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Herbal/Nutritional Gastroenterology ©2005 David Winston, RH (AHG)

Revised 2016

Digestion, absorption, and elimination are truly the foundation of health. In my clinical practice at least 60 to 65% of all of my patients have significant digestive health issues. Achlorhydria, hyperchlorhydria, leaky gut syndrome, IBS, IBD, GERD, SIBO, chronic diarrhea, GI dysbiosis, malabsorption, constipation and gastric ulcers are all common conditions. This is a major problem because if digestion is impaired, the grain Qi (Gu Qi) cannot be extracted. The old adage, “you are what you eat” has a basis in reality although it isn’t entirely accurate. You can ingest the healthiest foods, supplements, and herbs, but if they pass undigested through the alimentary canal, they offer little or no benefit. If there is good digestion this leads to enhanced absorption in the small intestine Simply adding bitters to the average diet can enhance both digestion and absorption. One of my early teachers, the late William LeSassier, used to say “you are what you don’t excrete”. There is truth to his statement as well. Normal bowel function allows for the elimination of fecal waste as well as bile salts, cholesterol, and hormones. Chronic constipation is not only uncomfortable, it can be associated with increased reabsorption of metabolic wastes, intestinal permeability and associated food sensitivities, higher levels of colon cancer, and possibly hormonally triggered cancers as well. Improving digestion, absorption, and elimination can have a profound and wide-reaching effect. It is not uncommon for a person with digestive issues to notice that as their GI health improves, so does their depression, arthritis, headaches, fatigue, lack of libido, and skin problems. Research clearly shows that the gut is much more than a channel for eliminating wastes. The GI tract contains the enteric nervous system, or enteric brain. This complex system (gut-brain axis) acts as an interface between the nervous, immune and endocrine systems, as well as the skin and the gut microbiome. Interestingly, this tissue not only has receptors for every neuropeptide and hormone produced in the brain and endocrine glands, but it makes these same chemicals. In fact, more serotonin is manufactured in the GI tract than by the brain, showing a strong link between GI health and emotional health (although serotonin produced in the gut cannot pass the blood brain barrier, the precursor chemicals made in the GI tract can and do in a healthy person). The small intestine also produces benzodiazapine-like chemicals that help prevent stress-induced GI symptoms as well as anxiety and irritability. A great deal of immune tissue and immune response is gut-mediated as well. Leaky gut syndrome (increased gut permeability) is linked to allergies, food sensitivities, some autoimmune diseases (allergic asthma, MS), Crohn’s disease, IBS and IBD. The GALT (gut associated lymphoid tissue), which includes the Peyer’s patches as well as the tonsils, appendix, and adenoids, are needed for effective innate immunity and especially for adaptive immunity. This tissue traps pathogens and activates lymphocytes to respond to viral, fungal, or bacterial threats. A healthy gut microbiome is comprised of over 1000 bacterial or fungal species. Studies suggest an adult human body contains 1014 cells. Only 10% of these make up our body, the remaining 90% are bacteria living mostly in the lumen of the large intestine (Thompson-Chagoyan, et al, 2005). This means we are 90% bacteria and the number of genes in our gut flora is 70-140 times that of our genome. It has been proposed by some researchers that the gut microbiome be considered a separate organ within its human host. In reality it is not separate and the newest studies often refer to the brain-gut-enteric microbiome axis to describe this vital interconnected system that is essential to maintain systemic homeostasis. The intestinal microbiota is capable of more metabolic conversions than the liver, it extracts energy from indigestible compounds, protects against non-indigenous microorganisms, is needed for synthesis of B-12 and K-2 as well as absorption of calcium, iron and magnesium and it maintains the health and growth of the intestinal epithelium (Thompson-Chagoyan, et al, 2005). The intestinal microbiome also strongly influences immune health, mental health, obesity and possibly autism (Grenham, et al, 2011)

Digestion Three common abnormalities of the digestive system are achlorhydria (a lack of gastric HCL), dyspepsia, and hyperchlorhydria (excessive gastric HCL). According to television commercials, it seems everyone has excess stomach acid. Americans spend billions of dollars per year on antacids, the purple pill, and gastric acid pump inhibitors (proton pump inhibitors and H2 receptor blockers). The truth is that the symptoms of excess stomach acid and a lack of stomach acid are very similar. Many people are actually making their condition worse by taking inappropriate medications. In people with achlorhydria, there is often stomach pain and a sense of burning. This is accompanied by excessive gas, belching, borborygmus, abdominal bloating, and a heavily coated (white moss) tongue.

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They are also more likely to experience chronic low-grade diarrhea with undigested food particles in the stool, SIBO (small intestine bacterial overgrowth), GERD and IBS. People suffering from too much stomach acid (hyperchlorhydria), which is less common, also have stomach pain and a burning sensation. They usually have little or no gas, belching, or diarrhea. They present with symptoms such as red, receding gums, aphthous stomatitis and a red, sometimes pointed tongue. These conditions are very different, even if some symptoms (gastric pain) are similar. Successful treatments need careful differential diagnosis to accurately assess the actual underlying problem.

Herbal Treatments for Achlorhydria and Dyspepsia Bitters Bitter herbs stimulate the entire process of digestion, absorption, and elimination. The non-alkaloidal bitters increase gastric HCL production, bile secretion and excretion, and small intestine and pancreatic juices. Herbs such as Dandelion root or leaf, Chicory root, Artichoke leaf, Gentian root, Quassia, Centaury herb, Mugwort, Hops, or Ground Ivy are excellent bitters. Most bitters are energetically cooling and so, while in the short-term they enhance digestion, over a period of time they can actually cool down “stomach fire” and decrease digestive function. A good bitters formula has cooling bitters, but adds either warming bitters or warming spices (Ginger, Cinnamon, Caraway, Cloves or Cardamom) to make a formula that can be used daily over the long-term to enhance digestion, absorption and elimination. Warming Bitters Angelica root (Angelica archangelica)– is my favorite warming bitter. It enhances digestion, relieves gas, nausea, and borborygmus. Like most bitters, Angelica enhances absorption. It is also an aperient, helping to promote normal bowel function and it acts as a prokinetic, enhancing gastric emptying. Tincture (1:5): 2-3 mL TID Tea: 1 tsp. dried root, 10 oz. water, decoct 10 minutes, steep covered 30 minutes, take 4 oz. TID Bai Zhu/Atractylodes root (Atractylodes macrocephala) – is used in TCM to tonify the Stomach/Spleen qi and relieve diarrhea, abdominal bloating, vomiting and lack of appetite. It is a prokinetic and enhances esophageal and small intestine motility and can be used as part of a protocol treating GERD or SBBO. A combination of Orange fruit and Atractylodes (Zhizhu decoction) promoted gastric emptying and had gastroprotective effects in an animal study (He, et al, 2012). Tincture (1:5):1-2 mL TID/QID Tea: 1 tsp. dried root, 8 oz. water, decoct 10 minutes, steep covered 40 minutes, take 4-8 oz. 2-3x/day Fenugreek seed (Trigonella foenum-graecum)– is a warming bitter that also binds with endotoxins in the gut, increasing their excretion. Regular use of the powdered seed lowers triglyceride and LDL/VLDL cholesterol levels and helps regulate blood sugar levels. Tincture (1:5): 2-4 mL TID Tea: 1-2 tsp. dried seed, 10 oz. water, decoct for 15-20 minutes, steep covered 30 minutes, take 4-6 oz. TID Qing Pi/Green Tangerine/Orange peel (Citrus reticulata) – is a warming bitter used in TCM for treating abdominal bloating, indigestion, belching, nausea and lack of appetite. It is often combined with Bupleurum, Licorice, Cyperus or White Peony for functional dyspepsia (what is known in TCM as liver attacking stomach). Tincture (1:5): .5-1 mL TID Tea: 1-2 tsp. fresh powdered/dried peel, 8 oz. water, steep covered 15-20 minutes, take 2 oz. 3x/day Turmeric rhizome (Curcuma longa) – is a mildly warming bitter, as well as a carminative, antiinflammatory, antitumor, hepatoprotective, and gastroprotective agent. Turmeric, used as a spice, as a powder in capsules, or as a tincture helps heal the gastric mucosa. The standardized product can also be useful, but high doses of the 90% Curcumin product can actually irritate the GI tract. Turmeric is a cholagogue and choleretic (it stimulates bile secretion by the liver and excretion by the gallbladder), promoting fat digestion and elimination of wastes by phase II liver pathways.

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Tincture (1:2): 3-4 mL TID Tea: 1-2 tsp. dried rhizome, 10 oz. water, decoct 10 minutes, steep covered 30 minutes, take 4-6 oz. TID

Herbs Used To Stimulate Gastric HCL Ginger root (Zingiber officinalis) – is a warming, stimulating digestive herb that also promotes gastric emptying, circulation, expectoration and diaphoresis. Ginger is well-known as an antiemetic for nausea, vomiting, and morning sickness. It enhances digestive function, and also relieves gas, diarrhea, and food poisoning. Zingiber has also been found to inhibit Helicobactor pylori (Cwikla, et al, 2010). Tincture (1:2): 1-2 mL TID Tea: 1 tsp. dried, powdered root, 8 oz. hot water, steep covered 15-20 minutes, take 2-4 oz. TID Juniper berry (Juniperus communis) – is a very strong and potentially irritating herb. Excessive doses can cause irritation of the urinary and GI tract. In small doses, the berries strongly stimulate gastric secretions enhancing sluggish digestion and relieving dyspepsia. Tincture (1:5): 1-2 mL TID Tea: 1 tsp. dried berries, 8 oz. water, decoct 5 minutes, steep covered 20 minutes, take 2-4 oz. TID Orange peel (Citrus spp.) - is, in my opinion, the premier herb for increasing gastric HCL production. I usually combine Orange peel with Angelica, Artichoke leaf, and Dandelion root as my basic “bitters formula”. Orange peel (Tangerine peel works as well) promotes “digestive fire”, acts as a GI prokinetic, and relieves gas, nausea, vomiting, and borborygmus. Tincture (1:5): .5-1 mL TID Tea: 1 tsp. dried peel, 8 oz. water, decoct 5 minutes, steep covered 20 minutes, take 2-4 oz. TID Prickly Ash bark (Zanthoxylum clava-herculis) – is a powerful herb that enhances digestion and circulation. As little as 5-10% of Prickly Ash in a formula increases absorption of the entire formula. Tincture (1:5): 10-15 gtt. TID Tea: 1/2 tsp. dried powdered bark, 8 oz. hot water, steep covered 20-30 minutes, take 2-4 oz. TID

Carminatives Used to Relieve Dyspepsia Carminatives are aromatic herbs that enhance digestion and most importantly relieve nausea, gas, belching, and borborygmus. Virtually all spices used in cooking are carminatives and most have the added benefits of being antiviral, antibacterial, antioxidant, and antiinflammatory. Some common carminatives include:

* Inhibits H. pylori ∆ Inhibits C. jejuni

Herbs for Gastro-esophageal Reflux Disease (GERD) GERD, also known as acid reflux, is a condition caused by obesity, overeating or rapid eating and what is known in TCM as rebellious qi, all of which can trigger problems with normal esophageal motility (Galland, 2012; Savarino, et al, 2011).

Anise Hyssop Cinnamon* Oregano Anise seed Cloves* Peppermint Basil Coriander Rosemary Bergamot herb Cumin* Sage * and ∆ Buchu Damiana Sassafras Dill seed Dill seed Savory Calamus Fennel seed ∆ Spearmint Cardamom Galangal* Spicebush leaf/bark Catnip Hyssop Thyme Cayenne* Lavender Zhi Shi Cilantro Nutmeg*

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Some research also suggests that hypoacidity, rather than hyperacidity is a cause of GERD (Galland, 2012). It can be exacerbated by medications such as prednisone as well as sleep apnea, smoking, alcohol consumption, gluten sensitivity, SIBO/SBBO, a high carbohydrate diet and possibly gallstones. In addition, the mucous membrane damage caused by this condition is due to an inflammatory response to pepsin, not just stomach acid (Nagakama, et al, 2006). The symptoms of GERD include heartburn, regurgitation of stomach acid, difficulty swallowing, nausea and chest pain. In chronic cases, damage to the esophagus can lead to Barrett’s Esophagus, laryngitis, chronic cough, damage to the teeth and asthma. People with GERD also have a much higher incidence of IBS as well. Orthodox treatments usually involve proton pump inhibitors (omeprazole), gastric H2 receptor blockers (cimetidine), antacids and alginic acid (Gaviscon©). Laparoscopic surgery is also used in chronic cases and seems to have better outcomes than pharmaceutical therapies. People who have GERD are recommended to lose weight (if overweight), sleep on their left side with their upper body elevated, eat smaller meals, avoid eating before bed and avoid fatty foods and highly acidic ones such as carbonated beverages, citrus, tomato sauce and coffee. In a clinical trial, a very low carbohydrate diet was effective in relieving GERD symptoms (Austin, et al, 2006). In addition to these lifestyle changes, herbs such as demulcents and GI antiinflammatories can help heal gastric erosion and inflammation (see Herbs to Heal Gastric and Intestinal Mucosa). GI analgesics such as Wild Yam, Kudzu or Peach Tree leaf can also be used for GERD, as they can improve symptoms, as do prokinetic herbs such as Atractylodes, Angelica, immature Orange/Zhi Shi, Ginger or processed Pinellia. In Chinese medicine, bitters are used to make the digestive energy descend. Anytime someone has rebellious qi (GERD, hiatal hernia, hiccoughs), bitters are used to correct this problem. A Japanese Kampo formula, Rikkunishito/Liu Jun Zi Tang (TCM), which contains Licorice, Ginger, Atractylodes, Jujube date, Orange Peel, Ginseng, processed Pinellia and Poria has been found in human trials to alleviate GERD, dyspepsia, nausea and diarrhea (Tominega, et al, 2012). A TCM formula, Si-Ni-San, which contains White Peony, Bupleurum, immature Orange fruits and Licorice, has been shown in many clinical trials to significantly reduce not only symptoms of GERD but also dyspepsia, duodenogastric reflux, gastritis, IBS and ulcerative colitis (Ling, et al, 2010). According to the authors of this study, the ability of this one formula to have such profound effects for so many GI problems suggests an underlying pathogenesis. They concluded that the possible causes include abnormal GI motility and sphincter control, visceral hypersensitivity, an impaired GI mucosal barrier, chronic stress affecting the gut/brain axis and impaired GI circulation (blood stasis). In a human clinical trial melatonin, combined with amino acids and vitamins, was more effective than omeprazole in treating GERD (Pereira, 2006).

