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Gastrointestinal - Herbal treatment for ulcers

by Paul Bergner and Sharol Tilgner, N.D.

Medical Herbalism 3(3):1,4-6

Ulcers affect about one person in ten in the American society. Ulcer drugs are among the most commonly prescribed in the world, with $3 billion in annual sales in the U.S. alone. Ulcer can be a life-threatening condition. The danger is in perforation of the gut wall, which can result in death. The symptoms of gastric ulcer are also similar to gastric cancer, so ulcer patients should be under the care of a physician.

The most commonly prescribed ulcer drugs are cimetidine (Tagamet) and ranitidine (Zantac). These may be appropriate for an acute ulcer, but they are not suitable for long-term use, even though they are commonly prescribed for six months to a year to prevent ulcer recurrence. They work by suppressing gastric acid secretion. Ironically, however, acid levels are often low in ulcer patients. This suppressive treatment is thus sometimes ineffective, but even when effective does not address the underlying problems causing ulcers. By suppressing stomach acid, these drugs also impair calcium absorption—calcium carbonate, the most common form of calcium in food, requires an acid gastric medium for bioavailability. Acid-suppressing drugs may also inhibit absorption of iron, magnesium, and vitamin B-12.

Tagamet and hyperestrogenism

The practitioner treating patients with ulcers will certainly come in contact with clients or patients taking Tagamet. This drug can have significant side effects. One side effect is that it can cause sexual dysfunction and breast development in some men who use it long term. Researchers recently discovered the reason—Tagamet inhibits the breakdown of estrogen in the liver, causing elevated levels in the blood. Normal doses of cimetidine in the study caused estrogen levels to rise by about 20% within a few weeks (Galbraith). Hyperestrogenic effects in women can include PMS, fibrocystic disease, endometrial cancer, endometriosis, and uterine fibroids, the last two being common causes of hysterectomy in the U.S. High estrogens also can aggravate some forms of breast cancer.

Lifestyle modifications

Holistic medicine has excellent treatments to promote healing and prevent recurrence of ulcers, especially through dietary modifications, lifestyle changes and the use of herbal formulas. Eliminating or cutting down on alcohol, tobacco, aspirin, other analgesics, coffee and soft drinks can reduce ulcer recurrence (Oxford). A high fiber diet alone may prevent the recurrence of ulcers by as much as 50%, which is as effective as the use of cimetidine (Pizzorno; Rydning). Food sensitivities are a common cause of ulcers; some ulcers can be eliminated completely with identification and removal of the offending food (Pizzorno; Riemann). Naturopathic physicians also recommend elimination of dairy and high fat from the diet (Pizzorno). The previous conventional practice of prescribing a high-dairy diet has been abandoned by orthodox medicine (Merck; Koop).

Stress reduction

Stress is a key factor in most ulcers. The digestive system must be in a relaxed state to properly digest and assimilate food. If a person eats while in the “fight or flight” mode of the nervous system, indigestion and possibly ulcers can result. Some ulcer patients can recover completely with no treatment other than stress reduction techniques, especially applied before meals.

Herbal treatments

Herbs can aid in ulcer healing and in preventing recurrence. There is no one single simple herbal treatment, because the underlying causes of gastrointestinal problems are in themselves complex. From a holistic medical point of view, an ulcer is only one manifestation of what may be a whole group of problems needing correction. There can be accompanying poor absorption, hypo or hyperacidity, bleeding, looseness of the stool, infection and sepsis, disordered flora and candidiasis, spasms and pain, and nervous tension each of which must be treated. No single medicine could possibly help all these conditions, so anti-ulcer herbs are traditionally given in combination, ideally tailored for the specific problems of the patient. The formula may be changed regularly, rotating or reformulating combinations with similar properties.

Formulas

Important elements of anti-ulcer formulas are:

Bitter herbs. Many ulcers are not due to excess acidity, but rather to a weakness of the protective factors in the gut wall. Bitter herbs help to tone the mucosa. They encourage production of digestive enzymes needed to digest and assimilate food.

