Oils (6% of II) Sun Flower Oil, Hazelnut Oil III. Gelling Agents (30-33%) a) Lanolin (75% of III) b) Vaseline (25% of III) IV. Analgesics The amounts are preferably selected to be pharmaceutically acceptable. V. Chemical Agents The amounts are preferably selected to be pharmaceutically acceptable. (17, 24). liquid containing herbal extracts, vegetable oils and Conservative treatment typically consists of gelling agents according to the invention application increasing dietary fiber, oral fluids to maintain (Table 1). hydration, non-steroidal anti-inflammatory drugs The most active ingredients in the first group (NSAIDs), sitz baths, and rest. While many topical are the following: fig leaves (Ficus carica), walnut agents and suppositories are available for the treatment husks (Juglans regia), and artichoke leaves (Cynara of hemorrhoids, there is little evidence to support scolymus) and horse chestnut fruit (Aesculus their use (17). hippocastanum). The preferred proportion of these Many different ointments are being used for active ingredients within the aqueous base liquid hemorrhoid treatment. A bland soothing cream, is 30-75% by volume, with 50-70% being better and ointment, or suppository may ease discomfort (19). A 55-65% being optimal. cream that contains an anesthetic may ease pain better, The second group of assisting ingredients and one that contains a steroid may reduce inflamma- consists of three subgroups: a subgroup of highly tion and help to reduce any swelling that may occur desirable ingredients, including pomegranate skin around the hemorrhoid. All these may help to ease the (Punica granatum), eggplant stems and stalks itchiness and pain associated with hemorrhoids**. (Solanum melongena), acorns (Quercus macrolepis), In our study, a hemorrhoid model was induced and pine cones (Pinus strabus); a second subgroup of by applying croton oil to the recto-anal area of rats somewhat less important ingredients, including cy- (21). Our goal was to compare different herbal creams press cones (Cupressus sempervirens), juniper berry used for the treatment of hemorrhoids and to develop seeds (Juniperus communis), oak tree skin (Quercus), an ointment for hemorrhoid treatment. nettle leaves and seeds (Urtica urens), myrtle leaves (Myrtus communis), dragon’s blood or Sanguis Materials and Methods draconis (Dracaena draco), and balsam apple fruits (Momordica charantia); and a third subgroup of even Plant Material and Preparation of the Herbal less critical ingredients, from which one or more may Hemorrhoid Cream be selected if desired, including Nigella sativa, Aloe vera, milfoil (Achillea millefolium), quince leaves All herbs and plant oils used in this study were (Cydonia vulgaris), Solidago officinalis, ginger obtained from certified herb sellers. Generally, the (Zingiber officinale), fennel (Foeniculum vulgare), herbal hemorrhoid cream (New European Patent Ap- rosemary (Rosmarinus officinalis), and cassia (Senna plication 07015624.5-2107/2022504 (K10432-EP); corymbosa). The preferred proportion of the entire International Patent Application PTC/EP 2009/000148 group of secondary ingredients is 10-50% of the (K10432-PTC)) is comprised of an aqueous-based aqueous base liquid by volume, with 20-40% being **http://www.cks.nhs.uk/CksContent/TopicReview/PreviousVersions/haemorrhoids.pdf [20 June 2011] Herbal Hemorrhoid Cream for Hemorrhoids 255 more favorable and 25-35% being the optimal con- amounts of analgesics used are selected to be phar- centration. maceutically acceptable and to alleviate unpleasant The third group of helping ingredients, from sensations. which one or more may be selected if desired, includes The group of chemicals in hemorrhoid creams, fern leaves, common buckthorn, mallow, Melissa from which one or more may be selected if desired, I I officinalis, Acanthus dioscoridis, Cichorium endivia, includes Alum (M Al(SO4)2), where M represents a hawthorn, leek, carob, ziziphora, borage, asa foetida, monovalent ion, such as ammonium or an alkali metal, plantago, Sambucus nigra, buttercup, oleander, preferably potassium), boric acid, salicylic acid, zinc coconut skin, mullein, Lesser celandine, coriander, oxide, calcium carbonate, sodium benzoate, and a arborvitae, anis, flax seed, and Vaccinium myrtillus. solution of basic aluminum acetate (liquor alumini The preferred proportion of this group of ingredients subacetatis). The total amount of chemicals preferably is 1-25% of the aqueous base liquid by volume, with comprises 0.1-20% of the total volume, with 1-10% 2-20% being more favorable and 5-15% being the being the most preferable concentration. The herbal optimal concentration. ingredients and stabilizing chemicals may be used in The cream is further composed of liquid vege- comminuted form, e.g., by crushing and/or milling, if table oils, with cade oil, storax, balsam apple extract, desired. and Nigella sativa oil being the most important. Any of these vegetable oils may be present in an amount Experimental Protocol between 0.0001-20% by weight based on the total amount of ointment, although a concentration of 0. Twenty-eight male Wistar albino rats, 6-8 weeks 001-10% is preferable. However, it is best if the oil old, and weighing 160-180 g were used in this study. volume contains 5-30% of storax oil,
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