ETHNOMEDICINAL PLANTS USED AGAINST COMMON DIGESTIVE PROBLEMS

Background: Ethnomedicinal knowledge is highly significant for persistence of human health care. Different studies have shown that medicinal plants are considered as curing agent for digestive disorders in Pakistan. The aim of present review is to explore this ethnomedicinal information all over the Pakistan and to investigate the ecological status of these species in the country. Methodology: Online literatures on ethnomedicinal plants used to treat digestive complaints in Pakistan were searched and gathered using online bibliographic databases including PubMed, Scopus, Google Scholar, Web of Science and Flora of Pakistan . Results: The review documented 178 medicinal plant species, belonging to 59 families, used for different digestive ailments. The majority of species were herbs (60%), used in drug preparation. The most frequent part used in preparation of these remedies is leaves (23%), followed by roots (19%). Conclusion: In conclusion, the study provides enormous ethno-medicinal knowledge and due to the unsustainable activities of the people of Pakistan, some medicinal plants need to be conserved for the future.


Introduction
Plants are a vital source of traditional medicines that are used for the treatment of various ailments.Approximately 4, 22,000 flowering plants reported from the world, more than 50,000 have been used worldwide for medicinal purposes (Walter & Hamilton, 1993).Man has cultivated the habit of observing plants for thousands of years and had used them for different purposes (Bako et al., 2005).The local uses of medicinal plants are common particularly in those areas of developing countries, which have little or no access to modern health services (Sandhya et al., 2006).Mostly local people keeping the centuries-old trend alive, rely hugely on the wild plants for their daily needs such as food, fodder and medicines.Treatment through traditional medicine system is progressing all over the world particularly in the Indo-Pak sub-contentment where this system is known by Unani or Ayurvedic (Haq, 1993).
Pakistan has a unique biodiversity that is stretched along nine major ecological zones.A major part of the country is quite rich in medicinal herbs due to its salubrious climate (Abbasi et al., 2010).Numerous medicinal plants are being used by local communities of different geographical regions of the country, having old traditional knowledge on such plants.Medicinal plants have been used as a source of curing various digestive disorders in the country.Digestive disorders generally occur due to the nature of food that we consume and it's incompatibility with our constitution or due to some viruses and bacteria like rotavirus, Helicobacter pylori, Salmonella, Shigella and Escherichia coli etc.Some of the most common digestive problems that people of Pakistan faces in their day to day life are stomach-aches, cramps, vomiting, dyspepsia, diarrhea and indigestion to the complicated conditions such as cancer and gastric ulcer etc (Zaidi et al., 2009, Khan et al., 2013).In early 1950, more than 80% of Pakistani population was totally dependent on ethnomedicines for traditional health practices (Hocking, 1958), but now, it is experienced only in the rural areas (Ibrar et al., 2007), because the indigenous knowledge changes with the passage of time, with change of natural resources and culture.Indigenous knowledge on ethnomedicines is under threat due to the current modernizing trends.In Pakistan, about 6000 plant species have been reported so far.However, only 600 plant species have been documented recently (Shinwari et al., 2003).Therefore, there is a dire need to preserve this valuable traditional knowledge (Khan et al., 2011) by conserving plants and educating people about ethnomedicinal knowledge.Conservation of medicinal plants is a serious issue of present times.Because studies have shown that plant biodiversity of Pakistan is under wonderful pressure due to the population explosion and unsustainable activities of people in the country (Abbas et al., 2010, Sheikh et al., 2002).Unfortunately, very little work has been done on threatened plants of the country and extremely limited information is available on this subject (Alam & ali., 2009).Thus the present review aims to collect and elaborate the ethnomedicinal data available for digestive problems in Pakistan.This could help in creating mass awareness regarding the need for conservation of endangered, threatened and vulnerable medicinal plant species used ethnobotanically in the country.The review also helps in the promotion of ethno-medico-botany knowledge all over the world.Hence people belonging to the countries having these species may also use the remedies mentioned in this paper for the treatment of their digestive problems.Above all, this review will provide baseline information for ecologists, pharmacists and researchers for further studies.

Methodology
This review paper was designed by consulting and compiling large number of mostly published literature on gastrointestinal problems of Pakistan.Literature on ethnobotanical information of medicinal plants against gastrointestinal diseases in the country has been searched using online bibliographic databases including PubMed, Scopus, Google Scholar, Web of Science and Flora of Pakistan.An extensive number of articles were found out of which approximately 105 articles were selected as the data was focused to only those medicinal plants whose recipes were mentioned for the gastrointestinal ailments.The material was thoroughly checked for the exclusion of duplicate material collected from different search engines.A detailed ethnomedicinal table was formulated on all the plants used for gastrointestinal complications in a systematic manner.In ethnomedicinal table, plant scientific names, local names, habit, reproductive status, part used, recipes and types of problems were included.Efforts were also made, to collect data regarding ecological status of these species in the country.However, this data was found limited and was compiled in table form.