Astringents. Herbs such as geranium can shrink swollen tissue, control bleeding, and tone the mucosa. Many bitter herbs are also astringent.

Demulcent herbs. Herbs like Marshmallow (Althea off.) have soothing, cooling mucilage which reduces inflammation and help to heal the gut mucosa.

Antiseptics. Herbs such as Echinacea or Baptisia may address any infection that is present. One strain of infective bacteria has recently been found by conventional medical scientists to be involved in a high percentage of gastric ulcers.

Nervines. Stress often accompanies ulcers, and nervine herbs may be a useful addition to a formula, or a valuable separate prescription. Chamomile and hops are both nervine and also bitter, and are especially well-suited to ulcer patients.

One classic formula, from which many other ulcer formulas have been derived, is the Roberts Formula (Sherman):

    1 part Marshmallow Root (Althea officinalis)

    1 part Spotted Cranebill (Geranium maculatum)

    1 part Golden Seal (Hydrastis canadensis)

    1 part Echinacea (Ech. spp.)

    1 part Poke rt. (Phytolacca decandra)

If painful: add one part slippery elm or okra.

In this formula, the marshmallow is included for its soothing qualities; geranium is highly astringent and may help control bleeding; golden seal is a bitter tonic, healing mucous membranes and promoting absorption; echinacea is antiseptic and immune stimulating, helping deal with any infection that may be present; poke tonifies the lymphatic system.

Slippery Elm

Indispensable in the treatment of ulcers is Slippery Elm (Ulmus fulva), which can give palliative relief for the pain of ulcers. A useful way to take it is in the form of a gruel or pudding. The following recipe was suggested by herbalist Cascade Anderson Geller in a class at National College of Naturopathic Medicine. The following method may help prevent slippery elm from clumping up in water, which it tends to do. Put 1 ½ tsp. of slippery elm powder in a small jar with ½ cup cold water and shake it up vigorously. Pour this out into a bowl, and pour over it one to two cups boiling water. Stir continuously for two minutes. Patients enjoy this with honey, raisins, lemon rind, cinnamon, or other well-tolerated foods.

References:

Galbraith RA and Michnovitz JJ. “The effects of cimetidine on the oxidative metabolism of estradiol.” New England Journal of Medicine. 1989; 3321:269-742.

Koop E., Surgeon General’s Report on Nutrition and Health. 1988

Merck Manual. 15^th Edition. 1987

Oxford Textbook of Medicine. Oxford University Press.

Physicians Desk Reference. 1984

Reimann HJ, Lewin J. “Gastric mucosal reactions in patients with food allergy. Am J Gastroenterol 1988; 83:1212-1219

Rydning, A et al. “Prophylactic effect of dietary fibre in duodenal ulcer disease. Lancet. 1982 ii:736-9

Sherman, J. Complete Botanical Prescriber. 1978. Natuional College of Naturopathic Medicine.

Tanaka S., et al. “Antiulcerogenic compounds isolated from Chinese cinnamon.” Planta Medica. 1989 55:245-48. 111

Textbook of Natural Medicine. Pizzorno and Murray. John Bastyr College Publications.

Weiss, RF. Herbal Medicine. 1988 Beaconsfield Publishers, Beaconsfield, England.

Case Studies

The following cases from the teaching clinic at the National College of Naturopathic Medicine demonstrate how herbal therapy and diet modification can be combined to heal ulcers. Included are cases of ulceration throughout the entire digestive tract, to demonstrate how treatment may be similar no matter where the ulcer occurs. Also included are “pre-ulcers”—cases of indigestion which respond to the same kind of treatments and lifestyle alterations.

Case 1: Indigestion, poor sleep, possible hiatal hernia.

Patient: 37 year old male. 6’3". 210 lbs. Bank executive. Married.

History: None relevant. Temporary job stress at present.

Treatment: Althea, Glycyrrhiza, Taraxacum: 1 teaspoon per cup of water. Decoct for twenty minutes. Then add passiflora and mint; use one teaspoon per cup of water. Infuse for five minutes. Take two cups per day; one in AM and one in PM. May make three days volume (six cups) at once. Refrigerate and heat portions before drinking if desired. Take the tea for five days per week. Skip two days and repeat for two weeks.

