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2406 Letters to the Editor 

aids. We have now demonstrated that the diagnosis can be

made easily by direct visualization during enteroscopy, using

 balloon-enteroscopy. The latest innovation in this   field has

 been the introduction of a single-balloon enteroscope. This

device is easier to handle and should facilitate the spread of 

this technology.

In conclusion, small bowel diverticulitis can now be de-tected directly by enteroscopy.

 Andreas Leodolter, M.D.

 Dietmar Zielinski, M.D.

 Daniela Borkenstein, M.D.

 Manfred Crone, M.D.

 Jochen Labenz, M.D.

 Faculty of Medicine, University of Duisburg/Essen

 Ev. Jung-Stilling Hospital 

Siegen, Germany

REFERENCES

1. Miller RE, McCabe RE, Salomon PF, et al. Surgical com- plications of small bowel diverticula exclusive of Meckel’s.Ann Surg 1970;171:202 – 10.

2. LeeRE, FinbyN. Jejunal and ileal diverticulosis. AMAArchIntern Med 1958;102:97 – 102.

3. Macari M, Faust M, Liang H, et al. CT of jeju-nal diverticulitis: Imaging   findings, differential diag-nosis, and clinical management. Clin Radiol 2007;62:73 – 7.

4. Kassahun WT, Fangmann J, Harms J, et al. Compli-cated small-bowel diverticulosis: A case report and re-view of the literature. World J Gastroenterol 2007;13:2240 – 2.

5. Kamal A, Gerson LB. Jejunal diverticulosis diag-nosed by double-balloon enteroscopy. Gastrointest Endosc2006;63:864.

6. Kita H, Yamamoto H. Double-balloon endoscopy for the di-agnosis and treatment of small intestinal disease. Best PractRes Clin Gastroenterol 2006;20:179 – 94.

Herbal Does Not At All Mean

Innocuous: The Sixth Case of 

Hepatotoxicity Associated With

Morinda Citrifolia (Noni)

TO THE EDITOR: Up to two-thirds of the population re-

 port using complementary and alternative self-medication

(1) without consulting health-care professionals (2). We are

concerned about this since we have seen two cases of hepa-

totoxicity related to the consumption of noni juice (Morinda

citrifolia), one of which required liver transplantation (3).

Three further cases have been reportedin theliterature to date

(4 – 6). We herein report another patient with hepatotoxicity

related to the ingestion of noni juice and provide a summary

of all cases reported to date in order to make hepatologists

aware of the potential of noni juice to cause liver damage.

Our patient is a 43-yr-old white male who was diagnosed 

with a gliobastoma in September 2007 after suffering two

seizures. He underwent surgery and was scheduled for radi-

ation and chemotherapy in early December 2007. To aid his

recovery, he started to drink noni juice (Tahitian Noni, Tahi-

tian Noni International UK Ltd, London, UK) in the recom-

mended dose of 20 mL twice daily. Two weeks later, routine

 prechemotherapy blood tests were performed; these revealed 

elevated transaminases: aspartate-aminotransferase (AST)192 U/L (normal  

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Letters to the Editor 2407

 Table 1.  Reports on Noni-Related Hepatotoxicity

Delay BetweenDuration Ingestion Laboratory

of Amount and Onset Tests ConcomitantCase Sex Age Ingestion Ingested of Symptoms (Maximum) Medication Outcome Presentation Reference

1 Male 45 Few

weeks

1 glass per 

day

Few weeks AST 604 U/l

ALT 1995 U/l bilirubin 0.82mg/dL

 None Spontaneous

recovery

Malaise,

thoracicdiscomfort

(5)

2 Male 29 3 weeks 1.5 L 3 weeks AST 1557 U/LALT 1626 U/L

 bilirubin 45.3UL/

Chinese herbs Liver trans- plantation

Acute liver failure

(3)

3 Female 62 4 months 2 L 4 weeks ASL 2020 U/LALT 3570 U/L

 bilirubin 3.9mg(dL

 None Spontaneousrecovery

Diarrhea (3)

