A Case of Ischemic Colitis Associated with the Herbal Food Supplement Ma Huang

Yonsei Med J 49(3):496 - 499, 2008
Case Report
DOI 10.3349/ymj.2008.49.3.496
A Case of Ischemic Colitis Associated with the Herbal Food
Supplement Ma Huang
Hyun Joo Song, Ki-Nam Shim, Kum Hei Ryu, Tae Hun Kim, Sung-Ae Jung, and Kwon Yoo
Department of Internal Medicine, Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea.
Ischemic colitis is a condition that usually occurs in the
occlusive ischemia. These medications include
elderly, as a form of vascular disease. However, ischemic
digitalis, diuretics, estrogen, cocaine, pseudoephe-
colitis also occurs, though rarely, in healthy young adults.
drine, methamphetamine, vasopressin, alosetron,
Moreover, food supplements containing Ephedra sinica or ma
huang have been linked to adverse central nervous and cardio-
and non-steroidal anti-inflammatory drugs.1,2
vascular events. A 40-year-old man was admitted to our
Ephedra sinica or ma huang is an evergreen
emergency department after 2 episodes of abdominal pain and
shrub native to Central Asia, and its primary com-
bloody diarrhea that lasted 24 hours. His medical history was
ponent is ephedrine.3 Food supplements contain-
unremarkable for risk factors of bowel ischemia, except for
ing ephedra alkaloids have been linked to adverse
well-controlled hypertension. However, a weight-loss supple-
cardiovascular and central nervous events.4
ment, Ephedra sinica, had been prescribed for daily use during
the previous month. Both abdominal/pelvic computed tomo-
Additionally, a case of ischemic colitis associated
graphy and colonoscopy revealed findings compatible with
with the use of an herbal product was reported
ischemic colitis. His conditions spontaneously improved
in a young woman.5 In this paper, we examine the
without any serious complications, and he was advised to dis-
strong association between the use of ma huang
continue the use of herbal medications containing ephedrine.
and the development of ischemic colitis.
In this paper, we describe a case of ischemic colitis that was
potentially linked to the use of ma huang with a review of
the relevant literature.
CASE REPORT
Key Words: Ischemic colitis, ephedra sinica, ma huang
A 40-year-old man was admitted to our emer-
INTRODUCTION
gency department with abdominal pain and
bloody diarrhea. The patient had watery diarrhea
Ischemic colitis results from the same conditions
for 3 days, but 3 hours prior to presentation, it
that cause hypoperfusion or embolic/thrombotic
became bloody. He had neither a history of
occlusion of the vascular supply of the colon.1
symptoms suggestive of an inflammatory bowel
Many factors may be involved in the hypoper-
disease nor a recent history of antibiotic use. In
fusive state that results in ischemic colitis. Non-
addition, he had neither a history of recent travel
occlusive ischemia is now a well-recognized
nor a diet change. His medical history was unre-
condition, though its pathophysiology is still not
markable for risk factors of bowel ischemia,
completely understood.2 Vasoconstrictive medica-
except for hypertension that was well controlled
tions may be implicated in some cases of non-
with angiotensin receptor blockers. He smoked 1
pack of cigarette per day for 10 years, and there
was no family history of cerebrovascular or cardi-
Received October 24, 2006
vascular disease. Notably, he had been taking an
Accepted December 1, 2006
herbal food supplement, Ephedra sinica or ma
Reprint address: requests to Dr. Ki-Nam Shim, Department of
huang (total 1,000 mg; 3 times/day) throughout
Internal Medicine, Ewha Womans University Mokdong Hospital,
911-1 Mok-dong, Yangcheon-gu, Seoul 158-710, Korea. Tel: 82-2-
the previous month for weight loss.
2650-2632, Fax: 82-2-2655-2076, E-mail: shimkn@ewha.ac.kr
His blood pressure was 110/70 mmHg, pulse
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Ischemic Colitis Associated with Ma Huang
rate 73/min, respiratory rate 20/min, and body
ferential wall thickening of the ascending, trans-
temperature 36.5 . His body mass index was 25.7
verse, and descending colon sparing the rectosig-
kg/m2. The patient appeared acutely ill but
moid junction (Fig. 1). Colonoscopy performed on
otherwise was a healthy, well-nourished man. His
admission showed findings compatible with
abdomen was soft and obese with mild tenderness
segmental colitis extending from the ascending to
in the periumbilical area, and his bowel sounds
the descending colon. The involved areas were
were normoactive. Laboratory data on admission
edematous and hyperemic, with areas of frank
showed hemoglobin 15.6 g/dL, hematocrit 44.4%,
hemorrhage (Fig. 2A). Three days after intra-
white blood cell count 7,500/mm3, and platelet
venous hydration and nutritional support, the
214,000/mm3. His serum sodium level was 138
bloody diarrhea resolved. At an 8-day follow-up,
mmol/L, potassium 4.1 mmol/L, chloride 103
colonoscopy showed markedly improved mucosa
mmol/L, fasting glucose 98 mg/dL, serum al-
without any complications (Fig. 2B). The colono-
bumin 3.9 g/dL, total cholesterol 145 mg/dL,
scopic biopsy specimen of the affected area
triglyceride 75 mg/dL, LDL cholesterol 81 mg/dL,
showed focal mucosal erosion and chronic inflam-
blood urea nitrogen 10 mg/dL, and creatinine 1.2
matory cell infiltration consistent with ischemic
mg/dL. The patient's coagulation profiles were
colitis (Fig. 3).