General Overview
Traditionally, different medicinal plants are used for various gastrointestinal problems such as diarrhea, dyspepsia, peptic ulcer vomiting and nausea etc. in the developing countries like Pakistan.In present review, a total of 178 plants belonging to 122 genera and 59 families are documented to be used in different regions of the country.These plants include Achillea millefolium, Achillea wilhelmsii, Achyranthes aspera, Adhatoda vasica, Allium sativum and many others (Table 1).Literature proved that herbs were mostly used (60%) in various gastrointestinal related ethnomedicinal recepies followed by shrub (21%) (Figure 1.)It might be due to the fact that herbs can be easily uprooted and extracted from the wild or due to their strong therapeutic activity (Murad et al., 2013).Most of the plants (50%) are annuals followed by perennials plants (44%) and 6% biennials.Different plant parts are used for remedy preparation in order to treat digestive disorders but leaves are mostly preferred (23%) followed by roots (19%), pulp (15%), whole plant (12%), fruits (11%), stem (9%) and 5% bark.However, other parts of the plants such as latex, rhizome and resin etc., are also used in some of herbal preparation.The use of specific plant parts for specific disease treatment suggests that these parts have strongest certain active phyto-constituents against digestive complaints with no or less side effects (Mitscher et al., 1980).Moreover, the maximum use of leaves for remedy preparation might be due to the reason that it is main site of most of the physiological process that result in production of variety of active compounds as well as the collection of leaves poses no significant threat to the survival of individual plants (Poffenberger et al., 1992).This article critically reviews only some common digestive disorders and their phytotherapy with locally used medicinal plants; furthermore, the ecological status of these species in the country is also discussed.Out of 178 species, the ecological status of only 34 plants was discussed in literature (Table 2).It was noticed that 14 plants were endangered and needs to be conserved otherwise they will be extinct in future.Similarly, 6 medicinal plants were found threatened and are at risk of becoming endangered in future if not protected (Figure 2).(Thapar & Sanderson, 2004).People with poor hygiene, children and adults are at high risk.More than 3.2 million children of developing countries died annually because of diarrhea (Rebiero, 2000).In Pakistan, different medicinal plants such as Acorus calamus, Albizia lebbeck, Allium sativum, Amaranthus viridis, Foeniculum vulgare, Mentha spicata and Adhatoda vesica etc., are used in order to cure the ailments.The decoction method is mostly preferred ethnobotanically for remedy preparation in the country.Traditionally, the bark of Albizia lebbeck in addition to Trchyspermum ammi and Commelina bengalensis are boiled in water to prepare a decoction for the diseases of diarrhea and dysentery.Moreover, people of Pakistan boil leaves, fruit and stem of Salvadora oleoides in water and locally the decoction is given to patients suffering from diarrhea (Table 1).However, due to human unsustainable activities, these plants are endangered in Pakistan (Table 2).If these are used with maximum ratio, they might become extinct in future.Similarly, some other anti-diarrheal and anti-dysenteric plants of Pakistan are traditionally administered in different ways, such as roots and leaves of Barberis lyceum are boiled and decoction is used against the diseases, in addition the roots of Bergenia ciliate are used as a tonic in the treatment of diarrhea (Table 1).However, these are considered as threatened species of the country and might be endangered in future, if not protected.In addition, researchers scientifically proved some medicinal plants of Pakistan as vulnerable species which are used against diarrhea.Examples are Achillea millefolium, Elaeagnus angustifolia and Ocimum bacilum (Table 2).These vulnerable plants are administered for the disease treatment.Literally, there is need to conserve all the above species and instead of them being protected or conserved medicinal plants should be preferred against diarrhea and dysentery.For example Allium sativum is protected plant species of Pakistan (Table 2) and should be preferred for the disease curing.This review calls for an urgent complementary conservation action to save these antidiarrheal and anti-dysenteric medicinal plant species in Pakistan and clinical studies are also required to justify the ethnomedicinal knowledge.

Peptic Ulcer
Peptic ulcer, being an inflamed break in the mucosa skin, can be divided into two broad categories that include ulcer in the stomach (gastric) and the duodenum (Tarnawski, 2005, Gadekar et al., 2010).The prevalence of gastrointestinal ulcers differs around the world: in Asia gastric ulcer is dominant while duodenal ulcer is more frequent in Western populations of the world (Yuan et al., 2006).The etiological factors of this disorder include: exogenous aggressive factors such as stress, smoking, nutritional deficiencies, infections due to Helicobacter pylori, frequent and indiscriminate use of non-steroidal anti-inflammatory drugs (Khazaei et al., 2006, Bandyopadhyay et al., 2001).During the past few decades, researchers were searching to identify new anti-ulcer therapies from natural sources.Thus herbs, spices, vegetables and crude drug substances are considered to be a potential source to treat these ailments and scientific literature, also reported a large number of medicinal plants with anti-ulcer potential (Al-Mofleh et al., 2006, Raffatullah et al., 1990, Al-Mofleh et al., 2008).In Pakistan different medicinal plants are used traditionally for the treatment of peptic ulceration.For example Achyranthes aspera is a perennial wild endemic herb of Pakistan (Table 2).It is boiled in water and the decoction is used for the treatment of ulcer.Similarly, decoctions of other medicinal plants are also recommended for the disease treatment such as seeds of Cordia oblique and Fruit, bark of Capparis deciduas are boiled, in order to make decoctions for the phytotherapy.The decoction of C. oblique is administered orally for 10-15 days to the patients.Similarly, the decoction and infusion are prepared from the leaves of Oxystelma esculentum and recommended as mouth wash for the treatment of ulceration in Pakistan.Leaves of Alstonia scholaris are pulverised to make poultice for peptic ulcer.Furthermore, the powdered flowers of Rosa damascena are mixed with with Quercus fruits and an infusion is prepared to be used against stomach ulcer (Table 1).From literature, it is noticed that there is no available data regarding the ecological status of the above anti-ulcer plants.Thus, further studies are required to gather ecological information in order to conserve these species if they are endangered or threatened.

