Full description

Background of the invention

Anal wounds are a common painful disorder of the anal area that are characterized by un tolerated pain upon defecation, anal bleeding, and anal sphincter spasms (1). Anal wounds are usually caused by trauma or injury to the anal canal while passing hard or large stools, constipation, diarrhea or childbirth (2). It could end with difficulty with bowel movements with severe pain and discomfort; till leading to major complications like clotting.

Treatment usually includes adopting simple methods to have stool soft such as increasing fiber and fluid intake to roll out the reason behind the formation of new wounds. Traditional practice such as soaking in warm water for 10-20 minutes as often as possible, particularly after bowel movements, also helps with healing and reducing discomfort. If symptoms still persist, further treatment is required which involves initially using special cream based. Topical anesthetics and pain medication may also be prescribed to control pain. Sometimes, injection of botulin toxin into the internal anal sphincter could be used as alternative treatment (3).

However, some patients with acute conditions do not heal and become chronic wounds. Surgery is recommended if the symptoms do not respond to conservative treatment. Anal surgery is aimed to re-establish the conditions which lead to healing of the small mucosa tears. This includes either a partial division of the internal sphincter (sphincterotomy) or manual dilatation of the anus. Surgical treatment for this condition has been associated with the side-effect and incontinence in up to 30% of patients (4). Therefore, a non-surgical method for the treatment of chronic anal fissures is highly desirable.

Over the past few years, a number of clinical studies have shown that topical application of ointments promotes the healing of chronic anal wounds (5). The important of development depends on the composition of the healing ingredients since some of them have complicated side effects (6). Wound healing is a complex multifactorial process that results in the contraction and closure of the wound and restoration of a functional barrier (35). Repair of injured tissues occurs as a sequence of events, which includes inflammation, proliferation and migration of different cell types .The difficulties in treatment becomes more challenges especially in case of possibility of wound become infected by fecal bacteria.

Aloe vera (L.) Burm. f. belongs to the Xanthorrhoeaceae plant family and has long been used as a traditional medicine. It is one of the most recognizable herbs in the world and the medicinal part of this plant is the succulent leaf. Aloe vera juice is obtained by breaking or slicing a leaf and is the principal part of the plant that is used in herbal medicine. It also has pharmacological properties that have been shown to provide antioxidant, wound healing, antibacterial, antifungal, and immunomodulatory effects (7). Recently, it has been shown that Aloe vera cream can facilitate wound healing in post hemorrhoidectomy patients (8). In addition, another study demonstrated that an aloe cream reduced the healing time in patients with burn injuries compared to silver cream

(9).

Pomegranate is one of the important fruits stated in Qur’an. Punica granatum belongs to the family of Punicaceae, is commonly known as pomegranate, grenade, granats and punica apple

(10). Pomegranate extract are becoming popular in the Western world for the treatment and prevention of arthritis and other inflammatory diseases (11). Pomegranate peels have been used since antiquity in the Middle East as colorant for textiles because of their high tannin and phenolic contents (12). Also, among the peel, pulp and seed pomegranate peel had the highest antioxidant activity (13, 14-17). In many culture’s folk medicine pomegranates have been used extensively (18). Pomegranate peel contains large amounts of polyphenols such as ellagic tannins, ellagic acid and gallic acid. It has been used in the preparation of tinctures, cosmetics, therapeutic formulae and food recipes (19) Dried fruit peel is used for diarrhea and to treat respiratory and urinary tract infections (20). Anti- fertility effect (21) cytotoxic activity (22,23) hepatoprotective activity (24) and hypoglycemic activity (25). MURTHY et al, (26) studied the wound healing activity of phenol-rich methanolic extract of dried pomegranate peel on the skin of Wistar rats. Following the application of the extract, formulated as a water-soluble gel, the animals treated with 5% gel showed complete healing after 10 days. Myrrh, is the stem resinous exudates belonging to different Commiphora species according to their growing area. It is an oleo-gum resin that form emulsion upon mixing with water. Published researches showed different medicinal effects for myrrh. The medical uses including fasciolicidal effect, and in the treatment of schistosomiasis (27-29). Myrrh as a whole or some of its components appear to have many therapeutic effectiveness in the treatment of different diseases as treating gynecologic cancer disease (30), anaesthetic, antibacterial, antifungal and antihyperglycemic (31,32). Other medicinal use include antiulcer, antipyretic, analgesic, antioxidant and anti-inflammatory (31, 33). Myrrh contained about 2-8% essential oil, 40-60% water-soluble gum and 23-40% alcohol-soluble resins. The essential oil was rich in furanosesquiterpenoids where about 20 compound have been isolated (34).