normal. The stool white blood cell test was nega-
The patient completely recovered without
tive, while the stool occult blood test was positive.
complications and with only conservative mana-
Stool specimens were negative for enteric patho-
gement. On discharge, he was advised to discon-
gens.
tinue the use of herbal medications and to avoid
Abdominal and pelvic CT scans showed a
any ephedrine- or pseudoephedrine-containing
patent superior mesenteric artery and circum-
cold remedies.
Fig. 1. Abdominal and pelvic CT
scans show a patent superior mesen-
teric artery (A) and edematous cir-
cumferential wall thickening of the
ascending, transverse, and descending
A
B
colon (B).
Fig. 2. (A) Colonoscopy on admission
show hemorrhagic friable mucosal
patches with mucosal edema from the
ascending to the descending colon. (B)
Colonoscopy at an 8-day follow-up
A
B
show marked mucosal improvement.
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Hyun Joo Song, et al.
they accounted for only 1% of the herbal supple-
ment market.11 Although a number of clinical
trials have reported adverse events associated
with Ephedria sinica,12-14 information regarding
the supplement is still incomplete. Ma huang is
considered to be potentially safe by the Food and
Drug Administration (FDA) when used orally for
a maximum of 7 days and in maximum doses of
24 mg/day of ephedrine equivalent.15 However, in
light of recently reported adverse events, the FDA
has proposed limits on the dose and duration of
these supplements.4 In this case, the patient was
Fig. 3. Colonoscopic biopsy specimen from the transverse
taking ma huang in a dose about 6 times higher
colon show focal mucosal erosion and chronic inflam-
than is recommended by the FDA. It is not sur-
matory cell infiltration (H&E stain, × 200).
prising, therefore, that ischemic colitis developed
in this patient. Infectious etiologies were also
ruled out with stool analysis.
DISCUSSION
Injury to the colon, especially ischemic colitis, in
patients using ma huang is presumably related to
Herbal weight loss supplements are popular
reduced splanchnic blood flow due to vasocon-
and may even be effective. Ma huang is a source
strictions such as those seen in myocardial infarc-
of ephedrine, a long-acting sympathomimetic that
tion8 and ischemic stroke.10 Potentially at-risk
acts primarily through the release of stored cate-
areas include sites in the splenic flexure, de-
cholamine via ?- and -
? adrenoreceptors.5 Ephedra
scending colon, and occasionally the rectosigmoid
and ephedrine are sometimes used to achieve
junction. The areas between the superior and
weight loss or to enhance athletic performance,
inferior mesenteric arteries and between the lower
but the efficacy and safety of these compounds
sigmoid and superior rectal arteries are known as
are uncertain.6 Moreover, during the past decade,
'watershed' areas.5
a considerable number of reports regarding the
Recently, a few cases of ischemic colitis have
adverse effects of ephedra have led to an in-
been reported to be linked with decongestant
creased awareness of the danger of these sympa-
use.16-17 In each of these cases, the vasoconstrictive
thomimetics. For example, herbal ephedra and
properties of pseudoephedrine were believed to
ephedrine-containing food supplements have been
be the possible cause of ischemic colitis. More-
reported to increase the risks of adverse psychi-
over, ischemic colitis after a dietary supplemen-
atric, autonomic, and gastrointestinal events.6
tation with phenteramine, an amphetamine-
Furthermore, ephedrine and related alkaloids
derived sympathomimetic, has been reported.18
have been associated with adverse cardiovascular
Although our patient did not take decongestant
events, including acute myocardial infarction,
medications, his herbal diet supplements con-
severe hypertension, myocarditis, and lethal
tained ephedrine products, which were similar to
cardiac arrhythmia.7-9 Ephedrine can also predis-
pseudoephedrine and caffeine products.12-14
pose patients to both hemorrhagic and ischemic
It is important to keep in mind that many
stroke.10
healthy people take a variety of herbal medica-
Ephedrine and ephedra are found to promote
tions, believing that these medications are com-
short-term weight loss in clinical trials, but no
pletely harmless. However, herbal products have
data are available regarding long-term weight
many active ingredients with pharmacologic
loss.6 A recent study found that products contain-
properties that may have undesirable effects. This
ing ephedra accounted for 64% of all adverse
paper suggests that use of ma huang, a known
reactions to herbal supplements reported to the
sympathomimetic and vasoconstrictor, carries a
US poison control centers in 2001, even though
risk for ischemic colitis in healthy people.
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Ischemic Colitis Associated with Ma Huang
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