Herbal Treatment for Gastric and Duodenal Ulcers In the 1960’s and 70’s, doctors had concluded that stress was the cause of gastric and duodenal ulcers. The saying “stop worrying, you’ll give yourself an ulcer” expressed a widely held belief. In the 1980’s a young medical student, Barry Marshall, came to believe that a bacteria, Helicobactor pylori, was the cause of ulcers. Ultimately he ingested the bacteria and sure enough he developed gastric irritation and lesions. He and the physician he worked with, Dr. Robin Warren, were awarded the 2005 Nobel Prize in Medicine for their discovery. Helicobactor pylori is a primary causative agent for gastritis, gastric ulcers (90%) and duodenal ulcers (80%), gastric cancers and possibly some inflammatory bowel conditions as well. Ironically, the elimination of this historically normal bacteria may be implicated in the significant increase in allergies and autoimmune diseases in first world countries (Arnold, et al, 2012). It should be noted that there are more than a few cases of people with ulcers that do not have H. pylori and people with H. pylori who do not have ulcers. Dismissed as having no serious implications in ulcerogenesis, stress is still a real causative factor for some ulcer patients, as are excessive alcohol consumption, aspirin, NSAIDs (ibuprofen, naproxin) and some other pharmaceutical medications. Smoking or chewing tobacco can also contribute to ulcer formation and inhibits the healing of ulcers. Effective treatments should include herbs to inhibit, reduce the virulence or prevent H. pylori infections, herbs to heal the gastric mucosa and herbs to normalize digestion and relieve underlying issues such as achlorhydria, hyperchlorhydria, or nervous stomach. Orthodox treatment of peptic ulcers usually involves what is called triple therapy. This includes two antibiotics (usually clarithromycin/Biaxin®, amoxicillin or metronidazole/Flagyl®) and a proton pump inhibitor (omneprizole or lansoprazole). Studies have shown that adding panitadine bismuth to this protocol enhances H. pylori eradication (Vitor & Vale, 2011).

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Even with the usual therapy, treatment failure occurs in 10-23% of patients. Primarily this is due to increasing drug resistance of H. pylori to the antibiotics.

Herbs to Inhibit H. pylori and Inhibit Bacterial Virulence Cinnamon bark (Cinnamomum verum) – the essential oil and cinnamaldehyde extracts have been shown to have potent H. pylori inhibiting effects (Safavi, et al, 2014). Cinnamon also reduces gastric bleeding and inflammation in people with duodenal or gastric ulcers. Tincture (1:4 or 1:5): 1-1.5 mL TID Tea: 1/4-1/2 tsp. dried powdered bark, 8 oz. water, steep covered 15-20 minutes, take 4 oz. 3-4x/day Cranberry (Vaccinium macrocarpon), Blueberry (V. angustifolium) – Cranberries are well known for their ability to prevent urinary tract infections due to anti-adhesion activity. Blueberries also have this activity and both can also prevent adhesion of H. pylori to the stomach wall, helping to prevent gastric ulcers. Capsules: 1-2 capsules BID Cranberry concentrate: 1 oz. BID Cranberry or Blueberry Solid Extract: 1/2 tsp. BID Goldenseal root (Hydrastis canadensis) – is indicated for mucous membrane tissue that is atonic, boggy, with a tendency toward infections and bleeding. It kills H. pylori (Cwikla, et al, 2010) and is a superb remedy for treating gastritis and gastric or duodenal ulcers. It tonifies the tissue, helps stop bleeding, and improves localized circulation. If Hydrastis is unavailable, Chinese Coptis is the next best Berberine-containing herb. Other Berberine-containing herbs such as Yellow Root, Oregon Grape Root, Barberry, Goldthread, and Phellodendron bark all have some benefit, but are inferior to Goldenseal for this specific purpose. Tincture (1:5): 1-2 mL TID Tea: 1 tsp. dried powdered root, 8 oz. hot water, steep 30 minutes, take 4 oz. TID Capsules: 2 (00) capsules BID Mastic gum (Pistacia lentiscus) – In a human clinical trial, Mastic Gum showed a modest ability to eradicate H. pylori infections (Dabos, et al, 2010). Capsules: 350 mg TID Oregano herb (Origanum vulgare) – has antiviral, antibacterial, and antifungal activity. In in vitro studies, Oregano has exhibited active inhibitory effects against H. pylori (Stanatis, et al, 2003). This common spice is also a carminative and can help relieve dyspepsia as well. Another popular spice, Rosemary, also showed significant activity against H. pylori. Tincture (1:5): 1-2 mL TID Tea: 1 tsp. dried herb, 8 oz. hot water, steep covered, 20 minutes, take 4 oz. TID Oil of Oregano softgels: 1 softgel BID Oil of Oregano: 1-6 drops per day Roberts’ Formula – is a classic formula created by Frank Roberts, a British herbalist. He used equal parts tinctures of Echinacea root, Poke root, Marshmallow root, Goldenseal root, and Cranesbill root. This formula has been used successfully for over 50 years, it inhibits H. pylori and heals both gastric and duodenal ulcers. Tincture: 30 gtt. in 4 oz. of water, taken 3 times per day between meals Sage herb (Salvia officinalis) – has a long history of use for many GI-related complaints. It helps reduce excessive secretions and inhibits hyperchlorhydria. It also helps relieve gas, abdominal bloating and is gastroprotective (Mayer, et al, 2009). In laboratory and animal studies it enhances healing of gastric ulcers, inhibits H. pylori, the cause of many peptic ulcers as well as C. jejuni, a common cause of diarrhea (Cwikla, et al, 2010). Tincture (1:5): 1-2 mL TID/QID Tea: 1 tsp. dried herb, 8 oz. hot water, steep covered for 20-30 minutes, take 4 oz. 3 times per day

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Tannin-rich herbs – several herbs with high tannin levels, including Pomegranate rind (Punica granatum), Potentilla (P. fruticosa), Geranium wilfordii, Geum iranicum, Green tea (Camellia sinensis), Chebulic myrobalans (Terminalia chebula) have all been shown to strongly inhibit H. pylori (Safavi, et al, 2014). In most cases water extracts had superior activity to alcohol extracts. Turmeric rhizome (Curcuma longa) – has long been used to treat gastritis, gastric ulcers and other GI inflammatory diseases. In an animal study, Turmeric (Curcumin) eradicated H. pylori infections and promoted healing of gastric damage (Vale & Oleastro, 2014). Tincture (1:2 or 1:4): 2-4 mL TID/QID Curcumin: 400-600 mg TID

Supplements for H. pylori Infections Lactoferrin – is an iron-binding glycoprotein found in animal and human milk. Lactoferrin, by itself and with probiotics, has been shown to increase the effectiveness of the orthodox therapy for treating H. pylori infections (Zou, et al, 2009). It also helped reduce adverse effects (especially nausea, diarrhea and gastric pain) caused by antibiotics. Capsules: 250-500 mg BID Probiotics – for people with peptic ulcers the use of probiotics is essential, especially if they are receiving the conventional “triple therapy”. In over 20 human trials various probiotics, including Lactobaccilus spp., Bacillus spp., Bifidobacterium spp., Saccharomyces boulardii (a beneficial yeast) and mixed strains have either enhanced H. pylori eradication, reduced antibiotic-induced adverse effects, or both (Vitor & Vale, 2011). In some cases they also decreased dyspepsia caused by ulcers. Many probiotic bacteria have also been found to produce proteins known as bacteriocins. These compounds are strongly antibacterial and have been found to inhibit H. pylori.

Foods That Inhibit H. pylori Brocolli sprouts – are a rich source of the isothiocyanate sulforaphane. This compound has been shown in animal and human studies to have potent antibacterial activity against H. pylori, as well as gastroprotective effects (Fahey, et al, 2015). Eating the sprouts daily inhibited H. pylori numbers and colonization, reduced gastric inflammation and gastric mucosal atrophy. The combination of broccoli sprouts and Black Currant seed oil was synergistic and more potently inhibited H. pylori than either substance by itself (Keenan, et al, 2010). Most other cruciferous vegetables are lacking in sulforaphane but do contain other isothiocyanates and epidemiological studies have shown an inverse association with consuming crucifers and H. pylori infections. . One common member of this family is cabbage, and drinking the raw juice has a long history of use for treating gastric ulcers. Dose: 6 per day of the fresh sprouts Fish oils – taking fish oil (especially DHA) has been shown to inhibit H. pylori and population studies have found in inverse association with frequent consumption of oily fish and the development of duodenal ulcers. DHA and fish oil are antiinflammatory and while they do not totally eliminate H. pylori colonization, they have been shown to significantly reduce H. pylori-induced gastric inflammation, atrophic gastritis and the risk of gastric cancer (Park, et al, 2013). Dose: 4-6 g per day

Other Foods Which Have Been Shown to Have H. Pylori Inhibiting Effects In addition to cranberries and blueberries inhibiting H. pylori and its attachment to the gastric mucosa, other fruits, fruit juices and concentrates such as raspberry, elderberry and strawberry have exhibited some activity. Dried okra powder is believed to have anti-adhesion effects and also inhibit H. pylori, as do a number of brown seaweeds.

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Herbs to Heal the Gastric and Intestinal Mucosa (for Gastric and Duodenal Ulcers as well as GERD, Ileitis, Leaky Gut Syndrome, Celiac Disease, and IBD)

Aloe gel (Aloe vera) - the fresh leaf gel is very effective for healing erosion of the stomach or the intestines. It inhibits H. pylori and stimulates mucosal healing due to its allantoin and mucilage content. In a human clinical trial Aloe vera gel was vastly more effective then placebo for treating ulcerative colitis. In the Aloe group 30% went into remission, 37% had improvement and 47% had a significant response compared to 7%, 7% and 14% with placebo (Langmead, et al, 2004). Fresh gel: 1-2 tbsp. BID/TID Calendula flowers (Calendula officinalis) – act as a vulnerary and antiinflammatory topically and internally. The flowers also have mild antibacterial and antiviral activity and are rich in antioxidant carotenoids. Calendula combines well with Propolis and Myrrh (all high alcohol tinctures) for gastritis, ulcers, leaky gut syndrome, esophageal ulceration, Ileitis, and IBD. Tincture (1:2 or 1:5): 2-4 mL TID Tea: 1-2 tsp. dried flowers, 8 oz. hot water, steep 40 minutes, take 4-8 oz. TID Chamomile flowers (Matricaria recutita) – are a carminative and a GI antiinflammatory. The high bisabolene chemotypes are especially useful for healing gastric ulcerations and relieving pain and abdominal discomfort. Various Chamomile extracts have also been shown to inhibit H. pylori (Safavi, et al, 2014). Roman Chamomile (Chamaemelum nobile) can also be used and it has a stronger antispasmodic effect for treating IBS symptoms. Tincture (1:2 or 1:5): 3-5 mL TID Tea: 1-2 tsp. dried flowers, 8 oz. hot water, steep covered 30 minutes, take 4-8 oz. TID Goldenseal herb (Hydrastis canadensis) – see herbs to inhibit H. pylori Gotu Kola herb (Centella asiatica) – is a southeast Asian herb with a long history of use for healing red, inflamed tissue. It is used topically for healing burns, decubitus ulcers and promoting wound healing. Internally it is used to treat gastric ulcers, IBD, Barrett’s Esophagus, leaky gut syndrome, and gastritis. Although no human studies have been done to confirm its use for treating ulcers, numerous animal studies suggest that it may be effective for this use. Tincture (1:2): 1.5 mL TID Tea: 1-2 tsp. dried herb, 8 oz. hot water, steep covered 45 minutes, take 4 oz. 3x/day Licorice root (Glycyrrhiza glabra, G. uralensis) – helps to heal inflamed gastric and intestinal mucosa, reduces excessive gut permeability, and inhibits H. pylori adhesion (Wittschier, et al, 2009). Licorice is also an antiinflammatory, an adaptogen (helps to re-regulate the immune, endocrine, and nervous systems) and is an immune amphoteric, which makes it quite useful for autoimmune conditions including Crohn’s disease and ulcerative colitis. In laboratory studies it also strongly inhibited H. pylori, the cause of most gastric ulcers (O’Mahony, et al, 2005). Tincture (1:5): 1-2 mL TID Tea: 1 tsp. dried root, 10 oz. water, decoct 10-15 minutes, steep 30 minutes, take 2-4 oz. TID DGL Licorice: 760 mg capsule TID Mucilaginous herbs – as mentioned under herbs for hyperchlorhydria, demulcent herbs soothe irritated mucosal tissue and promote mucin production and healing of the intestinal epithelial barrier. Slippery Elm is, in my experience, probably the best of the GI demulcents. It should be taken as a room temperature infusion between meals. Slippery Elm does not make an effective tincture, but Marshmallow retains some of its demulcent qualities in this form. A tea of Marshmallow is also very soothing. Comfrey (leaf and root) has a long history of use for healing ulcerated tissue, but because of its pyrrolizidine alkaloid content and the long period of time needed to heal ulcers, it is not a wise choice for chronic use. Other demulcent herbs, Chia seed, Flax seed, Psyllium seed, Irish Moss, Sterculia, and Prickly Pear, all have some benefit but are not, in my opinion, as useful as Slippery Elm or Marshmallow Root.