Follow up: thirty days.

Ginger added to decoction. Take one teaspoon per cup. Patient instructed to drink one glass of water and then raise up on toes and drop heavily on heels eleven times each morning, for possible hiatal hernia.

Editorial Comment: This is an artful combination of nervine herbs and more traditional digestive remedies. Note preparation method, adding more fragile aromatic herbs last. In a hiatal hernia, part of the stomach protrudes back up through the diaphragm. The rationale of the water treatment is to get water weight in the stomach, and then mechanically jar it back into place. The patient can also jump from a chair onto the ground.

Case 2: esophageal reflux, acid indigestion, heartburn, gas.

Patient: 36 year old male. 6’2". 230 lbs. Divorced, but in stable relationship with girlfriend.

History: Gastric ulcer five years ago. Vietnam veteran (adjusted well), recreational drugs and alcohol in past. Diet is mostly fast food on the job.

Botanical treatment:

Hydrastis; Althea; Geranium; Echinacea; Phytolacca

Equal parts powdered in capsules. Two capsules ten minutes after each meal.

Other treatments: Add fruits and vegetables to diet. Decrease soda pop and junk food. Homeopathic Lycopodium 30C twice a day. Exercise (walking) at least fifteen minutes per day.

Follow up: one week

Patient feels much better, with more energy, less gas, less heartburn, more emotional stability.

Follow up: two weeks after initial visit

Patient is still noticing improvement. Only one episode of heartburn in last week.

Follow up: four weeks after initial visit.

Patient requested more botanical formula; claims almost complete cure. Still having trouble changing diet and getting enough exercise.

Practitioner’s comment: I feel as does the patient that the Robert’s formula was very helpful in soothing the gastrointestinal complaints and improving digestion. The problem now is to ensure that the patient does not use the botanical combination like an antacid and avoid making necessary lifestyle changes.

Editorial comment: Here a pre-ulcerous condition is treated like an ulcer. This formula here is the classic Roberts Formula.

Case 3: hiatal hernia, ulcerated with blood loss.

Patient: eighty-two year old male, 5’11". 180 lbs.

History: loss of leg in an accident, back problems, nightmares.

Medications: Pain killers; antacids; Tagamet (cimetidine)

Treatment:

    Althea            3 drams

    Geranium        3 drams

    Hydrastis        2 drams

    Valerian        2 drams

Add distilled water to four ounces.

Add 15-30 drops to one half cup hot water 3-45 minutes before meals.

Slippery Elm gruel 2-3 times per day.

Follow-up: twenty-eight days.

Patient feeling fairly well. No bleeding. Will see regular MD in two weeks for follow-up visit.

Follow-up: fifty days after initial visit.

Patient feels more calm. “Less stressed and impatient.” No nightmares. Has not yet received MD’s follow-up report on status of ulcer.

Editorial comment: this ulcer may have been induced by the pain killer drugs, for which there appears to be a need. The back pain may be a result of structural imbalances after the leg amputation, and musculoskeletal manipulation may be of benefit. The case demonstrates how herbal treatment can ameliorate drug-induced ulcers. The use of valerian 30-45 minutes before meals is especially artful. The patient will be in a more relaxed state when eating. Note that the formula is diluted. This may be important for elderly patients.

Case 4: peptic ulcer

Patient: 34 year-old female. 5’2". 110 lbs. School teacher. Single mother with son; guardian of teenage girl.

History: abdominal pain.

Botanical treatment:

Anise        2 parts

Licorice root    2 parts

Althea        2 parts

Passiflora        1 part

Valerian        2 parts

Tincture: thirty drops three times a day.

Other treatments: bodywork and manipulation.

Follow up: four days.

Patient reports 60% reduction in abdominal pain.

Treatment:

Robert’s Formula capsules

Hydrastis; Althea; Geranium; Echinacea; Phytolacca

Two capsules per day.