Many scientific reports were published for single use of the invention four ingredients for wound healing (7-34). Three combination of herbal ingredients were also presented by Ehab at el., (35). None of the prior art documents has provided the synergistic effect of four ingredient working for the treatment of anal wounds unexpectedly and for the first time.

Summary of the invention

The present invention relates to an integrated herbal pharmaceutical composition for producing a synergistic effect for the treatment of anal wounds.

The said composition comprises an ethanolic extract of pomegranate peel, aqueous extract of myrrh and alum (potassium aluminum sulfate), and a pharmaceutical carrier.

The composition may further comprises Aloe Vera oil.

In a preferred embodiment, the said components are present in a range of 5-20% wt/wt.

In a further embodiment, the composition also comprises < 5% w/w Aloe Vera oil wt/wt.

The present invention is considered innovative because it unexpectedly provides a synergistic effect of the ingredients of said composition, working in combination for the treatment of anal wounds for the first time. In the closest prior art, Saudi patent 4550, it was disclosed that the components comprise different extracts. It is well known for a person skilled in the art that ethanolic and aqueous extraction procedures result in different extracts. In the current invention, ethanolic pomegranate peel extract was used while in 4550, aqueous pomegranate peel extract was used. Oppositely also, in the current invention, aqueous extract for myrrh was used while in the 4550, ethanolic extract from myrrh was used. Also, the additional use of Aloe Vera oil in the current invention provides for a four- component mixture which results in an increased wound healing as compared to Aloe Vera oil alone or the three-component mixture described in 4550 or herein.

Brief description of the drawings:

Figure 1: Pictures of the prepared suppositories.

Figure 2A: The rectum weight data for : Group 1 (negative control); Group 2 ( positive control ), Group 3 (administered suppository containing only Pomegranate); Group 4 (administered suppository containing only Myrrh), Group 5 (administered suppository containing only Alum), Group 6 (administered suppository containing only Aloe vera oil), Group 7 (administered the prepared suppositories containing: Pomegranate + Myrrh+ Alum), Group 8 (administered the prepared suppositories containing: Pomegranate + Myrrh+ Alum + Aloe vera oil). * presented statistically significant from others treatments; (p< 0.05).

Figure 2B: The percentage reduction in rectum weight data for Group 3 (administered suppository containing only Pomegranate); Group 4 (administered suppository containing only Myrrh), Group 5 (administered suppository containing only Alum), Group 6 (administered suppository containing only Aloe vera oil), Group 7 (administered the prepared suppositories containing: Pomegranate + Myrrh+ Alum), Group 8 (administered the prepared suppositories containing: Pomegranate + Myrrh+ Alum + Aloe vera oil).

Figures 3-10: show images of rectal (anus) tissues for wistar rats as follows: Figure 3: Negative control (normal animals); Figure 4: Positive Control (untreated wounds); Figure 5: Pomegranate suppository treated animals; Figure 6: Myrrh suppositoiy base treated animals; Figure 7: Alum suppository treated animals; Figure 8: Aloe Vera oil suppository treated animals; Figure 9: Alum+ Pomegranate + Myrrh suppository treated animals; and Figure 10: Alum+ Pomegranate + Myrrh+ Aloe Vera oil suppository treated animals

Detailed description Methodology:

The herbal extracts were purchased from GMP supplier (Table 1). All chemical used are of analytical or pharmaceutical grade.

Table 1: Source of herbal and medicated substances.

Specification of Prepared Suppositories:

The following table shows the pharmaceutical specification of the prepared suppositories. Table 2: the prepared suppositories pharmaceutical specification

Pharmaceutical Composition

The pharmaceutical composition intended for use as a medicament for the treatment of anal wounds, both internal and external use, comprises:

(a) 5-20% w/w of ethanolic pomegranate peel extract,

(b) 5- 20% w/w of aqueous myrrh extract,

(c) 5-20% w/w alum, and

(d) a pharmaceutical carrier.

In a preferred embodiment of the current invention, the components are in the following ranges:

(a) 10-15% w/w of ethanolic pomegranate peel extract,

(b) 10-15% w/w of aqueous myrrh extract,

(c) 10-15% w/w alum, and (d) a pharmaceutical carrier.

In a further preferred embodiment, the ethanolic pomegranate peel extract is present is greater than 10% w/w, the aqueous myrrh extract is greater than 10% w/w, the alum is greater than 10% w/w and the Aloe Vera oil is lower than 10% w/w.