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Myrrh gum resin (Commiphora myrrha) – has gastroprotective and gastric healing effects. It has a long history of use for treating gastric and duodenal ulcers, as well as gastrititis. It is antibacterial, antiamoebic, antiinflammatory and it promotes healing of mucosal tissue and the skin. Myrrh can also be useful for reducing gut permeability and IBD. Tincture (1:5): 1-2 mL TID/QID Tea (Decoction): 2 tsp. resin, 12 oz. water decoct 15-20 minutes, steep covered 1 hour, 4 oz. 4x/day Plantain leaf/root (Plantago major) – contains allantoin, chlorophyll, and flavonoids, which help heal inflamed and irritated skin, GI tract, and GU tract tissue. The root can be used with the leaf if there is gastric bleeding. A tea, tincture, or the juice can be used along with Chickweed juice and/or Cabbage juice to speed healing of ulcers. Tincture (1:2); 4-6 mL TID Tea: 2 tsp. dried leaf, 8 oz. hot water, steep 20-30 minutes, take 8 oz. TID Juice: 1 tbsp. TID Propolis Bee gathered resin – has a gastroprotective effect and can help prevent gastritis and ulcers. It is also strongly antibacterial and antioxidant, helping to inhibit H. pylori infections and the resulting inflammation. Tincture (1:5); 1-2 mL TID Capsules: 2 (00) capsules BID Turmeric root (Curcuma longa) – has a long history of use in India and China for treating gastric ulcers, GI pain and dyspepsia. Both the root and its isolated constituent curcumin have been found in human and animal studies to inhibit GI inflammation and proinflammatory chemicals including COX-2, LOX, TNF-a, IFN-gamma, and NF-kappaß. It also reduced the incidence of relapse in patients with quiescent IBD (Hanai & Sugimoto, 2009) and improved IBS symptoms in a pilot trial (Bundy, et al, 2004). Laboratory studies also suggest that Turmeric has very strong bactericidal activity against H. pylori and it inhibits bacterial adhesion as well (O’Mahony, et al, 2005). Turmeric also inhibits the formulation of intestinal polyps, heals excessive gut permeability and can reduce the risk of bowel cancers. Tincture (1:2 or 1:4): 204 mL TID/QID Tea: 1/2 tsp. dried, freshly powdered rhizome, 8 oz. hot water, steep covered for 45 minutes, take 4 oz. 4x/day Capsules: Standardized 80-90% Curcumin 250 mg – 500 mg TID Yarrow herb/flowers (Achillea millefolium) – have antibacterial, antiviral, antiinflammatory, vulnerary, and styptic effects. Yarrow is especially indicated for GI tract ulceration with bleeding or a heavy mucus discharge. I routinely use Yarrow to help treat gastric ulcers, ulcerative colitis or Crohn’s disease. Tincture (1:5): 2-4 mL TID Tea: 1-2 tsp. dried herb/flowers, 8 oz. hot water, steep covered 20-30 minutes, take 4 oz. TID

Hyperchlorhydria Hyperchlorhydria or heartburn is mostly associated with a younger age group, <40, and it can be triggered by over-eating spicy or acidic foods, stress, and certain medications and diseases. For some it is an occasional problem caused by holiday dinners or eating the “wrong” food. For many people, it can become a chronic condition. Some simple techniques can alleviate symptoms for many people. Avoid eating when stressed or anxious, eat smaller meals and slow down the pace of eating, chew food well, avoid foods that do not agree with you (i.e., cucumbers, garlic, onions, beans, or brassicas). If obese, work at losing weight. It can also help to simplify meals, listen to calming music during meals, avoid stressful conversations, and to briefly meditate or pray before eating.

Herbal Treatments for Hyperchlorhydria Catnip herb (Nepeta cataria)– like Chamomile, Valerian, or Hops, is very useful for stress-induced GI symptoms. Nervous stomach or bowel respond well to this herb. It is an effective carminative for gas, nausea, “butterflies in the stomach”, diarrhea, and stress–induced heartburn (use it with Slippery Elm and Chamomile). Tincture (1:2 or 1:5): 3-5 mL TID Tea: 1-2 tsp. dried herb, 8 oz. hot water, steep covered 20 minutes, take 4 oz. TID

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Chamomile flowers (Matricaria recutita) – are especially useful for stress-induced GI symptoms, including hyperchlorhydria, nausea, GERD, and gastritis. It is an effective nervine and antiinflammatory to the entire GI tract. Tincture (1:2 or 1:5): 3-5 mL TID Tea: 1-2 tsp. dried flowers, 8 oz. hot water, steep covered for 30 minutes, take 4-8 oz. TID Lemon Balm herb (Melissa officinalis) – is a flavorful herb that has a long history of traditional use for acid stomach, especially in children. It can be combined with Meadowsweet, Chamomile, Licorice, and Marshmallow for an effective tea for relieving hyperchlorhydria. Tincture (1:2.5 or 1.5): 4-5 mL QID Tea: 1-2 tsp. dried herb, 8 oz. hot water, steep covered for 15-20 minutes, take 2-4 cups/day Licorice root (Glycyrrhiza glabra, G. uralensis) – is antiinflammatory, a demulcent, and antibacterial/antiviral. It is best known for treating gastric or duodenal ulcers, but it is also useful for gastritis, hyperchlorhydria, ileitis, IBS and IBD. Small amounts of Licorice can be used along with the other herbs listed here to enhance the overall effect and to heal gastric or esophageal erosions. Tincture (1:5): 1-2 mL TID Tea: 1 tsp. dried root, 8 oz. water, decoct 10-15 minutes, steep 1/2 hour, take 2-4 oz. TID Marshmallow root (Althea officinalis) – is a very effective demulcent for GI tract irritation. It contains polysaccharides that soothe and help heal ulcerated tissue in the upper respiratory tract, stomach, and bowel. Marshmallow is effective as a tea or tincture. Tincture (1:5): 2-4 mL TID Tea: 1-2 tsp. dried herb, 8 oz. water, steep 1-2 hours, take 4-8 oz. TID Meadowsweet herb/flowers (Filipendula ulmaria)– are rich in salicylates and so many people would assume, like aspirin, it would irritate the gastric mucosa. The reverse is true. Filipendula relieves gastric irritation, pain, and helps reduce the over-secretion of gastric acid. It is most often combined with a mucilaginous herb to help heal and coat the stomach lining. Herbs such as Slippery Elm, Marshmallow, Psyllium, Flax seed, Linden Flower or Sterculia can be used with this herb. In an in vitro study Meadowsweet strongly inhibited H. pylori, the primary cause of gastric ulcers and gastritis (Cwikla, et al, 2010). Tincture (1:5): 2-4 mL TID Tea: 1-2 tsp. dried herb, 8 oz. hot water, steep, covered, 20 minutes, take 4-8 oz. TID Neem leaf (Azadirachta indica) – has a long history of use in India, where it is used in human and veterinary medicine. Even though this plant is intensely bitter, it has been shown to reduce gastric hypersecretion and helps heal gastric ulcers (Bandyopadhyay, et al, 2004). It also inhibits amoebic parasites. Tincture (1:5): .5-1 mL BID/TID Peach Tree leaf or twigs (Prunus persica) – is one of the most effective remedies for irritation of the stomach with nausea or vomiting. The medicine was popular with the Physio-medicalists and Eclectics who used it for gastritis, irritative diarrhea, dyspepsia and gastric pain. The patient’s tongue is pointed with red edges and red, raised papillae denoting excess stomach fire (hyperchlorhydria or gastritis). Tincture (1:5): .25-.75 mL TID/QID Tea – leaf: 1 tsp. recently dried leaf, 8 oz. cool water, steep for 1 hour, take 1-2 tsp. every 1-2 hours twig: 1/2 tsp. finely cut, recently dried twigs, 8 oz. cool water, steep for 1 hour, take 1-2 tsp. every 1-2 hours Slippery Elm inner bark (Ulmnus rubra) – is possibly the most effective GI tract demulcent. It is most effective as a tea and can help heal atrophic gastritis, gastric or duodenal ulcers and it relieves the discomfort from excessive stomach acid. Tea - 1/2-1 tsp. powdered bark, 8 oz. room temperature water, steep for 1-2 hours, take 3-4 cups/day

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Absorption/Small Intestine Most of the absorption of nutrients takes place in the small intestine. Lack of absorption usually indicates impaired digestion. Digestion starts when food is masticated and mixed with saliva. This is further digested by the stomach acid and then the bile, pancreatic, and small intestine juices finish the process of separating “the pure from the impure”. In TCM, the Gu qi or grain qi is the vital essence of foods, what we would recognize as vitamins, minerals, fatty acids, enzymes, and phytonutrients. As mentioned previously, enhancing digestion enhances absorption. Many issues of poor absorption are dealt with by adding bitters to the diet. The most common problem of the small intestine is probably duodenal ulcers, which was discussed along with gastric ulcers. Other diseases of the small intestine include acute Ileitis, Celiac disease (also known as Celiac sprue, regional enteritis or Crohn’s Ileitis) and SIBO (small intestine bacterial overgrowth). Ileitis is most often caused by a bacterial infection and is treated with antibiotics or herbs that clear damp/heat (see Andrographis, Goldenseal, Huang Qin, Rhubarb under herbs for hot/damp diarrhea).

Celiac Disease and Non-Celiac Gluten Sensitivity (NCGS) Celiac disease is an autoimmune reaction to the protein gluten found in wheat, rye, triticale and barley. It is also found to a lesser degree in spelt, kamut and possibly oats. When this substance is ingested it triggers an immune response that damages the villi in the small intestine. This can lead to impaired absorption of nutrients, chronic anemia, dyspepsia, diarrhea, weight loss, osteoporosis, pancreatic insufficiency, gallbladder problems and stunted growth in children. Over time Celiac can also cause neurological conditions (migraines, seizures, neuropathy, myopathy, dementia), dermatitis herpetiformis, miscarriage, and increased risk of developing other autoimmune diseases. Treating celiac is both simple and difficult. The focus is eliminating gluten from the diet. While finding gluten-free foods is much easier now than even a few years ago, total avoidance requires constant surveillance of one’s food and for many means avoiding restaurants, dinners at other people’s homes and it necessitates becoming a “food detective”. Herbs and supplements (see herbs to heal the gut mucosa and supplements for IBD) can help speed the healing of the small intestine, but will not significantly prevent further damage if gluten is consumed. Non-celiac gluten sensitivity (NCGS) is a condition where ingesting gluten does not cause an autoimmune (Celiac disease) or allergic response (wheat allergy), but triggers gut inflammation, “leaky gut” and a myriad of diverse symptoms. These symptoms include depression (Peters, et al, 2014), chronic GI problems, skin conditions, migraines, fatigue, anxiety and weight gain. The challenge is the science is contradictory. While many people feel better eating a gluten-free diet, researchers have noted that gluten may not actually be the problem for some people. In reducing wheat, barley, rye, oats, etc. people are also reducing FODMAPs (Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols), which for some may be the actual underlying issue (Biesiekierski, et al, 2013a; Biesiekierski, et al, 2013b). Foods containing FODMAPs* are believed to cause GI symptoms by triggering immune mediated/mast cell activation (food hypersensitivity), by ingestion of bioactive compounds such as gluteomorphins or caseomorphins or by triggering intestinal hypersensitivity (Thronas, et al, 2012). In the largest and most comprehensive study of this issue, they found that among people who believed they had gluten-sensitivity, approximately 14% actually did show symptom exacerbation upon a gluten challenge (Elli, et al, 2016). For this subset of people with chronic GI issues, avoidance of gluten is necessary. For other people avoidance of FODMAPs may yield better results.

Small Intestine Bacterial Overgrowth (SIBO)/Small Bowel Bacterial Overgrowth (SBBO) Is a condition where impaired small intestine motility, inadequate gastric HCl, pancreatic juices or bile (which are bacteriostatic) or secretory immunoglobulins (sigA) allowing pathogenic bacteria to overgrow in the small bowel. This creates a negative feedback loop, as the high concentration of abnormal bacteria (in a healthy person the bacterial content of the small bowel is very low and different species) further inhibits peristalsis in the small intestine and bacterial toxins cause inflammation and damage to the epithelial barrier. SIBO can cause intense and chronic abdominal bloating, flatulence, nausea, diarrhea, malabsorption and possibly GERD. Long-term consequences of SIBO can include malabsorption syndrome, weight loss, vitamin A, E, D and B12 deficiencies, macrocytic anemia, liver disease and chronic skin conditions such as erythema nodosum. * See Appendix A for a list of FODMAP-containing foods.

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Risk factors for developing SIBO include the use of proton pump inhibitors (Compare, et al, 2011; Lombardo, et al, 2010), GI surgery, defective iliocecal valve function, gastroparesis, achlorhydria, a carbohydrate-rich diet, SI diverticula, Celiac disease, liver disease, chronic pancreatitis or pancreatic insufficiency, immunosuppression or immunosuppressive medications, connective tissue disorders such as scleroderma, alcoholism, IBS and lactose intolerance. Diagnosis of SIBO is often done by a lactulose breath test (LBT) or a glucose hydrogen breath test (GHBT). Either test takes 1-3 hours and should be done in the morning after a 12 hour fast and a special diet the day before. The LBT has a low sensitivity and often gives a false-positive result (Miazga, et al, 2015). The GHBT is considered to be a more accurate test for SIBO although both tests can deliver inaccurate results. Orthodox treatment of SIBO usually focuses on antibiotics (usually rifaximin, 1200 mg day, for 10-14 days) to decrease the bacterial overgrowth. Another, and possibly more effective, approach is eating a low carbohydrate diet along with herbs to decrease bacterial overgrowth (Usnea, Chinese Coptis or Goldenseal, Andrographis, Rhubarb, Thyme, Huang Qin/Baikal Scullcap, Oil of Oregano, Houttuynia/Yu Xing Cao or Neem), bitters to relieve “rebellious qi” (Artichoke leaf, Gentian, Wormwood or Quassia), gastric HCl stimulants (Orange peel, Juniper berry, Ginger, Prickly Ash), GI anti-inflammatories to re-establish a healthy intestinal epithelial barrier and stimulate secretion of secretory immunoglobulins (fresh Aloe gel, Licorice, Marshmallow, Slippery Elm) and prokinetics to promote SI peristalsis (Bai Zhu/Atractylodes, Cang Zhu/Atractylodes lancea, green Citrus peel, Angelica or processed Pinellia/Ban Xia). In a human clinical trial, a combination of two herbal products was significantly more effective than rifaxamin for reducing SIBO symptoms and having a negative follow-up LBT (Chedid, et al, 2014). Multiple studies also show that probiotics given with antibiotics (Khalighi, et al, 2014; Rosania, et al, 2013) and given instead of antibiotics (Kwak, et al, 2014) can offer significant benefits for people suffering from SIBO (in SIBO there is a significant decrease in normal Bifidobacteria usually found in the small intestine). Prebiotics also have been shown to improve SIBO symptoms.

