Chemical Colitis due to Senna (Herbal Medicine) in an Elderly Patient

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OLGU SUNUMU/CASE REPORT Akad Geriatri 2012; 4: 51-54

Chemical Colitis due to Senna (Herbal Medicine) in an Elderly Patient

Yafll› Bir Olguda Sennaya Ba¤l› Kimyasal Kolit

Elife Erarslan1, Hatice Ünverdi2, ‹lhami Yüksel1

1 Department of Gastroenterology, Etlik Training and Research Hospital, Ankara, Turkey 1 SB Etlik ‹htisas E¤itim ve Araflt›rma Hastanesi, Gastroenteroloji Bölümü, Ankara, Türkiye2 Department of Pathology, Etlik Training and Research Hospital, Ankara, Turkey2 SB Etlik ‹htisas E¤itim ve Araflt›rma Hastanesi, Patoloji Bölümü, Ankara, Türkiye

ABSTRACTSenna is widely used as a laxative, although it has potential side effects. Senna, experimentally, can induce ulcerative colitis andmelanosis coli. Chemical colitis can occur as a result of accidental contamination of endoscopes or by intentional or accidentaladministration of enemas containing various chemicals. Patients present with nonspecific symptoms including abdominal pain,rectal bleeding and/or diarrhea. Agents that are implicated in chemical colitis include alcohol, radiocontrast agents, glutaraldehy-de, ergotamine, acetic acid, ammonia, sodium hydroxide, and herbal medicines, etc. There have been few reported cases of sen-na (herbal medicine)-induced colitis. Here, we described an uncommon case with chemical colitis induced by senna.

Key Words: Colitis, chemical colitis, senna, elderly patient.

ÖZETSenna muhtemel yan etkilerine ra¤men s›kl›kla kullan›lan bir laksatiftir. Senna deneysel olarak ülseratif kolit ve melanozis koli-ye neden olabilir. Kimyasal kolit çeflitli kimyasallar içeren lavmanlar›n al›nmas› veya endoskoplar›n kazara kontaminasyonu so-nucu oluflabilir. Hastalarda abdominal a¤r›, rektal kanama ve/veya ishal gibi nonspesifik semptomlar görülür. Alkol, radyokont-rast ajanlar, gluteraldehid, ergotamin, asetik asit, bitkisel ilaçlar vb. kimyasal kolite neden oldu¤u düflünülen ajanlard›r. Senna-ya (bitkisel ilaç) ba¤l› çok az say›da kolitli olgu bildirimi vard›r. Biz burada senna kullan›m›na ba¤l› kimyasal kolitli yafll› bir ol-guyu sunuyoruz.

Anahtar Kelimeler: Kolit, kimyasal kolit, senna, yafll› hasta.

Yaz›flma Adresi/Address for Correspondence

Uzm. Dr. Elife ErarslanSB Etlik ‹htisas E¤itim ve Araflt›rma Hastanesi, Gastroenteroloji Bölümü, Halil Sezai Erkut Caddesi, 06010 Etlik, Ankara/Türkiyee-posta: [email protected]

Gelifl Tarihi/Received: 27/06/2011 - Kabul Edilifl Tarihi/Accepted: 21/07/2011

INTRODUCTION

Among the plants that contain anthranoid laxatives,senna (Senna alexandrina or Cassia angustifolia) is themost preferred for constipation. Due to their natural ori-gin, apparent low oral toxicity, effectiveness, and acces-sibility without a medical prescription, the anthranoid la-xatives are a popular remedy for constipation and frequ-ently used abusively. Therefore, it is important to cha-racterize their harmful and/or toxic effects. Among themost frequently used laxatives that are self-administe-red or prescribed by a physician, senna infusions areconsidered as osmotic-type laxatives (1). Senna, experi-mentally, can induce ulcerative colitis and melanosis co-li (2). A literature search revealed an association betwe-en colitis and senna (3). Laxative-based regimens aremore likely to cause flattening of surface epithelial cells,goblet cell depletion and lamina propria edema (1).

There have been several case reports of chemical co-litis occurring as a consequence of contamination of en-doscopes or tubing by disinfecting solutions and both in-tentional and accidental exposure to various chemicals,including alcohol, radiocontrast agents, glutaraldehyde,ergotamine, acids/bases, and herbal medicines, etc. (4).Patients with chemical colitis often present with abdomi-nal and rectal pain, hematochezia and diarrhea. Patientsare usually afebrile with mild-to-moderate leukocytosis.Endoscopic and histologic findings are also often nonspe-cific and may mimic ischemic or inflammatory colitis. Cli-nical presentation ranges from mild, self-limited colitis tostrictures and perforations. Most patients demonstratethe resolution of chemical colitis after conservative ormedical therapy (5). In the present study, we report anuncommon case with senna-induced chemical colitis.