Follow up: seven days from initial visit

No abdominal pain

Follow up: fourteen days from initial visit

No abdominal pain.

Practitioner’s comment: It is difficult to assess the effectiveness of the initial tincture because it was not used long enough, though she did receive significant benefit from it. The Robert’s formula would have to be given the bulk of the credit.

Editorial comment: Skillful use of nervines in original formula.

Case 5: Duodenal Ulcer

Patient: 44-year-old male. 5’11". 190 lbs. Salesman

History: Reports a deep dull ache or boring pain that is tender to touch in the area between the navel and the breastbone. The pain is very easily relieved by eating food. Pain sometimes shoots to the back between the shoulder blades. Constipation. Tarry looking stools. The patient wakes in the night with hunger pains which are relieved by a snack and a glass of milk. MD recently diagnosed as a duodenal ulcer. Drinks alcohol and smokes tobacco.

Botanical treatment:

Tincture, equal parts:

Hydrastis

Althea

Geranium

Echinacea

Phytolacca decandra

30 drops in a glass of water three times a day between meals.

Other treatments: cut out all meat and fish for thirty days. Eat small frequent meals. No alcohol. Try to stop smoking. No milk.

Follow up: two weeks.

Patient reports he is feeling better on a meatless diet. Pain has not diminished totally but is less than it was. Patient requested a refill of the formula.

Follow up: four weeks after initial visit.

Patient reports all pain is gone and he is eating well with no complications. A refill of the formula was given.

Practitioner’s comment: I suggested eliminating milk because although it first relieves pain, it hinders long-term healing of ulcers.

Editorial comment: There are two theories about why milk should be eliminated in ulcers. Milk initially absorbs some of the stomach acid, but because of its protein content its long-term effect is to increase stomach acid. Milk may also cause allergy-induced ulcers. Note that the Roberts Formula here is in tincture rather than powder form. Slippery elm tea or gruel is indicated for this patient because of the pain. Note that although alcohol as a beverage should be eliminated with ulcers, the amount of alcohol in the tincture is apparently more than counterbalanced by the medicinal effect of the herbs.

Case 6: Duodenal ulcer

Patient: 35 year-old female.

History: duodenal ulcer diagnosed by family physician.

Taking Tagamet for two months with no relief.

Herbal treatment:

Robert’s Formula capsules—see main article or cases above.

Slippery elm tea. 2-4 cups per day.

Cabbage juice when thirsty

Other treatments: Eliminate coffee, dairy products, and alcohol; reduce fats.

Follow up: two weeks.

Compliance good. All symptoms gone.

Editorial comment: This case demonstrates the power of using Robert’s Formula, slippery elm, and cabbage juice in combination. This condition was quickly resolved. Fresh cabbage is juiced in a juicer for this treatment.

Case 7: Duodenal ulcer.

Patient: 26 year-old high school teacher.

History: Duodenal ulcer diagnosed by MD.

Botanical treatment:

    8 parts Marshmallow (Althea Officinalis)

    4 parts Wild Indigo (Baptisia tinctoria)

    8 parts Echinacea angustifolia

    8 parts Spotted Cranebill (Geranium maculatum)

    8 parts Golden Seal (Hydrastis Canadensis)

    8 parts Poke (Phytolacca americana)

    8 parts Slippery Elm (Ulmus fulva)

    2 parts pancreatin

    1 part niacinamide

    2 parts duodenal substance

    One quart of cabbage juice per day.

Other treatments:

Eliminate alcohol and coffee. Stress reduction techniques.

Follow up: two weeks

Patient is cutting back on the herbal formula and cabbage juice, and all symptoms are relieved.

Editorial comment: this is a modification of Robert’s formula known as Bastyr’s Formula. This case demonstrates again how the introduction of fresh cabbage juice can speed healing time.

Case 8: Ulcerative colitis

Patient: 32 year old male, 5’8"; 150 lbs. Single, lives alone. Unemployed.

History: ulcerative colitis off and on for ten years. Onset of present attack when he was fired from his last job.

Botanical treatment: Slippery Elm added to diet. One tablespoon mixed in with his morning millet.