4 Female 24 4 weeks 1-1.5L 3 weeks AST 2818 U/lALT 3648 U/l

 bilirubin 43.5mg/dL

Interferon beta-1a

Spontaneousrecovery

Subacute liver failure

(4)

5 Female 33 2 weeks Not stated 1 weeks AST 3382 U/LALT 2740 U/LBilirubin 8.1mg/dL

 None Spontaneousrecovery

Abdominal pain, nausea,vomiting,anorexia

(6)

6 Male 43 2 weeks 2 × 20 ml per day

2 weeks AST 192 U/LALT 516 U/LBilirubin 0.58mg/dL

Levetiracetam Spontaneousrecovery

Routinelaboratorycheck-up

This report

consider these reports when assessing the risk of “novel food ”

and add appropriate warnings to the labels of such products.

Vanessa Stadlbauer, M.D.1

Sabine Weiss, M.D.2

 Franz Payer, M.D.2

 Rudolf E. Stauber, M.D.1

 Departments of   1 Internal Medicine and 2 Neurology, Medical University of Graz 

Graz, Austria

REFERENCES

1. Kessler RC,Davis RB,FosterDF, et al.Long-term trendsinthe use of complementary and alternative medical therapies

in the United States. Ann Intern Med 2001;135:262 – 8.2. Saydah SH, Eberhardt MS. Use of complementary and 

alternative medicine among adults with chronic dis-eases: United States 2002. J Altern Complement Med 2006;12:805 – 12.

3. Stadlbauer V, Fickert P, Lackner C, et al. Hepatotoxicityof NONI juice: Report of two cases. World J Gastroenterol2005;11:4758 – 60.

4. Yuce B, Gulberg V, Diebold J, et al. Hepatitis induced by Noni juice from Morinda citrifolia: A rare cause of hepato-toxicity or the tip of the iceberg? Digestion 2006;73:167 – 70.

5. Millonig G, Stadlmann S, Vogel W. Herbal hepatotoxicity:Acute hepatitis caused by a Noni preparation (Morindacitrifolia). Eur J Gastroenterol Hepatol 2005;17:445 – 7.

6. Lopez-Cepero Andrada JM, Lerma Castilla S, Fernan-

dez Olvera MD, et al. Hepatotoxicity caused by a Noni(Morinda citrifolia) preparation. Rev Esp Enferm Dig2007;99:179 – 81.

7. Stickel F, Patsenker E, Schuppan D. Herbal hepatotoxicity.J Hepatol 2005;43:901 – 10.

8. Danan G, Benichou C. Causality assessment of adversereactions to drugs – I. A novel method based on the con-clusions of international consensus meetings: Applica-tion to drug-induced liver injuries. J Clin Epidemiol1993;46:1323 – 30.

9. Maria VA, Victorino RM. Development and validation of a clinical scale for the diagnosis of drug-induced hepatitis.Hepatology 1997;26:664 – 9.

10. Bironaite D, Ollinger K. The hepatotoxicity of rhein in-volves impairment of mitochondrial functions. Chem BiolInteract 1997;103:35 – 50.

11. Pawlus AD, Su BN, Keller WJ, et al. An anthraquinonewith potent quinone reductase-inducing activity and other constituents of the fruits of Morinda citrifolia (noni). J Nat

Prod 2005;68:1720 – 

2.12. Kamiya K, Tanaka Y, Endang H, et al. New anthraquinoneand iridoid from the fruits of Morinda citrifolia. ChemPharm Bull (Tokyo) 2005;53:1597 – 9.

An Unusual Cause of Colonic

Obstruction

TO THE EDITOR: Medications with anticholinergic prop-

erties have long been recognized as having numerous side

effects, including urinary retention, constipation, decreased 

secretion, and tachycardia (1, 2). The differential diagnosis

of acute colonic obstruction has traditionally been relatively