Clinical Study And Its Mechanism Of Xiangshaliujunzi Decoction Treating Functional Dyspepsia

Objective and SignificanceFunctional dyspepsia (FD) is a common clinical condition, characterized by clinical symptoms such as upper abdominal pain or fullness, or heartburn, early satiety, without evidence of organic disease.The nosogenesis of FD is indefinite. The mechanisms underlying impaired gastroduodenal motor function are unclear, but possible factors include abnormal neurohormonal function, autonomic dysfunction, visceral hypersensitivity to acid or mechanical distention, Helicobacter pylori infection, acute gastrointestinal infection, psychosocial comorbidity, and stress.Although the optimum treatment for FD is not yet clearly established, acid-suppressive drugs, prokinetic agents, eradication of H. pylori, and antidepressants have been widely used in the management of patients with FD. The therapeutic efficacy of prokinetics such as itopride hydrochloride and mosapride citrate in the treatment of FD is supported by the results of relatively large and well-controlled studies. In addition, recent research has yielded new therapeutic agents and modalities for dysmotility in FD, including agonists/antagonists of various sensorimotor receptors, activation of the nitrergic pathway, Kampo medicine (Chinese medicinal herb), acupuncture, and gastric electric stimulation.Accordingly, in TCM, FD attributes to "fullness and oppression", "stomach pain", failure to transport due to spleen deficiency as the root and failure to descend the stomach as the manifestation. Xiangshaliujunzi decoction is be considered to be effective for treating Syndrome of spleen-deficiency and QI stagnation, which is one pattern of syndromes of FD.Ginseng, the root of Panax ginseng C. A. Meyer (Araliaceae) is a traditional, well-known oriental folk medicine and has been used in therapy for thousands of years. Recently, its chemical and pharmacological properties have been reported by many investigators Ginsenoside, a class of component of ginseng, has a four-ring steroid like structure with attached sugar moieties. Approximately 30 ginsenosides have been isolated from the root of Panax ginseng and identified. These ginsenosides appear to be responsible for most of the pharmacological effects of ginseng.Ginseng is the most important componet of Sijunzi decoction (SJZD), which is the charge of Xiangshaliujunzi decoction (XSLJZD). Sijunzi decoction(SJZD), widely used as one of the regular decoctions in Chinese Traditional Medicine clinic, is recognized as a basic decoction which can invigorate Pi viscera and replenish Qi. Conventionally, SJZD is useful for treatment of hypofunction of the spleen, symptom of which is partially equivalent to that of gastrointestinal motility disorders, e.g. abdominal distention and dyspepsia. Its mechanism improving the symptom of gastrointestinal disorder disease may relate to gastrointestinal hormones and motility. SJZD could correct deficiency of the spleen and stomach which to some extent is caused by digestive dysfunction Syndrome of rat models with Pi-deficiency could be significantly recovered to the normal level by SJZD treatment. Recently, its major active components, including ginsenoside, flavonoid and triterpenoid, have been identified by using LC/MS/MS. Hyun Soo Kim Kazunori et al. testified that ginsenosides modulate the pacemaker activities of the ICC, and the ICC can be targets for ginsenosides, and their interaction can affect intestinal motility. The ICC and SMC are coupled electrically, forming a multicellular syncytium. Activation of depolarizing or hyperpolarizing ionic conductances in either cell type affects the total input resistance and excitability of the syncytium. For example, activation of K+ channels in ICC reduces excitability of coupled SMC and reduces the likelihood of reaching the action potential threshold. Responses to other stimuli, such as hormones and paracrine substances, are likely to target both ICC and SMC, depending upon the expression of appropriate receptors and second messenger pathways. Hashimoto et al. reported that Rbl was one representative of compounds contained in Ginseng Radix capable of ameliorating the accelerated transit of the small intestine. Till now, the mechanism of ginsenosides effecting GI smooth muscle has not been fully studied. This study focused on the mechanism of ginsenosides effecting GI smooth muscle.MethodsMethods of clinical research:72 patients fulfilling the inclusion criteria were randomly divided into two groups.39 cases in experimental group were treated with Xiangshaliujunzi decoction, while 33cases in control group were treated with placebo. The course of treatment lasted for 4 weeks. The clinical efficacies were evaluated by observing patients with clinical symptoms and signs, the characteristics of tongue and pulse.Methods of experimental study:The small intestine of Balb/C mice (7-13 days old) of either sex was removed from lcm below the pyloricring to the caecum, and luminal contents were washed out with Krebs-Ringer bicarbonate. Tissues were pinned to the base of a silica gel dishand the mucosae removed. Small strips of intestinal muscle were dispersed in 37℃water bath for 23 min with enzyme solution containing:1.3mg/ml collagenase (type II),2mg/ml bovine serum albumin, 2mg/ml trypsininhibitor and 0.27mg/ml ATP). After three washes to remove the enzyme, tissues were triturated through bluntpipettes. There sulting cells uspension was plated on murine collagen-coated (2.5 mg/ml) sterileglasscoverslipsinculturedishes. The cells were allowed to settle for 30 min before adding SMGM medium supplemented