The Liver and Gallbladder Bile is produced by the liver. It acts as a natural laxative and helps promote detoxification of metabolic wastes. The bile used for digesting fats is stored in the gallbladder, where it is concentrated 7-10 times. This thick viscous fluid helps emulsify fat-soluble nutrients including vitamins A,D,E, and K, as well as Omega 3 and 6 fatty acids, and carotenoids. This process makes these essential compounds bioavailable so they can be used as antioxidants, anti-inflammatories, to promote bone health, immune function, tissue repair, and normal metabolism. Biliary Dyskinesia is a term used in Europe to describe functional disturbances of the hepato-biliary system. The Eclectics referred to a similar condition they called hepatic torpor. In either case, the terms refer to a lack of bile produced by the liver, or an inadequate secretion of bile from the gallbladder. This can cause constipation, biliousness, gallstones, clay colored stools, elevated blood lipids, increased re-circulation of metabolic wastes and hormones, headaches, skin conditions, lymphatic stagnation, and impaired portal circulation (this can lead to hemorrhoids and varicose veins). Herbal therapy primarily utilizes two types of herbs to stimulate hepatic and gallbladder function. Choleretics increase bile secretion from the liver and cholagogues enhance bile excretion from the gallbladder. Many herbs that affect the liver and gallbladder actually do both so there is significant overlap in activity. This type of herb is used when there is deficient liver function with stagnation and biliousness. In TCM, this therapy is known as dredging the liver. Cholagogues and choleretics are contraindicated for inflammatory liver or gallbladder disease, blockage of the bile ducts or with large gallstones.

Choleretics/Cholagogues and Bitter Tonics Artichoke leaf (Cynara scolymus) – is a bitter tonic, mild hepatoprotective agent, and antiemetic. It enhances bile secretion and excretion and can be utilized on a daily basis to enhance digestion, absorption, and liver/gallbladder function. Tincture (1:2) – 2-3 mL TID Tea: 1 tsp. dried herb, 8 oz. hot water, steep 30 minutes, take 2-3 oz. before meals.

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Blessed Thistle herb (Cnicus benedictus) – has a long history of use in Europe as a cholagogue/choleretic, a bitter tonic, galactagogue, and febrifuge. It is used to promote digestion and absorption for people with dyspepsia, biliousness, rebellious qi (hiccoughs, hiatal hernia, GERD) and hepatic torpor. Excessive doses can cause nausea and it is contraindicated in people with ulcers. Tincture (1:5): 1-2 mL TID (before meals) Tea: 1 tsp. dried herb, 8 oz. hot water, steep 15-20 minutes, take 2-4 oz. TID Celandine herb (Chelidonium majus) – is a very strong cholagogue/choleretic, as well as an antiviral, gall- bladder antispasmodic, and analgesic. It has become popular in Germany for treating biliary dyskinesia. With regular use has come a number of cases of moderate to severe liver damage. In my mind, this is not an herb for chronic use. It is indicated for gallbladder pain or spasm, gallstones (less than 1.5 cm), and chronic clay colored stools. It should be combined with other herbs and used sparingly. Tincture (1:2): 5-10 gtt. TID Chicory root (Cicorium intybus) – is a bitter tonic, aperient, mild hepatoprotective agent and cholagogue. It is very similar in use to Dandelion root and can be used interchangeably with it. Chicory and Dandelion root are rich sources of inulin, a source of fructo-oligosaccharides (FOS). These prebiotics promote the growth of normal bowel flora and enhance overall gut health. Tincture (1:4 or 1:5): 3-4 mL TID Tea: 1 tsp. dried root, 8 oz. hot water, decoct 10 minutes, steep 20 minutes. Take 4 oz. TID Culver’s Root (Veronicastrum virginicum) – was known to the Eclectics as Leptandra or Black Root. It is a cholagogue/choleretic, bitter tonic, and laxative. Its function as a laxative is primarily from its ability to stimulate bile secretion, rather than stimulating peristalsis like most stimulant laxatives. It is specifically used for constipation with clay colored stools, poor fat metabolism with a tendency toward forming gallstones, and hepatic pain. Tincture (1:5): 5-15 gtt. 2-3 times per day Dandelion root (Taraxacum officinalis) – is an excellent bitter, aperient and liver tonic. I use it more frequently than any other “liver” herb. It is appropriate for lack of bile secretion, abdominal fullness, constipation, biliousness, “liver headaches”, chronic pancreatitis, mildly elevated liver enzymes, and to enhance hepatic elimination. I usually combine it with Orange Peel, Angelica, and Artichoke Leaf as a base for my “bitters” formula. Dandelion root has also been shown to have mild hepatoprotective activity. Tincture (1:2): 2-3 mL TID Tea: 1 tsp. dried root, 10 oz. water, decoct 15 minutes steep 30 minutes, take 4 oz. TID Fringe Tree root bark (Chionanthus virginicus) - was the Eclectic physician’s most commonly used “liver herb”. It is a cholagogue/choleretic, aperient, and bitter tonic. It is indicated for a sluggish gallbladder, hepatic colic, chronic clay colored stools, gallstones (less than 1.5 cm), gallbladder pain caused by eating fats, hepatomegaly, and acute pancreatitis. Tincture (1:2): 5-20 gtt. TID Mugwort herb (Artemisia vulgaris) – is a common weedy plant that is useful as a simple bitter. In TCM it is used for stomachaches, flatulence and for bacterial diarrhea. In animal studies Mugwort also showed significant hepatoprotective activity (Gileni, et al, 2005). Tincture (1:5 or 1:2.5): 1-1.5 mL TID Tea: 1 tsp. dried herb, 8 oz. water, steep, covered, 40 minutes, take 4 oz. 3x/day Turmeric rhizome (Curcuma longa) – is a mildly warming bitter with antitumor and hepatoprotective activity. Turmeric is a cholagogue and choleretic (it stimulates bile secretion by the liver and excretion by the gallbladder), promoting fat digestion and elimination of wastes by phase II liver pathways. It increases hepatic glutathione levels and enhances hepatocyte regeneration. Tincture (1:2): 3-4 mL TID Tea: 1-2 tsp. dried rhizome, 10 oz. water, decoct 10 minutes, steep covered 30 minutes, take 4-6 oz. TID Capsules: Standardized 80-90% Curcumin 2 (00) capsules BID

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Liver Damage and Hepatoprotective Herbs The liver is responsible for metabolizing, detoxifying, and eliminating most chemicals and drugs as well as hormones and cholesterol that we ingest, manufacture, or absorb. This process involves two stages, Phase I and Phase II detoxification. Phase I reactions utilize cyclic P-450 (CYP-450) enzymes to make compounds more excretable. Usually this also makes these compounds less toxic but in some cases, such as pyrrolizidine alkaloids or acetaminophen, it can actually substantially increase the hepatotoxicity of the substance. Good Phase II detoxification (sulfation, glucuronidation, acylation, or conjugation with glutathione) is necessary to quickly allow excretion of these compounds. Phase I reactions can be affected by many factors including age, ethnicity, gender, drug or alcohol use, smoking, hypoxia, liver disease, certain foods and herbs, and whether a person is a fast or slow metabolizer. Phase II reactions are less susceptible to external factors but can be negatively affected by a lack of hepatic glutathione, inhibition of beta-glucuronidase, and fasting. Many herbs have shown the ability to prevent liver damage and to help increase hepatic glutathione levels and regenerate hepatocytes. Hepatoprotective herbs have also been shown to help inhibit liver inflammation and to some degree repair damage caused by non-alcoholic fatty liver disease (NAFLD) or non-alcoholic steatohepatitis (NASH), which can lead to liver fibrosis or cirrhosis. In addition to using herbs for treating NAFLD or NASH, a low calorie, carbohydrate and trans fat diet, along with exercise and weight loss, have repeatedly been shown to improve liver function, reduce inflammation and normalize liver enzymes (Hossain, et al, 2016). These liver protecting herbs can also be a part of a protocol to treat hepatitis A, B or C (for more on treating Hepatitis B or C, see my paper Herbal and Nutritional Approaches for Treating Hepatitis B and C, 2015, DW-CHS). Human studies have found that advanced liver disease can also cause increased intestinal permeability, bacterial translocation and SIBO. In an animal study even early stage acute liver damage had significant repercussions in the GI tract, with changes in the intestinal microbiome, decreased tight junctions and intestinal permeability (Fonts, et al, 2012). This suggests that for any serious liver disease, support of the rest of the GI tract is also necessary. Hepatoprotective herbs and supplements include: Milk Thistle (Silybum marianum) Andrographis (Andrographis paniculata) Schisandra (Schisandra chinensis) Licorice (Glycyrrhiza glabra, G. uralensis) Turmeric (Curcuma longa) Reishi (Ganoderma lucidum) Picrorhiza (Picrorhiza kurroa) Huang Qin (Scutellaria baicalensis) Indian Madder (Rubia cordata)* Guduchi (Tinospora cordifolia Green Tea (Camellia sinensis) SAMe (S-adenosylmethionine) Amla (Phyllanthes emblica) N-acetylcysteine (NAC) Yin Chen Hao (Artemisia capillaris) Alpha-Lipoic Acid (ALA) Lycium fruit (Lycium barbarum) Spirulina (Anthrospira spp.) Melatonin *Small doses have been found to be hepatoprotective, while large doses have caused liver damage. In addition, hepatosupportive herbs (see Bitters and Cholagogues, pp. 11-2) are beneficial when combined with hepatoprotective herbs.

Gallstones Gallstones are most frequently comprised of cholesterol that has precipitated out of the bile (80% of gallstones). Women are twice as likely to have gallstones than men. Women who are overweight, fair skinned and in their 40’s are the most susceptible population for developing gallstones. Other risk factors for developing gallstones include taking birth control pills, hormone replacement therapy or pregnancy, regular fasting, genetics (if you are of Native American or Mexican descent or have immediate family members with gallstones you have a greater chance of developing them, especially as you age), high triglyceride levels, rapid weight loss, diabetes, metabolic syndrome and diets high in simple carbohydrates and low in fiber. A person may be asymptomatic, or they may experience intense pain radiating from the hepatic region to the back with gas and nausea. Orthodox treatment utilizes analgesics, chenodeoxycholic acid (chenodiol), or ursodeoxycholic acid (ursodiol) to dissolve stones, lithotripsy to break up stones, and surgery to remove the gallbladder. Herbal treatments can be effective for relieving pain and helping to pass small gallstones (1.5 cm or less).

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Larger stones should be treated using orthodox therapies. Regular use of bitter cholagogues (see Liver) can reduce the risk of developing future gallstones. I use a formula consisting of: Wild Yam 2 parts Fringe Tree root bark 1 part Celandine 1/2 part

Cyperus 1 part Khella seed 1 part

For helping to pass small gallstones, the dose is 3-4 mL, followed by a 2nd dose 1-2 hours later.

Gallbladder Spasms Are not common but are very painful and disturbing when they occur. Several herbs are very effective at relieving this condition. The patient should also be checked for magnesium deficiency. Celandine herb (Chelidonium majus) – is sometimes referred to as the “opium of the gallbladder”. This refers to its ability to relieve pain, dilate the common bile duct, and inhibit biliary spasm and colic. This herb is best used on a short-term basis (see the previous entry for Celandine). Tincture (1:2): 5-10 gtt. TID Cyperus tuber/Xiang Fu (Cyperus rotundus) - is known as Xiang Fu in TCM. These small aromatic tubers are superb for relieving gynecological, abdominal, and gastrointestinal pain. I use Cyperus for gallbladder spasms, flatulent colic, intestinal and rectal spasms, IBS and spasmodic diarrhea. Tincture (1:5); 2-4 mL QID Tea: 2 tsp. dried tuber, 10 oz. water, decoct 10 minutes, steep 40 minutes, take 4-6 oz. 3-4 times per day Khella seed (Ammi visnaga) – is a very useful antispasmodic to the respiratory tract (asthma), genitourinary tract, cardiovascular system, and gastro-intestinal tract. It is used to relieve spasms of the gallbladder, intestine, rectum, and bile ducts. Tincture (1:5): 10-20 gtt. TID Tea: 1 tsp. dried seeds, 8 oz. hot water, steep covered 45 minutes, take 4 oz. TID Wild Yam rhizome (Dioscorea villosa) – see IBS.

The Pancreas The pancreas has both endocrine and exocrine function. The endocrine function comes from the Islets of Langerhans which produce insulin. The body of the pancreas produces pancreatic juice, which buffers stomach acid and contains enzymes which enhance protein, fat, and carbohydrate digestion and absorption in the small intestine. Bitters stimulate both secretin and cholecystokinin in the duodenum, which in turn stimulates production of pancreatic juice.