Other treatment: homeopathic podophyllum 6c twice a day. Weekly back massage; weekly hydrotherapy treatment. Hypoallergenic diet; fast one day a week.

Follow up: four days.

Patient is feeling better. Still has 4-6 bowel movements a day but they are less watery; his gut feels less active.

Treatment: add a tablespoon of slippery elm to the evening meal too.

Follow up: seven days after initial visit.

Patient is feeling much better. Still has 4-6 bowel movements but are now well formed and contain no blood or mucous. Less bowel activity and gas between stools.

Follow up: fourteen days after initial visit.

Condition same as last week, and patient is pleased.

Practitioner’s comment: We are very happy with the effectiveness of the slippery elm in reducing the inflammation of his colon and in soothing his mucosa. No other treatment on this patient in ten years was rewarded with such a positive result, and especially in such a short time with such a benign treatment.

Clinical Tip

    When giving digestive herbs in capsules, instruct the patient to break the capsules open and sprinkle them in a cup of warm water. This prevents the herbs from bypassing the stomach before the capsule is digested. It also prevents possible injury from strong herbs all being released at one spot on the gut wall. The taste of the herbs may also be important to promote digestion.

Herbs and Ulcers

    The following are some specific herbs which are often used in treatment of ulcers wherever they occur in the digestive tract. See the main article for a discussion of general categories of herbs.

    Licorice Root (Clycyrrhiza glabra) is useful when ulcers are inflamed. Research has shown that it increases mucous formation and secretion, thus protecting the tissues from the digestive acids. Deglycyrrhizinated licorice root, which is available commercially, has had its glycyrrhizic acid removed to the eliminate the potential side effects of low potassium, edema and possible high blood pressure. Licorice has been shown by research to be as effective as Tagamet in reducing the healing time for ulcers (Pizzorno). It is important to either take the deglycyrrhizinated licorice root (DGL) as a powder or to chew tablets thoroughly to insure that their contents are fully exposed to the gut mucosa.

    Cabbage juice is a traditional naturopathic ulcer remedy, and is a common treatment in Germany today. A quart of freshly made cabbage juice is taken through the course of the day, for several weeks. The ulcer-healing properties of cabbage juice were verified in the 1950s in clinical trails both in the U.S. and Europe (Weiss). A substance with anti-inflammatory properties has been isolated from cabbage.

    Meadow Sweet (Spiraea ulmaria) is an important herb for either hypo or hyper acidity. Note that duodenal ulcers usually result from an elevated amount of acid secreted by the stomach from the stomach, but that gastric ulcers usually have normal or low stomach acid, being a problem of weakness in the stomach lining instead of one of excess acid. Meadow Sweet reportedly restores normal balance to gastric secretory function, increasing stomach acid in hypoacidic conditions, and reducing it in hyperacidity.

    Marshmallow (Althea officinalis) is a useful herb when there is bleeding or irritation. It is mucilaginous, and has a soothing action on inflamed tissues. Marshmallow is a good nutritive herb as well, and may help with many of the underlying and accompanying problems of ulcers.

    Comfrey (Symphytum officinale) is a classic ulcer herb. Unfortunately, recent evidence indicates that it may not be appropriate for long-term use, because of potential toxicity of its pyrrolizidine alkaloids. A woman taking a commercial comfrey product daily for four months develop potentially life-threatening hepatic veno-occlusive disease. A ten year-old boy with ulcerative colitis taking comfrey tea imtermittently for two years developed the same condition. Comfrey is especially hazardous for children and in pregnancy.

    Slippery Elm (Ulmus fulva) can give palliative relief for the pain of ulcers. A useful way to take it is in the form of a gruel or pudding. See the recipe in the main article.

    Chamomile (Matricaria chamomilla) Chamomile is both bitter and anti-spasmodic, and is a soothing nervine as well. Chamomile stimulates the secretion of naturally produced cortisone in the body, and may be especially useful in colitis.

    Hops (Humulus lupulus) Hops is both bitter and nervine, and good when nervous problems accompany G.I. problems.