with 2% antibiotic/antimycotic and murine stem cell factor. Cells were incubated at 37℃in a 5% CO2 incubator.The whole cell patch clamp technique was used to record inward currents (voltage clamp), membrane potential (current clamp) from cultured ICCs (48-72 h).Intestinal smooth muscle strips were isolated from male ICR mice (5 weeks old) and the spontaneous contraction was recorded by electrophysiolograph. Ion channel currents were recorded on freshly isolated single cells by using whole cell patch clamp technique.Results1 The results of clinical study:1.1 Scoring for major symptoms:after treatment, the improvement of 7 symptoms, including upper abdominal fullness, upper abdominal pain, decreasing food intake dose, dry throat with a bitter taste, exhaustion, nausea and vomiting, and gastric upset, the observation group, was superior to the control group(P<0.05). The improvement of other symptoms, comparing the two groups the difference was not statistically significant (P>0.05).1.2 Syndromes judged by Chinese traditional medicine standards:in observation group, among the 39 cases,6 cases were cured,26 cases were markedly effective, 3 cases were effective and 3 cases were in effective, the total effective rate was 92.3%. As for control group, among 33 cases,0 case was cured,5 cases were markedly effective,17 cases were effective and 11 cases were in effective, the total effective rate was 66.67%. the observation group was superior to control group in term of Chinese medicine syndromes efficacy (P<0.05)1.3 Syndromes judged by modern medical semiological standards:after treatment, the improvement of 4 symptoms, including upper abdominal pain, feeling of fullness after meal, nausea and vomiting, the observation group, was superior to the control group(P<0.05). The improvement of other symptoms, comparing the two groups, the difference was not statistically significant (P>0.05).The result of clinical comprehensive efficacy:in observation group, among the 39 cases,29 cases were cured,8 cases were markedly effective,2 cases were effective and 0 cases were ineffective, the total effective rate was 100%. As for control group, among 33 cases,3 cases were cured,6 cases were markedly effective,14 cases were effective and 10 cases were ineffective, the total effective rate was 69.7%. The observation group was superior to control group in term of clinical comprehensive efficacy (P<0.05)1.4 The result of efficacy of different typed:In observation group, among the 39 cases,18 cases were PDS,9 cases were EPS, and 12 cases were PDS+EPS. As for control group, among the 33 cases,13 cases were PDS,10 cases were EPS, and 10 cases were PDS+EPS.After treatment, in observation group, in the 3 subtypes of PDS, EPS and PDS+EPS, cases cured were 4,0 and 2 respectively, markedly effective cases were 13,6, and 8 respectively, effective cases were 0,2, and 1 respectively, ineffective case was 0, the total effective rates were 94.4%, 88.9% and 91.7% respectively. As for control group, in the 3 subtypes of PDS, EPS and PDS+EPS, cases cured were 0 respectively, markedly effective cases were 2,2, and 1 respectively, effective cases were 7,5, and 5 respectively, ineffective cases were 4,3, and 4 respectively, the total effective rates were69.2%,70.0% and 60.0% respectively.For the 3 subtypes of PDS, EPS and PDS+EPS, comparing the two groups correspondingly, the difference of the total effective rates was not statistically significant (P>0.05).1.5 The result of adverse reactions:Two groups had no obvious side effects during treatment.2 Ginsenoside Rbl had no effect on the pacemaker current of cultured interstitial cells of Cajal fom murine small intestine.3 Ginsenoside Rbl dose-dependently inhibited the spontaneous contraction of intestinal smooth muscle by 21.15±3.31%,42.03±8.23% and 67.23±5.63% at concentrations of 25μM/L,50μM/L and 100μM/L, respectively (n=5, p<0.05). The inhibitory effect of ginsenoside Rbl on spontaneous contraction was significantly blocked but not completely by lOmM/L TEA or 0.5mM/L 4-AP, respectively (n=5, p<0.05).The inhibitory effect of ginsenoside Rbl on spontaneous contraction was not affected by glibenclamide 10μM/L or TTX 0.4μM/L. In cell level, ginsenoside Rbl increased outward potassium currents and the voltage-gated K+ channel current (IKV) was enhanced from 1137.71±171.62 pA to 1449.73±162.39 pA by 50μM/L Rbl at+60 mV (n=6, p<0.05). Ginsenoside Rbl increased calcium-activated potassium channel currents and enhanced the amplitude of spontaneous transient outward currents (STOC) from 582.77±179.09 mV to 788.12±278.34 mV (n=5, P<0.05). Ginsenoside Rbl (50μM/L) had no significant effect on ATP sensitive potassium channel (KATP) current (n=3, p>0.05).Conclusions1 The clinical research results indicate that Xiangshaliujunzi decoction (XSLJZD) has specific curative effects for patients suffered from FD with syndrome of spleen-deficiency and QI stagnation.2 The experimental research results indicate that Ginsenoside Rbl had no effect on the pacemaker current of cultured interstitial cells of Cajal fom murine small intestine.3 The experimental research results indicate that ginsenoside Rbl exerted an inhibitory effect on the spontaneous contraction of intestinal smooth muscle in mouse, in the manner of decreasing the amplitude of the spontaneous contraction dose-dependently. The inhibitory effect of Rb1 is mediated by potentiating IKv and IKCa channel currents.4 Combining literature research, clinical research and experimental research, we deduce that ginsenoside Rb1 could be one of the active ingredients of XSLJZD relieving symptoms involving abdominal fullness, pain and vomiting.