Dietary and Medicinal Herbal Recommendation for Management of Primary Bile Reflux Gastritis in Traditional Persian Medicine

Dear Editor-in-Chief

Bile reflux is severe in patients with gasteroesophageal reflux, especially who has severe esophagitis and Barrett esophagus (1). It is one of the primary factors leading to gastric mucosal lesions in chronic gastritis (2). High concentration of bile acid seems to be associated with an elevated risk of intestinal metaplasia (2). The treatment is the same as acidic reflux (1) but non-operative therapy largely is ineffective (3). Unfortunately, now, there are no drugs in clinical practice to avoid bile production specifically (1). Therefore, it is necessary to find appropriate remedies for bile reflux management. In Traditional Persian Medicine (TPM), there is special attention to the stomach (4–6) and it has a main role of the creation and development of diseases such as fatty liver and heart problems (7, 8). Food digestion is done by four stage process. It seems that the first and most important stage of digestion occurs in the stomach (4–6). In fact, an imbalance between the hotness and coldness or between wetness and dryness leads to the stomach dysfunction (4–6). One of these disorders called sue-Mizaj Safravi (Stomach Yellow Bile distemperament) defined by one or more of these symptoms: great thirst, tendency to drink cold water, low appetite (often), mouth bitter taste, nausea, bile vomiting, bile defecation associated with burn and boiling sensation in the stomach, thinness and cachexia (4, 5). Its pathogenesis is bile increase in the stomach (4–6) similar to bile reflux. As a matter of fact Persian physicians applied three main categories of medicaments for this problem:

1. Nutritional therapy and life style modification.

2. Medicinal herbs in form of simple or compound dosage

3. Physical manipulations (9). On the other hand, in this study all above mentioned instructions are divided into nutritional and non-nutritional plans. In TPM nutritional habits and types of foods have very important role in treatments (4–6). Each food has special temperaments. Cold, wet or cold and wet foods such as cucurbit, baked lentil, oat bread, fresh cheese, lettuce, tamarind, coriander, sumac, fresh fish, vinegar and berberis are recommend for dietary program in Stomach Yellow Bile distemperament (Table 1).

Table 1:

Suitable dietary program for Stomach Yellow Bile distemperament

Meals	Type of food	Explanations
Breakfast	Sangak bread or oat bread and rose jam, cucurbit jam and butter or fresh cheese and cucumber and tomato or baked lentil with vinegar or verjuice.	Sangak bread: an Iranian whole wheat sourdough, baked on a bed of small river stones in an oven; Stew (Khoresh):baked vegetables, legumes and fruits with a little boiled meat often eaten with rice; tah-chin: an Iranian rice cake that includes rice, yogurt, saffron, egg and chicken fillet; potages and soups: baked vegetables and fruits and a little meat in a watery environment; pilof: well cooked rice; ma’oshair: much diluted barley soap
Snack	Peach, apricot, cucumber with vinegar, lettuce, prune, tamarind, sour yogurt, doogh, water melon, pomegranate juice
Lunch	Boiled chicken and baked vegetables, tah-chin, cucurbit stew, cucurbit and spinach stew, okra stew, prone stew pomegranate soup, sumac soup, verjuice soup, berberis soup, doogh soup, oat soup, chicken soup, yogurt soup, cooked lentil and pilof, sumac and pilof, cooked mug and pilof, spinach and pilof, cooked fish and cooked tripe and vinegar
Dinner	It is better to limit a simple food, as bread, cucumber and doogh or bread and ma’oshair rather than meat or legume.

Non-nutritional plan include

1. The bile excretion by induced vomiting is done after drinking warm water and oxymel (honey and vinegar mixture) or water and olive oil or water and honey. We can recommend drinking ma’oshair (boiled barley juice) before induced vomiting.

2. Bile excretion is done by purgative like Golghand (a sweet rose jam), prune, apricot and tamarind, can be used to as extract or decoction. Pear juice, manna of hedysarum and cotoneaster are useful too.

3. The use of single herbal drug takes 3–5 days for the bile exertion for example cassia fistula, tamarind and viola.

4. Combinatorial herbal drug:

   1. Maa-ol-jobon-e-sade (the liquid material created as a by-product of cheese production.)
   2. The mixture of fruit juices as mentioned in part 2.
5. Stomach strengthening:

   1. Maviz (black and sweet raisin), lettuce and oxymel and hard skin of gizzard birds (as a dry powder).
   2. Reducing the frequency of intercourse.
   3. Herbal drug (Table 2).

Table 2:

Useful herbal drugs for stomach reinforcement in Stomach Yellow Bile distemperament

No	Family	Scientific name	Common name	Iranian Traditional name	Temperament	Part used (10)
1	Anacardiaceae	Rhus coriaria L.	Sumac	Somaq	Cold & dry	Fruit
2	Apiaceae	Apium graveolens L.	Celery	Karafs	Hot & dry	Fruit
3	Apiaceae	Coriandrum sativum L.	Coriander	Kozbarah	Cold & dry	Fruit
4	Asterraceae	Cichorium intybus L.	Chicory	Hendeba	Cold & dry	Fruit
5	Berberidaceae	Berberis vulgaris L.	Barberry	Anberbaris	Cold & dry	Fruit
6	Boraginaceae	Cordia myxa L.	Sebestan plums	Sepestan	Moderate& moist	Fruit
7	Caesalpinaceae	Cassia angustifolia Vahl.	Senna	Sena	Hot & dry	Leaf
8	Caesalpinaceae	Cassia fistula L.	Purging Cassia Pod	Khiarshanbar	Hot & moist	Fruit
9	Capparaceae	Capparis spinosa L.	Caper	Kabbar	Hot & dry	Fruit
10	Chenopodiaceae	Spinacia oleraceae L.	Spinach	Esfanakh	Cold & moist	Leaf
11	Combretaceae	Terminalia chebula Retz.	Myrobalan Fruit	Ihilag	Cold & dry	Fruit
13	Euphorbiaceae	Phyllanthus emblica L.	Myrobalan emblic	Amlag	Cold & dry	Fruit

This study is the first descriptive paper about Stomach Yellow Bile distemperament treatment. This recommended dietary and medicinal plant can be used for bile reflux patients. Clinical study should be conducted for effectiveness of these nutritional and non-nutritional plans.