CASE REPORT

A 69-year-old male suffered from severe diarrhea,abdominal pain and cramping after senna (herbal medi-cine) usage for constipation. He had used senna juice(200 cc) once a day for 2-3 weeks. He was admitted toour gastroenterology clinic with watery diarrhea (>10episodes per day), abdominal pain and cramping. Hismedical history revealed diabetes mellitus and hyper-tension for 12 years and he was on regular medicationincluding metformin 1700 mg/day and amlodipine 10mg/day, but not on any herbal remedy. His physicalexamination revealed a temperature of 37.4°C, abdo-

minal tenderness and increased bowel sounds. Othersystem findings were normal. Laboratory tests showeda white blood cell count of 11.4 x 109 cells/l (normal:4.6-10.2), C-reactive protein 8 mg/L (normal: 0-8 mg/L)and sedimentation 12 (normal: 1-20 mm/hour). Therewere few leukocytes, erythrocytes and mucus in stoolmicroscopy. Clostridium difficile toxin A was negativein the stool examination. A colonoscopy revealed hype-remic and edematous mucosa with white-coated ulcera-tions of variable size in the distal sigmoid colon and pro-ximal rectum (Figure 1). Other parts of the colonic mu-cosa were normal. Biopsies showed severe inflammati-on of the lamina propria, crypt destruction, capillary di-latation, and neutrophilic infiltration (Figure 2). A cont-rol sigmoidoscopy was normal after 10 days of treat-ment with metronidazole 2 x 500 mg PO. In our case,mucosal injury triggered by senna probably precipita-ted the mucosal damage and further led to colitis for-mation.

DISCUSSION

Herbal medicines can be potentially toxic to humanhealth. Senna is an important herbal drug used worldwi-de for the treatment of constipation and is the most stu-died anthranoid laxative (6). Senna contains variousanthranoids, the most important of which are sennosi-des A and B, followed by aloe-emodin, emodin andchrysophanol. The sennosides, the main active metabo-lite of senna, show a very low toxicity in rats, and move

Chemical Colitis due to Senna (Herbal Medicine) in an Elderly Patient

Erarslan E, Ünverdi H, Yüksel ‹.

Akad Geriatri 2012; 4: 51-5452

Figure 1. A colonoscopy showed that the lumen ofthe distal sigmoid and proximal rectum ranged frommucosal edema, erythema and ulcers of varying size.

through the small intestine as prodrugs and are thenmetabolized in the large bowel by intestinal bacteria tothe active laxative metabolite rhein anthrone (7,8). Ove-rall, senna extracts displayed low toxicity in animaltests following single or repeated administrations (1).

Senna, experimentally, induces ulcerative colitisand melanosis coli (2). A literature search revealed anassociation between colitis and senna. There was a do-se-dependent laxative effect beginning at 300 mg/kgper day and above. It was reported that senna compo-nents may be carcinogenic in mice and rats, and thechronic use or abuse of this agent resulted in a numberof symptoms, such as abdominal pain, nausea andchronic diarrhea (3). Morphologically, the repeated oral

administration of senna caused epithelial hyperplasiaof the large intestine of all treated groups (9).

Chemical colitis has been reported to occur afterthe rectal administration of various chemicals, inclu-ding alcohol, glutaraldehyde, herbal medications, andstrong acids/bases, etc. Populations at high risk inclu-de individuals with mental illnesses, certain African tri-bes who use enemas for ritual purposes, and those whouse enemas for chronic constipation (5,10). Most of thereported cases of chemical colitis have occurred afteraccidental contamination of endoscopes with glutaral-dehyde and/or hydrogen peroxide or with the use of ra-diocontrast agents in the setting of obstruction (11).There have been several case reports of chemical coli-tis resulting from the unintentional administration ofthe caustic chemicals. Clinical studies from local hospi-tals in South Africa reported a total of six cases of her-bal enema-induced colitis. Most patients presentedwith rectal bleeding and perianal excoriations and 5patients had peritonitis (5). One patient was treatedconservatively, while the remaining patients requiredcolostomy (10).

Herbal medicine-induced chemical colitis is rare,but important, because it might cause serious symp-toms. Most patients with chemically induced colitispresent with nonspecific symptoms including abdomi-nal and rectal pain, hematochezia and diarrhea. Endos-copic evaluation usually reveals non-specific findingsranging from edema to friable, hemorrhagic or necroticmucosa with ulcerations. The histologic features are si-milar among most patients and range from mild erythe-ma to extensive mucosal sloughing and necrosis. Ho-wever, specific clinical presentations of chemical-indu-ced colitis depend on the type of chemical agent used.Once the diagnosis is made, treatments include discon-tinuation of exposure of the inciting chemical, bowelrest, broad-spectrum antibiotics, and possible use ofsteroids. Endoscopic and surgical intervention is occa-sionally indicated in the setting of perforation or stric-ture (5). Our case was admitted for severe abdominalpain and diarrhea after using senna fluid. The colonos-copy and biopsies were consistent with colitis. It wasaccepted as chemical colitis due to senna fluid on thebasis of this information.

In conclusion, a correct diagnosis of chemical coli-tis in any patient who presents with colitis of unknown

Yafll› Bir Olguda Sennaya Ba¤l› Kimyasal Kolit

Erarslan E, Ünverdi H, Yüksel ‹.

Akad Geriatri 2012; 4: 51-54 53

Figure 2. Light microscopic examination of the histo-logical appearance of colonic mucosa in senna-indu-ced colitis; extensive mucosal damage was generallyaccompanied by severe inflammation in the laminapropria. Cryptitis and crypt distortion are seen.

Chemical Colitis due to Senna (Herbal Medicine) in an Elderly Patient

Erarslan E, Ünverdi H, Yüksel ‹.

Akad Geriatri 2012; 4: 51-5454

etiology depends on a high index of suspicion, aware-ness of the possible chemical culprits and a detailedhistory. Physicians should keep in mind chemical coli-tis in elderly patients suffering from diarrhea due tosenna (herbal medicine).

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