Acute and Chronic Pancreatitis Acute pancreatitis is most often associated with alcoholism but it can also be caused by infection, medications, gallstones, abdominal trauma or malignancy. It is treated with antibiotics, withholding food (IV fluids only) and in some cases surgery. Herbal therapies can also be of some benefit for this condition. Chronic pancreatitis is mostly caused by alcohol abuse, but can also have an idiopathic cause, where pancreatic enzymes are activated while still in the pancreas. This activates pancreatic stellate cells, which causes chronic inflammation and fibrosis of the pancreas with decreased pancreatic function, diarrhea, jaundice, anorexia, and pain. Several herbs offer modest benefits for chronic pancreatitis. Amla fruit (Emblica officinalis) – has been shown in multiple animal studies to inhibit pancreatic inflammation (Aruma, et al, 2014; Sidhu, et al, 2011; Thorat, et al, 1995). Tincture (1:4 or 1:5): 3-5 mL TID/QID Tea: 1/2-1 tsp. dried powdered fruit, 8 oz. water, decoct 10 minutes, steep 1 hour, take 2-3 cups/day

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Chaga fungus (Inonotus obliquus) – a polysaccharide extract of the fungus was able to reduce inflammation and symptoms of chronic pancreatitis in mice (Hu, et al, 2016). Tincture (1:5): 3-5 mL TID-QID Tea: 2-3 tsp. of the ground, dried fungus, 12-24 oz. water, decoct 30 minutes-1 hour, steep 45 minutes, take 2-4 cups/day Dandelion root (Taraxacum officinale) - is an excellent bitter and liver tonic. It is appropriate for lack of bile secretion, abdominal fullness, constipation, biliousness, “liver headaches”, chronic pancreatitis, mildly elevated liver enzymes, and to enhance hepatic elimination. Tincture (1:2): 2-3 mL TID Tea: 1 tsp. dried root, 10 oz. water, decoct 15 minutes, steep 1/2 hour, take 4 oz. TID Dan Shen root (Salvia miltiorrhiza) – in two human clinical trials, Dan Shen reduced inflammatory cytokines in people with severe acute pancreatitis (Wang, et al, 2013; Peng & Zheng, 2007). Tincture (1:4 or 1:5): 1.5-3 mL TID/QID Tea: 1-2 tsp. dried root, 8 oz. water, decoct 5 minutes, steep 45 minutes, take 2-3 cups/day Fringe Tree root bark (Chionanthus virginicus) – was used by the Eclectic physicians to relieve pain, inflammation, nausea and diarrhea associated with pancreatitis or hepatitis. Unfortunately, only the fresh tincture is active and this limits when it can be safely used. Tincture (1:2): .5-1 mL TID, dilute in 4 oz. juice or water (do not use with alcoholics) Japanese Knotweed (Fallopia japonica) – is one of the richest sources of resveratrol, which has been shown to prevent the activation of pancreatic stellate cells which initiate pancreatic fibrosis. Japanese Knotweed is also used to clear damp heat in the GI tract. Tincture (1:5): 1.-2 mL TID Tea (Decoction): 1 tsp. dried root, 10 oz. water, decoct 10 minutes, steep 40 minutes, 4 oz. 2x/day Milk Thistle seed (Silybum marianum) – was used by the Eclectics for pancreatitis and it is not only hepatoprotective but it helps reduce swelling in the liver (hepatomegaly), spleen (splenomegaly), and pancreas. In this situation, the standardized capsules should be used instead of the tincture. Standardized capsule: 320 mg per day (160 mg BID) Red Root (Ceanothus spp.) – was used by the Eclectic physicians along with Milk Thistle and Fringe Tree for treating chronic pancreatitis. These herbs can also offer some benefits in acute pancreatitis. The tea can be used, but if possible, small amounts of the tincture (highly diluted) are more effective. Tincture (1:2.5): 1-2 mL TID, mix in 4 oz. juice or water – do not use with alcoholics. Rhubarb root (Rheum palmatum) – in Chinese medicine, small amounts of Rhubarb mixed with other herbs such as Bupleurum, Baikal Scullcap and Dan Shen, have been used with reported success to treat acute and chronic pancreatitis. Tincture (1:5): .5-1 mL BID/TID Tea: 1 tsp. dried root, 16 oz. water, decoct 1 hour (slowly reduce the liquid to 8 oz.), use a small amount (1/2 – 1 oz.) mixed with other herbs (8 oz.) Turmeric root (Curcuma longa) – several phenolic compounds, including curcumin, have been shown to inhibit activation of pancreatic stellate cells, which initiates pancreatic fibrosis (Lin, et al, 2015). Turmeric and curcumin have powerful antiinflammatory activity. Tincture (1:2 or 1:4): 2-4 mL TID/QID Tea: 1/2 tsp. dried, freshly powdered rhizome, 8 oz. hot water, steep covered for 45 minutes, take 4 oz. 4x/day

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TCM Formulas Three TCM formulas, Qingyi Tang, Yihuo Qingyi Tang and Huoxue Qingyi Tang, have been shown in human clinical trials to reduce pancreatic inflammation, fibrosis, and to some degree pain as well (Chao, et al, 2016; Zhang, et al, 2014; Yang, et al, 2008). Qingyi Tang is comprised of Rhubarb root, Mang Xiao/Mirabilitum, Huang Qin, White Peony, Saussurea root, Bupleurum, Corydalis and Picrorrhiza. Yi Huo Qingyi Tang contains the forementioned herbs with the addition of Areca seed, Melia fruit, Ligusticum root, Quisqualis, Dan Shen, Astragalus and Ginseng. Huoxue Qingyi Tang contains Dan Shen, Desmodium styracifolium, Rhubarb, Mang xiao/Mirabilitum, Magnolia bark, White Peony, Bupleurum, immature Bitter Orange and Baikal Scullcap root.

Bowel Health-Elimination The large intestine absorbs fluid (mostly water), some vitamins and minerals from the digested food and eliminates undigested food and waste products from the body. Diarrhea or loose stools is a common bowel problem and can be caused by hypermotility of the bowel, food poisoning, amoebic or protozoal parasites, intestinal viruses, pathogenic bacteria, intestinal dysbiosis, bowel inflammation (see IBS and IBD), medications, or food sensitivities. Diarrhea can be generally divided into 2 broad categories: Hot/damp diarrhea – is usually acute, with a sudden onset and a burning liquid stool, sharp pain, fever, blood or mucus in the stool, dehydration, and a red tongue. Most hospital-acquired diarrhea fits into this category, especially that caused by Clostridium difficile, as well as Norovirus and Campylobacter jejuni. Cold/damp or deficient diarrhea - is a chronic condition characterized by loose stools, undigested food particles in the stool, little or no pain, excessive gas, borborygmus, a white coated tongue, and abdominal distension. In TCM this fits the pattern known as a “damp spleen”.

Each of these types of diarrhea is treated differently and it is always important to identify the underlying cause if possible. Herbs will not alleviate the diarrhea of Celiac disease, only eliminating gluten from the diet and healing the gut mucosa will do so. People who are lactose intolerant will also need to avoid dairy or take Lactaid® when consuming it. Certain medications may need to be changed if they cause persistent diarrhea and amoebic and protozoal infections need to be treated as well. For most types of diarrhea, taking probiotics has been shown to be of benefit. I prefer a product known as VSL #3. Medicinal clays have also been found to modestly help control watery diarrhea, especially in children. To treat antibiotic-resistant Clostridium difficle infections, I use a combination of herbs that clear damp heat in the bowel, along with VSL #3 extra strength and the probiotic yeast Saccharomyces boulardii. If this still is not effective, fecal transplants work in about 90% of cases.

Herbs For Hot/Damp Diarrhea

Andrographis herb (Andrographis paniculata) – is an herb used in India and China to relieve blood heat (viral or bacterial infections). It is effective for treating bacterial or viral diarrhea as well as amoebic dysentery and bacterial enteritis. I often combine it with Chinese Coptis and Baikal Scullcap. Tincture (1:5): 1.5-3 mL QID Tea: 1 tsp. dried leaf, 8 oz. hot water, steep ½ hour, take 4 oz. 3x/day Astringents – can be useful for stopping acute diarrhea, as well as blood in the stool. They should never be used as a monotherapy and long-term use is not recommended. Simple astringents include Oak bark, Alum root, Wild Geranium, Blackberry root, Tormentil, Bistort, Bayberry root bark, Witch Hazel bark, Red Root, Indian Madder and Sanguisorba/Di Yu. These herbs also have mild antiviral and antibacterial activity. Astringent–demulcents are an unusual category of herbs that inhibit excess secretions while reducing inflammation of mucous membrane tissue. They can be useful for hot/damp diarrhea, IBS, and Crohn’s disease. Herbs included in this category are White Pond Lily (Nymphaea odorata), Purple Loosestrife herb (Lythrum salicaria) and Linden Flower (Tilia platyphyllos). Chamomile flowers (Matricaria recutita) – have a long history of use for GI disturbances (see hyperchlorhydria). They can also be of benefit for acute diarrhea. The Eclectic indications for Matricaria are diarrhea with a greenish, slimy discharge, flatulence and irritation of the anus.

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Laboratory studies indicate that Chamomile strongly inhibits Campylobacter jejuni, a common cause of severe diarrhea (Cwikla, et al, 2010). Tincture (1:2 or 1:5): 3-5 mL TID Tea: 1-2 tsp. dried flowers, 8 oz. hot water, steep, covered, 30 minutes, take 4-8 oz. TID Goldenseal root (Hydrastis canadensis) – is very effective for clearing damp heat from the bowel. Other berberine-containing herbs such as Chinese Coptis (Coptis chinensis), Yellow Root (Xanthorrhiza simplicissima), Barberry root bark (Berberis spp.), Oregon Grape Root (Mahonia spp.) or Huang Bai/Phellodendron (Phellodendron chinensis) are also of benefit. Berberine is an active antibacterial, antiviral, antifungal agent and antiinflammatory to the mucous membrane tissues. It reduces excess intestinal secretions and smooth muscle contractibility, as well as bleeding and inflammation. Research on isolated berberine found it could reinforce tight junctions in the mucus barrier, thus reducing gut permeability (Chen, et al, 2014). The root can also be used as part of a protocol for leaky gut syndrome or IBD. Tincture (1:5): 1-2 mL TID Tea: 1 tsp. dried powdered root, 8 oz. hot water, steep 30 minutes, take 4 oz. TID Capsules: 2 (00) capsules BID-TID Huang Qin/Baikal Scullcap root (Scutellaria baicalensis) – is very effective for treating damp heat conditions including IBD, dysentery, diarrhea, hepatitis, cholecystitis and pancreatitis. It is often combined with Chinese Coptis or Phellodendron, Coix Seed, and Rhubarb. Tincture (1:5): 2-3 mL QID Tea: 1-2 tsp. dried root, 12 oz. water, decoct 15 minutes, steep 45 minutes, take 4-6 oz. TID Kudzu root (Pueraria lobata) – is an antiinflammatory, antispasmodic and demulcent used for clearing heat and spasms in the bowel. It can be used as part of a protocol for any type of diarrhea, but is most appropriate for hot diarrhea. Tincture (1:5): 3-5 mL TID/QID Tea: 1-2 tsp. dried root, 12 oz. water, decoct 15-20 minutes, steep 1 hour, take 2-3 cups/day Neem leaf (Azadirachta indica) – has a long history of use in India for treating diarrhea, amoebic infections and cholera. In an animal study Neem leaf extract had antibacterial, antisecretory and antihemorrhagic effects. This gives some evidence to its traditional use for these conditions. Tincture (1:5): .5-1 mL BID/TID Capsules (4:1): 150-250 mg TID Olive leaf (Olea europaea) – is widely promoted as a broad spectrum antibacterial agent. In a laboratory study, it was effective for inhibiting Campylobacter jejuni, a common cause of bacterial diarrhea. It also inhibited H. pylori and MRSA, but had little to no antibacterial activity on the other 119 species of bacteria studied (Sudjana, et al, 2009). Tincture (1:5): 2-4 mL TID Tea: 1-2 tsp. dried leaf, 8 oz. water, decoct 10 minutes, steep 40 minutes, take 4 oz. TID Rhubarb root (Rheum palmatum) – in moderate doses is a laxative and in large doses is a purgative. In very small doses it stops diarrhea and clears heat. The anthaquinones are strongly antibacterial, and this herb is used in TCM for dysentery, blood in the stools, and acute bacterial diarrhea. It is always used in formulas with other herbs to help prevent a laxative effect. Several other herbs such as Japanese Knotweed root (Fallopia japonica) and Yellow Dock (Rumex crispus), have activity similar to Rhubarb but are milder acting. Tincture (1:5): 5-10 gtt. QID. Tea: 1 tsp. dried root, 16 oz. water, decoct 1 hour (slowly reduce the liquid to 8 oz.), take ½-1 oz. BID with other herbs (8 oz.)