In yet a further embodiment, the pharmaceutical composition comprises between 1-20% w/w Aloe Vera oil, preferably between 1-5% w/w Aloe Vera oil. Induction of anal wounds:

Hemorrhoids were induced in male wistar rats by a modification of the methods described by Nishiki et al. (31) and Okumura et al.(32). In brief: male wistar rats (250±5g body weight) were used in this study. All rats were fasted from food for 3 days but allowed drinking water ad libitum. To induce hemorrhoids a mixture of 6% croton oil in diethyl ether: pyridine: diethyl ether: water in the ratio of 10: 4 : 5: 1 (v/v) was used.

On the day of experiment each rat was immobilized in restrainer cage. The tampon of an ear cotton bud (produced by septona SA, Greece and purchased from the local market in Riyadh, kingdom of Saudi Arabia) was dipped in 10 ml of the above inducer contained in a 10 ml vial for 60 seconds. Then it was inserted into the rectum and allowed to contact the mucosa to a depth of 2cm for 60 seconds and then removed smoothly. The animals were freed from their restrainers and placed in their cages with no food or water for complete 4 hours. The volume of the inducer absorbed by each tampon was 333 mΐ. The animals were then sacrificed by an overdose of diethyl ether. The lower abdomen was opened, all of the reproductive organs removed, the hip bone cut and the lower rectum cleared from any adhering tissues. Then a rectum-anus portion measuring 2 cm was cut from each rat starting from the circular hairline on the anus epithelium using a pair of campus and a pair of scissors. The cut piece was then opened longitudinally, blotted on a piece of filter paper and weighed immediately. The weight of tissues corresponding to 150 g body weight was then calculated in mg.

Treatment of animals with the prepared suppositories

Male wistar rats (250±5g body weight) were fasted from food for 3 days but allowed drinking water ad libitum. The animals were divided into 3 groups:

Group 1 (negative control) (not administered any suppository without wound inducing) but the cotton bud was immersed in distilled water only.

Group 2,( positive control ) administered plain suppository.

Group 3, administered suppository containing only Pomegranate Group 4, administered suppository containing only Myrrh Group 5, administered suppository containing only Alum Group 6, administered suppository containing only Aloe vera oil

Group 7, administered the prepared suppositories containing: Pomegranate + Myrrh+ Alum Group 8, administered the prepared suppositories containing: Pomegranate + Myrrh+ Alum + Aloe vera oil (four ingredients’ combination suppository)

Each suppository was allowed to contact the rectum for 1 hour. During this time, the anus was closed using a large bull-dog. Thereafter, the bull-dog was removed. The percentage reductions in the weights of recti of the treated animals were then calculated relative to the control weights (Table 3).

Table 3: Rat rectum weight of normal and treated rats after simulation of hemorrhoid

It is clear from the data that the invented formula has tremendously reduced the weight of the rectum which is statistically significant from other treatment (p< 0.05) (Table 3, Figure 2A and Figure 2B). The new invented formula with addition of Aloe Vera oil has more pronounced effect comparing to single treatment or the three combination. This because wound healing is complex process which needs more treatments modalities that may sometime synergies internal healing processes. For instance, Aloe vera preparations have many biological effects, including immunomodulatory, anti-inflammatory, antioxidant, and wound healing properties (36). These properties were synergized with Pomegranate, Myrrh and Alum. It is evidently that figures 3-10 confirm previous results in rectum weight study. Normal mucosa and Normal blood vessels was shown with negative control group (Figure 3). Differently, in case of (Positive Control), it shows presence of edema in mucosa and submucousa, ulceration on surface, sever damage, extensive necrosis (Figure 4). In case of Pomegranate suppository, Skin appears normal with small Congested blood vessels meaning the need of improvement (Figure 5). Similarly, with Myrrh suppository Congested blood vessels and dilatation was existing (Figure 6). Due to the effect of Alum on blood vessels, Alum suppository had less necrosis in mucosa less hemorrhage (Figure 7). In case of Aloe Vera oil suppository, blood vessels still congested and dilated (Figure 8). The suppositories containing the three combination (Alum+ Pomegranate + Myrrh) showed that blood vessels still congested and dilated with no necrosis. To make the wound healing more alleviated, the synergistic action of the four ingredient was induced in (figure 10). Blood vessels completely healed and thick wall arterioles appears normal size.

List of symbols used in the figures: G: groups

RW: rectum weight (mg)

Y: % reduction in mass (mg)

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