Oropharyngeal and Gastric Cancer
According to World Gastrointestinal Organization, it is noticed that sometimes the malignant lesions occur in the oropharyngeal wall and overall, 15 to 20% of these lesions progress to carcinoma (Lambert, 2010).However, cancer is not only limited to the pharyngeal region, it also affects other parts of digestive system like stomach and known as gastric cancer.This disease is mostly found in young population.According to a study it was noticed that the existence of malignant gastrointestinal tumors is found in higher frequency in the young population of Pakistan (Butt et al., 2012).The causal factors of cancer include tobacco smoking or chewing, alcohol drinking, socioeconomic status and nutritional deficiencies, Human Papilloma Virus and Helicobacter pylori (Lambert, 2010).
This review notifies that there must be some anti-cancerous medicinal plants in the country but they have no ethnobotanical and pharmacological proves.Therefore, they should be checked for gastrointestinal cancer in Pakistan.

Dyspepsia
Dyspepsia is defined as epigastric fullness after meals, often described by the patients as indigestion.It affects 14 to 40% population of world annually.The symptoms of dyspepsia usually contain upper abdominal fullness, eructation, heartburn, nausea and vomiting (Zaidi et al., 2009;Tally et al., 1999).In Pakistan, different medicinal plants are recommended for the treatment of dyspepsia.Mostly decoction and powdered form of the plants are used for remedy preparation in the country.Foeniculum vulgare is a perennial herb in Pakistan; its fruits are directed for the treatment of dyspepsia.Traditionally, 250gm of dried fruits is grinded to obtain powder.This powder is mixed with 250gm seeds of pomegranate and 375gm of sugar candy, 4-6 seeds of Green cardamom in powder form are added.One teaspoon of this powder is used thrice a day before and after meal, in order to cure the dyspepsia (Table 1).According to Zaidi et al., green cardamom is employed traditionally more for dyspeptic symptoms than black cardamom.As Helicobacter pylori is considered to be one of the causative factors for dyspepsia, the comparatively strong bactericidal activity of green cardamom might explain its traditional use (Zaidi et al., 2009).In addition, some other plant species such as Zanthoxylum armatum, Elaeagnus angustifolia and Echinops echinatus are also used for the dyspepsia treatment.However, due to unsustainable activities of people, some species are at risk of becoming extinct in future, if not protected.For example Z. armatum wild endemic shrub of Pakistan is critically endangered (Table 2) and needs to be conserved.This species is traditionally recommended in the treatment of dyspepsia or its symptoms and 50gm seeds or fruits of the plant are mixed with flour and is orally given to patients.Similarly, E. angustifolia is vulnerable perennial tree in the country.Its fruit Juice, seeds and roots is recommended traditionally against gastrointestinal ailment (Table 1).Being the vulnerable species it also needs to be conserved for the future.The fruit extract of Olea ferrugini is given orally for 5-6 days to dyspepsia patients.This medicinal plant is also endangered in Pakistan (Table 2).Therefore, it is necessary that people of the country should use protected plant species in place of endangered, threatened and/or vulnerable species.Additionally, further studies are required to find out the ecological status of species in the country because limited literature is available.

Conclusions
The study provides enormous ethno-medicinal knowledge all over the world administered via different recipes for digestive problems.However, the phytoterapy should be checked for gastrointestinal cancer in Pakistan.Further, due to unsustainable activities of people of Pakistan, some medicinal plants like Acacia nilotica, Acorus calamus, Aesculus indica, Albizia lebbeck, and Zanthoxylum armatum etc. are at risk of becoming extinct in future, so it is a dire need to conserve these species.Additionally, the ecological status of most species is unknown, so these findings are research provoking for future.Furthermore, clinical studies are required to scientifically justify the rationale of traditional uses of medicinal plants of Pakistan.

Figure 1 :
Figure 1: Classification of plants on the basis of their habits.

Figure 2 :
Figure 2: Ecological status of plants used for digestive problems in Pakistan

Table 1 :
Ethnobotanical uses of medicinal plants of Pakistan against gastrointestinal problems Plant

species/ Families Local name Plant status
in milk is laxative.Tea made from the plant is used for dirrhoea.Whole plant extract is used in constipation.Fresh or dried ground leaves for relieving anorexia, constipation andstomachache.

Table 2 :
Ecological status of plant species.