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Sage leaf (Salvia officinalis)* - and White sage (Salvia apiana) ▲ are antibacterial, antiviral, and antifungal. They are powerful antioxidants and antiinflammatory agents that reduce excessive secretions and clear damp heat in the respiratory and gastrointestinal tracts. An in vitro study found that Sage strongly inhibited Campylobacter jejuni, a major cause of diarrhea (Cwikla, et al, 2010). Tincture (1:5) *: 1-2 mL TID Tincture (1:5) ▲: .5-1 mL TID Tea: 1 tsp. dried herb, 8 oz. hot water, steep covered 20 minutes, take 4 oz. TID

Herbs for Cold/Damp Diarrhea Atractylodes/Bai Zhu root (Atractylodes macrocephala) – is warming and drying and used in TCM for deficient or damp spleen conditions with chronic diarrhea. It helps relieve abdominal bloating, vomiting, lack of appetite and diarrhea associated with HIV. Tincture (1:5): 1-2 mL TID Tea: 1 tsp. dried root, 10 oz. water, decoct 5-10 minutes, steep covered 20-30 minutes, take 4 oz. TID Cinnamon bark (Cinnamomum verum) – is very effective for enhancing digestion, stopping diarrhea, and alleviating gas, nausea, or borborygmus. Cinnamon is astringent, antibacterial, helps regulate blood sugar levels, and enhances circulation. It can be used as a simple or in a formula. Tincture (1:5): 1-2 mL QID Tea: 1 tsp. dried powdered bark, 8 oz. hot water, steep, covered 30 minutes, take 4 oz. TID Fu Ling fungus (Wolfiporia cocos) – is thought of as a diuretic in TCM, but it actually works more via the bowel than the kidney. It absorbs excess fluids and solidifies the stool. It is usually combined with aged Orange Peel/Chen Pi and Atractylodes as the basis of a very effective formula for treating cold/damp diarrhea. Tea: 1-2 tsp. dried fungus, 10 oz. water, decoct 20 minutes, steep 20 minutes, take 4-6 oz. TID Ginger root (Zingiber officinalis) – is antiinflammatory, a carminative, and an anti-emetic. It can be used with other warming herbs such as Cardamom, Calamus, Turmeric, or Galangal, to benefit damp spleen conditions. Zingiber strongly inhibits Campylobacter jejuni, a major cause of diarrhea (Cwikla, et al, 2010). Tincture (1:2): 1-2 mL QID Tea: 1 tsp. dried root, 8 oz. hot water, steep covered 40 minutes, take 4 oz. QID Myrrh gum resin (Commiphora myrrha) – can be combined with Cinnamon or Ginger, or astringents to make a very effective formula for relieving chronic low grade diarrhea. Myrrh is also effective for treating leaky gut syndrome and mucus colitis. Tincture (1:5): 1-2 mL QID Orange Peel (Citrus spp.) – is warming to the bowel, improves digestion, and relieves gas, nausea, and borborygmus. It is used with Atractylodes and Poria for damp spleen diarrhea. The peel is an antioxidant and regular use may inhibit bowel cancers. Tincture (1:5): .5-1 mL TID Tea: 1/2 tsp. freshly ground dried peel, 8 oz. hot water, steep covered 15-20 minutes, take 2-4 oz. TID

Constipation and Long Transit Time Normal transit time (the time between consuming food and defecating) is usually between 12-24 hours. Extended transit time and constipation are linked to elevated blood lipids, increased gut permeability and possibly increased risk of intestinal cancer. Probiotics and fermented foods (kimchi, yogurt, kefir, kombuchu, etc.) have also been shown to improve bowel function and can be used for all types of constipation. It should be noted that for some people probiotic supplements can worsen constipation. Constipation can also be differentiated into several patterns: Cold/dry constipation – is associated with a mildly atonic bowel, a pale tongue with a heavy white lingual coating, and a dry mouth or dry cough. Make sure the person has adequate soluble fiber and fluids in their diet. Herbs used to relieve cold/dry constipation include:

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Dang Gui root (Angelica sinensis) – moistens and warms the intestines, it is used in TCM with yin tonics such as Ophiopogon, Processed Rehmannia, or Chinese Asparagus root for dry constipation. Tincture (1:5): 2-4 mL TID Tea: 1-2 tsp. dried cut/sifted root, 10 oz. water, decoct 10 minutes, steep covered 30 minutes, take 4 oz. TID Fenugreek seed (Trigonella foenum-graecum) – is a warming demulcent that binds endotoxins in the GI tract. Regular use of this herb lowers cholesterol and triglyceride levels and it acts as a bulk laxative. Tincture (1:5): 3-4 mL TID Tea: 1-2 tsp. dried seed, 10 oz. water, decoct 10 minutes, steep for 20-30 minutes, take 4 oz. TID Licorice root (Glycyrrhiza glabra, G. uralensis) – is antiinflammatory, demulcent, and an aperient. It soothes irritated mucous membrane tissue in the stomach and intestines and moistens the bowel, benefiting cold/dry constipation. Tincture (1:5): 1-2 mL TID Tea: 1 tsp. dried root, 10 oz. water, decoct 10-15 minutes, steep 30 minutes, take 2-4 oz. TID Yin tonics – such as Ophiopogon/Mai Men Dong, Chinese Solomon’s Seal, Prince Seng, Sesame seed, Processed Rehmannia, and Chinese Asparagus/Tian Men Dong can also help cold/dry constipation by moistening the bowel.

Deficient/laxative dependent constipation - is caused by an atonic bowel with a lack of peristaltic activity, usually caused by chronic laxative abuse. This is a very difficult condition to treat and in most cases improvement, not cure, is the best that can be hoped for. Bulk laxatives – that are rich in soluble fiber such as Fenugreek seed powder, Psyllium seed, Chia seed, Flax seed, and Guar gum are of benefit. Taken with adequate water they gradually improve bowel function and transit times. Daikenchuto – is the most frequently prescribed Kampo formula in Japan. It contains processed Ginger, Asian Ginseng and Schezuan pepper. In human trials it improved post-operative constipation or atonic constipation in children and in adults with Parkinson’s disease (Mochiki, et al, 2010). It has also been found to enhance GI hormone production, intestinal blood flow and bowel motility. Mistletoe herb (Viscum album) – is used to enhance the tonus and function of the large intestine (as well as the bladder and uterus). It can be combined with Triphala, Yellow Dock or Kudzu for laxative-dependent constipation. Tincture (1:5): 1-2 mL TID Tea:1/2 tsp. recently dried herb, 8 oz. water, steep for 1 hour, take 2 oz. TID Triphala - is an Ayurvedic formula used as a Rasayana or rejuvenative remedy. It is a combination of Amla (Emblica officinalis), Haritaki (Terminalia belerica), and Vibhitaki (Terminalia chebula). It is the single most effective treatment for an atonic bowel. It tonifies the bowel, as well as having a mild laxative effect. The formula also has pronounced antiinflammatory activity. Capsules: 2 (00) capsules BID Warming spices - such as Cardamom, Ginger, Turmeric, Galangal, can help stimulate intestinal circulation and peristalsis. Yellow Dock root (Rumex crispus) – has antiinflammatory, choleretic/cholagogue, astringent and mild laxative effects. It can be effective as part of a protocol for laxative-dependent constipation. Tincture (1:2.5 or 1:5): 1-2 mL TID/QID Tea: 1 tsp. dried root, 8 oz. water, decoct 10 minutes, steep for 30 minutes, take 4 oz. TID

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Hot/dry constipation – is usually caused by fevers or chronic lack of fluids, resulting in dry, painful stools, a dry, red tongue (with a brown or yellow coating), and thirst. Herbs used to relieve hot/dry constipation include: Mucilaginous herbs/bulk laxatives – Slippery Elm is, in my experience, probably the best of the GI demulcents. It should be taken as a room temperature infusion between meals. Slippery Elm does not make an effective tincture, but Marshmallow can be made into a reasonably demulcent alcohol and water extract. A tea of Marshmallow is also useful. Other demulcent herbs including Chia seed, Flax seed, Aloe gel, Guar gum, Psyllium seed, Irish Moss, Sterculia, and Prickly Pear are effective for treating dry (yin deficient) constipation. Stimulant laxatives – including Senna, Buckthorn bark, Cascara Sagrada, Butternut bark, and Rhubarb root (in moderate doses) are frequently used to treat constipation, but in my experience are usually not indicated. These herbs can cause bowel dependence, deplete potassium, and reduce blood levels of other medications. Butternut bark is the mildest of the stimulant laxatives and is the only one that, when used properly, does not cause bowel dependency. All other laxatives in this category are appropriate for short-term use only for occasional situational constipation. Purgatives or cathartics such as Jalap, American Mandrake, Colocynth, Poke Root, and Aloe resin are dangerous and should never be used in material doses (some are used in tiny doses that do not cause purgation for other complaints).

Irritable Bowel Syndrome (IBS)

There are three main categories of irritable bowel syndrome (IBS): IBS-M (mixed type) has alternating diarrhea and constipation as well as gas, nausea, abdominal distension and pain, IBS-D has diarrhea as the prominent symptom along with pain, gas and nausea, and IBS-C is constipation predominant with pain, bloating, and nausea. One other IBS-like syndrome is chronic abdominal pain (CAP), where the person experiences visceral pain (intestinal hypersensitivity), but has normal bowel movements. When this occurs in children it can be a precursor to full blown IBS. People who suffer from IBS also have increased levels of depression (see GI-based depression) and anxiety. IBS has many possible causes including food allergies or intolerance, loss of normal intestinal barrier function (Leaky Gut syndrome), achlorhydria, residual post-infection inflammation, magnesium deficiency, chronic stress, genetics, and abnormal bowel flora (intestinal dysbiosis). Determining the underlying issues is vital for success in treating IBS. In addition, people with IBS have a much higher incidence of GERD (and vice versa), suggesting a common underlying cause (Yarandi, et al, 2010). Some research suggests that SIBO may be the common underlying pathology. For many people with IBS a combination of these causative factors is involved. This causes dysregulation of the gut-brain axis, with excessive (causes diarrhea) or too little (causes constipation) intestinal serotonin, elevated levels of inflammatory cytokines, and overproduction of signaling molecules that in a healthy person maintain a healthy GI function and ecology. Elimination diets for sensitivities to common foods are an important place to start treatment (Drisko, et al, 2006). Common problem foods that can trigger IBS include wheat or other gluten containing foods as well as beef, pork, dairy, eggs, fructose, sugar alcohols (sorbitol, mannitol, xylitol, erythritol, lactitol, etc.) and soy (Zar, S., et al, 2005; Spanier, et al, 2003). Conventional treatment for IBS-M and C includes the use of soluble fiber, antispasmodics, antidepressants and prokinetic drugs. Treatment of IBS-D utilizes opioid receptor agonists (Coperamide), codeine, antidepressants, anticholinergics, antispasmodics and anti-nausea drugs such as 5-HT3 receptor antagonists. Most of these medications have limited efficacy and significant potential for adverse effects. Low FODMAP diets (fermentable carbohydrate restriction-oligosaccharides, disaccharides, monosaccharides and polyols) significantly reduced pain, bloating and gas in people with IBS (Halmos, et al, 2014).

Herbs for IBS Artichoke leaf (Cynara scolymus) – is frequently used for biliary dyskinesia, nausea and as a bitter tonic. In a human clinical trial a standardized extract of Cynara significantly reduced symptoms of IBS and dyspepsia as well as improving quality of life in study participants (Bundy, et al, 2004). Tincture (1:2 or 1:4 or 1:5): 1.5-3 mL TID Tea: 1 tsp. dried herb, 8 oz. hot water, steep for 15-20 minutes, take up to 3 cups/day Capsule: standardized extract, 1-2 capsules (320-640 mg) per day

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Chamomile flowers (Matricaria recutita) – see hyperchlorhydria. Cyperus/Xiang Fu tuber (Cyperus rotundus) - see gallbladder spasms. GI Tract antiinflammatories – in addition to several herbs mentioned in this section (Chamomile, Kudzu, Cyperus), other herbs that reduce GI tract inflammation and help restore tight junctures to the intestinal epithelium can offer some relief for people with IBS. Most of these herbs are discussed in more detail under “herbs to heal the gastric and intestinal mucosa” on page 6. Iberogast (STW 5) – is a well-researched proprietary herbal formula that has been found to effectively relieve IBS pain, diarrhea, constipation and bloating (Ottilinger, et al, 2013). The product contains Chamomile, Peppermint, Caraway, Licorice, Lemon Balm, Milk Thistle, Angelica, Celandine and Bitter Candytuft (Iberis amara). Dose: 1 mL TID Kudzu/Ge Gen root (Pueraria lobata) – is an effective antispasmodic used for the musculoskeletal system (torticollis), the cardiovascular system (angina), and the GI tract. It relieves bowel spasms and helps soothe irritated or inflamed gastric or intestinal mucosa. Tincture (1:5): 2-4 mL TID Tea: 2 tsp. cut/sifted dry root, 16 oz. water, decoct 20 minutes, steep 40 minutes, take 4-6 oz. TID Peppermint Essential Oil (Mentha piperita) – has a long history of use for digestive upset, biliousness, flatulence and nausea. Over the last 25 years, the use of enteric-coated Peppermint essential oil capsules for IBS has been widely studied. In a review of 17 clinical trials (Grigoleit & Grigoleit, 2005) it was found that these products offer a safe and effective treatment for this condition. A more recent RCT (Meret, et al, 2010) found that Peppermint essential oil was effective in relieving IBS symptoms such as abdominal pain and improving quality of life. Dose: 1 capsule TID Soluble Fiber – two common sources of soluble fiber Flaxseed (Linum usitatissimum) and Psyllium seed (Plantago ovata) have been shown to have some benefit for people with IBS. Flax seed has been found to help control diarrhea (IBS-D), as well as constipation (IBS-C) and this dual mechanism also makes it of use for treating IBS mixed type (Hanif, Palla & Gilani, 2015). In a RCT, Psyllium fiber was twice as effective as a placebo in reducing IBS-induced abdominal pain in children (Shulmann, et al, 2016). Valerian root (Valeriana officinalis) – most people think Valerian is only a sedative for insomnia and nervousness. It is also useful for stress-induced GI symptoms, IBS, and flatulent colic. I often use it with Catnip, Chamomile, or Hops to calm anxiety-induced nausea, diarrhea, constipation, or gas. Tincture (1:2): 1.5-2 mL TID Tea: 1 tsp. dried herb, 8 oz. hot water, steep covered 30 minutes, take 4 oz. TID Wild Yam rhizome (Dioscorea villosa) – is a very effective antispasmodic to the intestinal tract, liver (hepatic colic), and gallbladder. It is used for gallbladder spasms, biliousness, intestinal spasms, flatulent colic, nervous bowel and IBS. Tincture (1:2): 1.5-2 mL QID Tea: 1-2 tsp. dried cut/sifted root, 12 oz. water, decoct 15 minutes, steep 1 hour, take 4-6 oz. TID

Supplements for IBS Betaine HCl - is a supplemental form of gastric acid. In practice, I prefer to give herbs to stimulate the person’s natural gastric HCl, but in some cases this is not adequate. As mentioned in the introduction to this section, a lack of stomach acid may contribute to IBS, GERD and SIBO. Capsules: 1 per meal

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L-Glutamine – although people with IBS do not exhibit the profound intestinal inflammation found in IBC, they do have chronic low level inflammation. The amino acid L-Glutamine can help reduce GI inflammation and soothe the gastric mucosa. Powder: 5 g. TID Melatonin – in several small human studies, taking this hormone at bedtime was found to relieve IBS symptoms (Lu, et al, 2005; Song, et al, 2005). Dose: 2-5 mg per day Probiotics – several strains of bacteria have been shown to improve some IBS symptoms, especially diarrhea in diarrhea-dominant IBS (Ki Cha, et al, 2011). A Bacillus coagulans strain reduced IBS-induced abdominal pain and bloating (Hun, 2009), as did some strains of Lactobacillus, E. coli (ECN), and Bifidobacterium. Studies of multistrain products have also shown improvements in bowel function, quality of life and pain in IBS patients (Hungin, et al, 2013; Williams, et al, 2001). There are fewer studies for the use of probiotics for IBS-C but these also show evidence of improving symptoms (Hungin, et al, 2013). Research indicates probiotics can work on many levels for treating IBS. They have been shown to have antiinflammatory activity, enhance intestinal epithelial barriers, help re-establish a healthy gut flora and reduce visceral hypersensitivity (Barbara, et al, 2012). Capsules: 1-2 per day VSL #3 extra strength: as recommended by the prescribing physician

Other Therapies for IBS Emotional stress is known to exacerbate IBS symptoms and a number of stress-reducing techniques have been shown in human trials to help relieve them. Yoga, hypnosis and relaxation techniques (Tai Qi, meditation, deep breathing exercises) have all been found to reduce IBS symptoms and enhance the quality of life (Yoon, et al, 2011), as has acupuncture (Grundmann & Yoon, 2014).

Inflammatory Bowel Disease (IBD) IBD is a more severe class of intestinal disorder that includes Crohn’s disease (CD) and ulcerative colitis (UC). In IBD there is chronic diarrhea with a mucus or bloody discharge, moderate to severe abdominal pain, bowel urgency, and frequency. Ulcerative colitis affects only the mucosal membrane of the colon, whereas Crohn’s disease can occur throughout the intestinal tract (small and large intestine, rectum). The pathogenesis of CD and UC are not entirely understood, but certain basic facts have been determined. There can be a genetic predisposition for IBD, but environmental (especially antibiotic use) and/or endogenous factors are usually responsible for triggering the chronic inflammation. People with IBD have decreased GI tract microbiota diversity and a defective intestinal endothelial barrier (decreased mucin production and increased zonulin, which increases intestinal permeability). Those with UC exhibit a loss of tolerance of their normal gut flora, while those with CD seem to be unable to clear bacteria from the GI mucosa (Rountree, 2014). There is often an overgrowth of gram positive bacteria, especially Bacteroides and Coliforms. Crohn’s disease and ulcerative colitis have an underlying autoimmune cause with chronic activation of inflammatory pathways (pro-inflammatory cytokines) and people with IBD also have higher than normal levels of asthma, MS, psoriasis, chronic fatigue and arthritis. IBD-like symptoms can also be caused by Celiac disease, Clostridium difficile infections (pseudomembranous colitis) or chronic diverticulitis. The most effective method to accurately diagnose UC or CD is a colonoscopy, although stool analysis (especially fecal calprotectin) can help differentiate between IBS (normal calprotectin levels) and IBD (elevated levels). IBD is very difficult to treat only via diet and herbal therapies, orthodox medical therapies including mesalazine or prednisone and surgery may be necessary. A very interesting and novel approach to treating Crohn’s disease is giving porcine whipworm eggs to people with this challenging disorder. The introduction of these non-pathological parasites (in humans) alters the gut-mediated immune response. Crohn’s disease is associated with excessive Th1 response, which promotes production of pro-inflammatory compounds such as IL-12, interferon-gamma and TNFα. People given this therapy have had significant improvement in Crohn’s symptoms and many have gone into complete remission (Summers, et al, 2005; Summers et al, 2003). A low FODMAP diet (see IBS, page 20) also offered significant symptom relief from people suffering from IBD (Prince, et al, 2016).

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Herbs for IBD Aloe gel (Aloe vera) – see Herbs to Heal the Gastric Mucosa. Andrographis herb (Andrographis paniculata) – in a RCT an extract of this herb was as effective as mesalazine for treating ulcerative colitis (Tang, et al, 2011). In another study, 1200 mg or 1800 mg of Andrographis was significantly more effective then placebo in helping people with UC achieve remission (Sandborn, et al, 2013). The herb clears damp heat, inhibits pathogenic gut bacteria and is antiinflammatory. Tincture (1:5): 1.5-3 mL QID Tea: 1 tsp. dried leaf, 8 oz. hot water, steep ½ hour, take 4 oz. 3x/day Astringent–demulcents - see previous entry under herbs for hot/damp diarrhea. Bilberry/Blueberry fruit (Vaccinium spp.) – in a small preliminary human trial (Biedermann, et al, 2013), a Bilberry extract (high in anthocyanins) helped 63.4% of people with mild to moderate UC achieve remission (99% of the test subjects had reduced GI inflammation). Both Blueberries and Bilberries are rich in antiinflammatory phenolics. Capsules: 2-3 capsules/day- standardized Bilberry extracts Solid extract: 1/8 - 1/4 tsp. 2x-3x/day Blueberry syrup: 1-2 tbsp. per day Fresh blueberries: 1-2 oz. per day Boswellia gum resin (Boswellia serrata) – is an Ayurvedic herb used as an antiinflammatory for arthritis, asthma and IBS. In several small human trials Boswellia increased remission rates and reduced symptoms in people suffering from ulcerative and chronic colitis (Madisch, et al, 2007; Gupta, et al, 2001; Gupta, et al, 1997). Tincture (1:5): 1.5-2.5 mL TID Tea: ½ - tsp. dried resin, 12 oz. water, decoct 15-20 minutes, steep covered 45 minutes, take 4 oz. 3x/day Cat’s Claw/Una de Gato bark (Uncaria tomentosa) – is antiinflammatory, an immune amphoteric, an astringent, and bowel tonic. It is very useful for treating leaky gut syndrome, IBS, IBD, and regional enteritis. Tincture (1:5): 1-2 mL TID Tea: 1-2 tsp. dried bark, 12 oz. water, decoct 10-15 minutes, steep 1/2 hour, take 4-6 oz. TID Goldenseal root (Hydrastis canadensis) – see hot/damp diarrhea. Green Tea (Camellia sinensis) – has significant antiinflammatory and antioxidant activity. The polyphenols found in Green Tea have been found to inhibit disease activity in people with mild to moderate UC (Rountree, 2014). Tea: 5-6 cups per day Huang Qin root (Scutellaria baicalensis) – see hot/damp diarrhea. Licorice root (Glycyrrhiza glabra, G. uralensis) – see hyperchlorhydria. Mastic gum (Pistacia lentiscus) – also known as gum mastic, comes from a tree that only grows on the Greek island of Chios. In a human clinical trial the use of this gum reduced inflammatory markers (IL-6 & CRP) associated with Crohn’s disease and decreased the Crohn’s activity index (Kaliora, et al, 2007). Capsules: 6 per day Milk Thistle seed (Silybum marianum) - in a RCT Silymarin (extracted from Milk Thistle) was far superior to placebo in helping people with UC to maintain remission over 6 months (Rastegarpanah, et al, 2015). Capsules: 140 mg per day Mucilagenous herbs – see herbs to heal the gastric mucosa

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Myrrh gum (Commiphora myrrha) – helps to heal ulcerated mucous membrane tissue. It promotes regeneration of tissue and improve mucous membrane integrity, helps stop bleeding or excessive mucus production and reduces inflammation and allergic response. Use Myrrh with Yarrow, Licorice, and Sarsaparilla for IBD. Tincture (1:5): 1-2 mL QID Plantain leaf/root (Plantago major) – see herbs to heal the gastric mucosa. Psyllium seed (Plantago ovata) – one of the treatments that can significantly improve distal UC is the use of butyrate enemas. When Psyllium is taken orally, butyrate is formed via colonic fermentation. In a RCT patients with UC who were in remission were given Psyllium, the medication mesalazine or both. Psyllium alone was almost as effective as mesalamine at preventing reactivation of the disease (40% treatment failure vs. 35%). The combination of the medication and Psyllium was more effective (30% treatment failure) than either treatment alone (Fernandez-Banares, et al, 1999). Dose: 10 g BID Qing Dai (Indigo naturalis) – is a naturally occurring dye compound extracted from various plants (Isatis spp., Baphicacanthus cusia, Polygonum tinctorium). It is used in TCM to clear heat, cool the blood and expel toxins. Qing Dai by itself and in combination with orthodox medications helped UC patients reduce symptoms and achieve remission (Sugimoto, et al, 2016; Suzuki, et al, 2013). A suppository of Xilei-San (which contains Qing Dai) has been found to be effective for treating ulcerative proctitis. Powder: 2 g per day Sarsaparilla rhizome (Smilax officinalis) – binds endotoxins in the gut, improving excretion of metabolic wastes. It is indicated for red, inflamed tissue (skin, mucous membrane, or muscle). I frequently use it with Gotu Kola and Turmeric for treating inflammatory bowel disease. Tincture (1:5): 3-5 mL QID Tea: 2 tsp. dried rhizome, 10 oz. water, decoct 10-15 minutes, steep 40 minutes, take 4-6 oz. TID Tienqi Ginseng root (Panax notoginseng) - is indicated for IBD with excessive intestinal bleeding. It is used short-term to help stabilize the ulcerated bowel tissue (it can also be used for bleeding ulcers) along with the herbs that help heal the gut mucosa. If Tienqi by itself does not stop the bleeding, the patent medicine Yunnan PaiYao could be tried. Tincture (1:5): 2-3 mL QID Tea: 1-2 tsp. dried root, 24 oz. water, decoct 40 minutes, until liquid is reduced by 1/2. Take 4-6 oz. QID. Tormentil root (Potentilla erecta) – is a tannin-rich plant with a long history of use for treating diarrhea, hematochezia and dysentery. In a human clinical trial patients with ulcerative colitis taking this herb had significant reductions in inflammatory markers and disease activity (Huber, et al, 2007). The high tannin content was associated with mild GI discomfort in slightly more than a third of the participants. Dose: 2400 mg per day Turmeric rhizome (Curcuma longa) – see herbs to heal gastric and intestinal mucosa Wheat Grass juice (Triticum aestivum) – is popular in natural foods circles as a nutrient-dense super food. It does contain vitamin E and K as well as some iron and potassium, but in reality it has significantly less nutritional value than many vegetables. It is rich in chlorophyll which has been shown to have benefits for healing skin and mucous membrane tissue. In a small RCT patients with UC given Wheat Grass juice had significant reductions in disease activity and less severe rectal bleeding (Ben-Arye, et al, 2002). Dose: 1 oz. TID Wild Indigo root/leaf (Baptisia tinctoria) – was used by the Eclectics for evacuations from the bowel that look like “washings of meat”. The stool is bloody with small bits of intestinal tissue mixed in. It is also used for diarrhea that looks like “prune juice” with a foul odor. It can be combined with Myrrh, Tienqi Ginseng, Turmeric or Gotu Kola for Crohn’s disease.

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Tincture (1:2): 25-.50 ml (5-10 gtt.) TID/QID Wormwood herb (Artemisia absinthium) – in a human clinical trial, Wormwood reduced tumor necrosis factor alpha (TNF-α) in Crohn’s patients and helped promote remission of active disease (Krebs, et al, 2010). In a second RCT trial, Crohn’s patients were taken off steroids and Wormwood was able to keep 60% symptom free (Omer, et al, 2007). Tincture (1:5), 35% ETOH Dose: .25-.75 mL (5-15 gtt.) BID Tea (Infusion): 1/2 tsp. dried herb, 8 oz. hot water, steep covered for 30-40 minutes, take 1-2 oz. before meals Yarrow herb/flowers (Achillea millefolium) –see herbs to heal gastric and intestinal mucosa. Since IBD has an underlying autoimmune causation, using immune amphoterics (immunomodulators and immunoregulators) is essential to re-regulate normal immune response. Herbs that are immune amphoterics include: Maitake (Grifola frondosa), Reishi, Ashwagandha (Withania somnifera), Asian Ginseng (Panax ginseng), American Ginseng (Panax quinquefolius), Cordyceps (Cordyceps sinensis), Guduchi (Tinospora cordifolia), Cat’s Claw and Licorice. Immunoregulators which help down-regulate excess immune response and inhibit inflammation are also of benefit. Herbs in this category include Bupleurum (Bupleurum chinensis), Sarsaparilla, Gotu Kola, Turmeric, Baikal Scullcap, Dan Shen (Salvia miltiorrhiza), Indian Madder, Boswellia, and Unprocessed Rehmannia (Rehmannia glutinosa).

Supplements for IBD Butyrate – is a short chain fatty acid that is naturally produced in the gut by fermentation of non-soluble fiber such as psyllium seed. Butyrate has been used in enemas as well as an oral supplement. Oral calcium magnesium butyrate or sodium butyrate acts as an intestinal antiinflammatory. It helps heal intestinal epethial cells, inhibits pro-inflammatory cytokines, it reduces UC and Crohn’s disease activity (Won, e tal, 2014) as well as enhancing intestinal barrier function (Canani, et al, 2011). Dose: 4 g. per day of calcium/magnesium butyrate Chlorella – is a green algae high in protein, essential fatty acids, vitamins and minerals. In a human study it reduced symptoms in people suffering from ulcerative colitis (Mercant & Andre, 2001). Dose: 10 g. per day Fish Oils – Due to the antiinflammatory effects of fish oil, it has been studied for treatment of Crohn’s disease and UC. While fish oils reduced pro-inflammatory prostaglandins and interferon γ, it did not inhibit the disease. In several studies a combination of fish oils, soluble fiber and antioxidants was able to significantly reduce prednisone dosage and fewer people needed mesalazine for symptom control (Wiese, et al, 2011; Razack & Seidner, 2007; Seidner, et al, 2005). I frequently use high doses of fish oils as part of my IBD protocols. Dose: 2-6 g. per day L-glutamine – helps to reduce GI tract inflammation and promotes healing of the gut mucosa. It can help re-establish a healthy intestinal barrier by promoting mucin production and reducing gut permeability. Dose: 5 g. TID N-acetylcysteine (NAC) – given with the pharmaceutical medication mesalamine, improved IBD patient outcomes. NAC decreased inflammatory cytokines and the two medications together had a greater effect on reducing ulcerative colitis symptoms (Guijarro, et al, 2008). Dose: 2.4 g. per day Olive Oil – extra virgin olive oil has significant antiinflammatory activity and helps to heal the GI tract as well as the skin. Regular daily intake of EVOO inhibits inflammatory cytokines and in animal studies reduced UC symptoms. Dose: Use frequently in the diet

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Phosphatidylcholine (PC) – is a choline-containing phospholipid that is an essential part of cell membranes. The supplement is extracted from egg yolks or soy beans. In three clinical trials, a delayed-release PC was found to significantly increase remissions in people with ulcerative colitis (Stremmel, et al, 2010). Dose: 2-6 g. per day Probiotics – concurrent use of probiotics (Lactobacillus and/or Bifidobacterium) and prebiotics in the form of Psyllium seed, was more effective than either therapy alone for improving symptoms and inducing remissions in patients with Crohn’s disease (Fujimori, et al, 2007) and improving quality of life in people with ulcerative colitis (Fujimori, et al, 2009). The term the authors use for this combination therapy is synbiotics. In a meta-analysis of the use of probiotics for IBD there was significant evidence that probiotics were effective for inducing and maintaining remissions in people with UC and pouchitis (Ghouri, et al, 2014). In my practice I use a combination of VSL #3 (extra-strength) and the probiotic yeast saccharomyces boulardii for helping to reestablish a healthy gut flora and inhibit IBD symptoms. Dose: VSL #3: 450-900 billion live bacteria per dose Saccharomyces boulardii: 100 billion live bacteria per day Propionyl L-carnitine – is an amino acid that plays a vital role in fatty acid metabolism, which is impaired in UC. In a RCT propionyl-L-carnitine was given to patients with mild-to-moderate UC. People taking the supplement had significant reduction in symptoms and increased numbers of remissions (Mikhailova, et al, 2011). Dose: 1 g. per day Other Supplements – several other supplements have been proposed for treating UC or Crohn’s disease based on laboratory or animal studies. Bromelain, selenium with vitamin E, and alpha-lipoic acid have been shown to have benefits in rats, but human studies are lacking. Vitamin D has also been investigated for IBD in human trials but clear evidence for efficacy has not been found in several small trials.

Gastrointestinal and Hepatic Depression The enteric or gut brain is the source of 85% of the body’s serotonin and significant levels of naturally occurring benzodiazepine-like compounds. The intestinal microbiome also plays a major role in regulating CNS and HPA axis function. Probiotics have been shown to reduce anxiety and depression, reducing inflammatory cytokines and enhancing serum tryptophan levels (Grenham, et al, 2011). GI conditions such as chronic constipation or diarrhea, GI dysbiosis, IBS, IBD or leaky gut syndrome can interfere with normal production of these essential chemicals and the diversity and health of the intestinal flora. These biochemical or bacterial imbalances can lead to GI-based depression or anxiety. The symptoms of GI-based depression include moodiness, lethargy or despondency along with significant and persistent dyspepsia or other digestive or bowel complaints. Hepatic depression is similar but the person is more likely to be angry, irritable, with mixed anxiety/depressive disorder, as well as experiencing biliousness, insomnia, liver headaches or nausea. Herbs are especially effective for healing the gut mucosa and relieving symptoms of GI-based dysthymia. They also enhance liver function and promote both phase I and II liver detoxification. I use the following herbs for these types of depression: Culver's Root/Leptandra (Veronicastrum virginicum) – is utilized for depression with dull headaches, especially behind the eyes. The person may also have an enlarged liver, constipation, clay-colored stools, or a slow transit time. Leptandra is used with Rosemary and St. John’s wort for “hepatic depression”. Tincture (1:5) 2-5 gtt, every 2-3 hours Evening Primrose leaf, root bark, flower (Oenothera biennis) – is indicated for depression associated with chronic dyspepsia or vomiting, and frequent desire to urinate. The patient is apathetic, gloomy, and despondent. This is one of the most effective herbs for GI-related depression, use it with Culver’s Root and St. John’s wort. Tincture (1:5) - 2-3 mL TID Rosemary herb (Rosmarinus officinale) – is beneficial for people who have a dull, lethargic depression, thinking is too much of a bother, or they have constant mental fog. It is also effective for bilious (hepatic)

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depression (use it with Culver’s Root and St. John’s wort) or depression due to cerebral insufficiency (use it with standardized Ginkgo and Bacopa). Tincture (1:5) - 2-4 mL TID Tea - 1 tsp. dried herb, 8 oz. water, steep 20 minutes, take 4 oz. TID Saffron (Crocus sativus) – this costly spice is also an effective antiinflammatory and antidepressant (Shahmansouri, et al, 2014; Hausenblas, et al, 2013; Moshiri, et al, 2006). I primarily use it to treat GI-based depression, as well as relieving sexual dysfunction in men and women caused by SSRIs (Kashani, et al, 2013;Modabbernia, et al, 2012). Tincture (1:5) -.25-.75 ml BID Tea- 6-8 stigmas to 8 oz. hot water, steep covered 10-15 minutes. Take 2 oz. BID Capsules: 15 mg. BID St. John’s wort flowering tops (Hypericum perforatum) – is useful for mild to moderate dysthymic or situational depression. The person has a dyspeptic outlook, a sour stomach, and a sour attitude (GI-based depression). Use it with Saffron and Evening Primrose herb. Combining St. John’s wort with SSRIs should only be done under a physician’s supervision and with caution. Tincture (1:5) - 3-4 mL QID Wormwood herb (Artemisia absinthium) – is used to treat melancholia (GI or liver based depression). This bitter herb has antiinflammatory, cholagogue and antidepressant effects. In two human trials, Wormwood not only helped to prevent recurrence of IBD, it improved HAM-D scores as well. Tincture (1:5): .5-.75 mL BID Tea: ½ tsp. dried herb, 8 oz. hot water, steep covered for 30-40 minutes, take 1-2 oz. before meals

Prevention of Adenomatous Polyps and Bowel Cancer There is a significant body of literature suggesting that various herbs, foods, and supplements can offer protection against developing adenomatous polyps and bowel cancer. Adenomatous polyps are pre-cancerous and there is a very high risk that they will become malignant. There is a genetic condition known as familial adenomatous polyposis (FAP) where people constantly form many adenomatous polyps. People with this condition have a very high risk of developing intestinal cancer. In animal studies, berberine (Zheng, et al, 2013), Aloe vera (Chihara, et al, 2013), thymoquinone, the active constituent of Black Seed (Lang, et al, 2013), Curcumin (Perkins, et al, 2002), silymarin and lignans (Calabrese, et al, 2013), Olive oil (Barrone, et al, 2014) and the Boswellia extract acetyl-11-ketobeta Boswellic acid (Wang, et al, 2014) all inhibited formation of adenomatous polyps. In a unique human study, suppositories made of Black Raspberry powder helped regress rectal polyps (Wang et a, 2014). Risk factors for developing intestinal cancers include a western style, high fat, high calorie diet, familial adenomatous polyposis, smoking, excess alcohol and grilled meat consumption, a lack of exercise and dietary antioxidants, as well as obesity. Numerous foods and supplements have shown possible benefits for reducing risk of coleo-rectal cancers, including apple procyanadins (Gosse, et al, 2005), inulin-type fructans (Pool-Zobel, 2005), Ginger (Manju, et al 2005), Cardamom (Sengupta, et al, 2005), Vitamins D and E (Ahmed, 2004), Phytic acid (Reddy, 1999), Kimchi (Park, et al, 2014), aspirin (Wakeman, et al, 2015), selenium (Ahmed, 2004), Cayenne Pepper (Lu, et al, 2010) and coffee (Galeone, et al, 2010). There is a great deal of conflicting data on this topic with both positive and negative studies. This is especially true for calcium, fish oils, folic acid and antioxidants. Several herbs, including Hu Zhang root/Japanese Knotweed (Fallopia japonica, syn. Polygonum cuspidatum), Rhubarb root, and Turmeric may also offer protective benefits. Analysis of numerous studies indicates there is no relationship between high fiber intake and a reduced risk of colorectal cancers (Park, et al, 2005).

Amoebic Infections Common amoebas and amoeba-like organisms include Giardia, Blastocystis hominis, Dientamoeba fragilis, Cryptosporidium, and Entamoeba histolytica. Infections can be asymptomatic, or they can cause cyclical diarrhea, dysentery, mal-absorption, weight loss, and severe GI tract pain and inflammation.

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Antiamoebic Herbs Black Walnut hulls (Juglans nigra) – are antiamoebic, a vermifuge and antifungal. The fresh green hull is the part used. I usually combine it with other herbs to inhibit amoebas as we well as nematodes. Large doses tend to cause nausea and digestive upset, add herbs such as Pipalli Long Pepper to prevent GI upset. Tincture (1:2): 1-1.5 mL TID Elecampane root (Inula helenium) – has little toxicity and can be used as part of a formula for amoebas or nematodes. The taste, like almost every herb in this category, is terrible but these herbs can be effective in many chronic infections where orthodox therapies such as metronidazole (Flagyl) have failed. Tincture (1:2): 1-1.5 mL QID Myrrh gum resin (Commiphora myrrha) – in the Middle East, Myrrh has a long history of human and veterinary use for treating giardiasis, cryptosporidiosis and other intestinal parasitic infections (Fathy, 2011; Massond, et al, 2008). It is not curative, but can help relieve symptoms such as diarrhea, pain, and mucosal damage. It can be combined with stronger herbs such as Wormwood, Quassia or Neem. Tincture (1:5): 1-2 mL TID/QID Neem (Azadirachta indica) – see hyperchlorhydria. Pippali Long Pepper (Piper longum) – is an important Rasayana in Ayurvedic medicine. Like its relatives, Black Pepper and Cubeb berries, it has a long history of use as a carminative and respiratory remedy. Pipalli is also effective for treating amoebic dysentery caused by Entamoeba histolytica (Ghoshal, et al, 1996) and can be used along with other antiamoebic herbs for most, if not all, amoebic infections. The pungent, warming taste of this herb helps prevent nausea caused by the cold and bitter tasting herbs it is used with and it enhances their absorption. Tincture (1:5): .75 – 1.5 mL TID Tea: ½ tsp. freshly ground dried berries, 8 oz. hot water, steep covered for 20 minutes, take 2-4 oz. 3x/day Quassia bark/wood (Picrasma excelsa) – and its relative, Cascara Amarga (Picramnia antidesma) are intensely bitter woods that have a long history of use for nematodes, amoebas, and malarial fevers. Overdose of this herb can cause nausea and diarrhea. Children are especially sensitive to its potentially toxic effects. Tincture (1:5): 10-20 gtt. TID Sweet Annie herb (Artemisia annua) – is very effective at inhibiting Plasmodium spp., the protozoans which cause malaria, as well as Cryptosporidium infections. Tincture (1:5): 3-4 mL BID Capsule: 1-2 (00) capsules BID Wormwood herb (Artemisia absinthium) – is best used as a tea due to its thujone content (although its taste is very unpleasant). It stimulates digestion, hepatic function, and kills various amoebas. I usually combine Wormwood with Quassia, Elecampane, and Black Walnut hulls for gastrointestinal amoebiasis. Tincture (1:5): 1-2 mL TID Capsule: 1 (00) capsule BID Bibliography Ahmed, F.E., Effect of Diet, Life Style, and Other Environmental/Chemopreventive Factors on Colorectal Cancer Development, and Assessment of the Risks, J Environ Sci Health C Environ Carcinog Ecotoxicol Rev, 2004;22(2):91-147

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APPENDIX A

FOODS, SWEETENERS AND HERBS WITH HIGH FODMAP CONTENT

Some information from Thomas, et al, 2012 and Nestlehealthscience.us/lowFODMAP/fodmap-101

OLIGOSACCHARIDES DISACCHARIDES MONOSACCHARIDES POLYOLS

FRUCTO-OLIGOSACCHARIDES (FRUCTANS)

GALACTO-OLIGOSACCHARIDES (LACTOSE) (FRUCTOSE) Artichoke Baked beans Buttermilk Agave syrup Apples Asparagus Black beans Cow, goat or sheep milk Apples Apricot

Barley* Carob Evaporated milk Artichokes Avocado Broccoli Cashews Ice Cream Asparagus Blackberries

Brussels Sprout Chickpeas Kefir Beets Cauliflower Burdock root Lentils Ricotta, cottage cheese, mascarpone Boysenberries Isomalt

Cabbage Pistachios Sour Cream Cherries Longan fruit Cauliflower Red Kidney beans Yogurt (dairy) Coconut sugar Lychee

Chamomile tea Soy milk Coconut water Maltilol Chicory root Soybeans Dates Mannitol

Dandelion root Split Peas Figs Mushrooms Dried fruit Tofu High fructose corn syrup Peaches Fennel tea Honey Pears

Garlic* Mango Plums Inulin Many dried fruits Polydextrose

Jerusalem artichoke Papaya Prune Jicama Pears Snow peas

Jujube date Persimmon Sorbitol Leek Rum Xylitol

Lycium fruit Sugar Snap peas Nectarine Sweet corn

Onions Sweet desert wines Peas Watermelon

Persimmon Rye

Shallot Watermelon

Wheat White Peach