Geniposide Causes Idiopathic Mesenteric Phlebosclerosis

We read with interest the manuscript by Chou et al1 titled “Idiopathic Mesenteric Phlebosclerosis: A SingleInstitute Experience in Taiwan,” which was published on February 25, 2023. Idiopathic mesenteric phlebosclerosis (IMP) is a rare form of ischemic bowel, commonly involving the proximal ascending colon, and characterized by wall thickening and serpentine calcifications of mesenteric veins. Asian descents with long-term Chinese herbs ingestion seem to be the most susceptible etiology. Chou et al1 reported that 36.1% of 38 patients with IMP had a history of using Chinese medicine. Which Chinese herb is the culprit is often unclear, but extracts of Gardenia jasminoides have been reported to be responsible. For example, Hiramatsu et al2 showed that 70.4% of IMP patients have exposure to sanshishi, which is an extract of Gardenia jasminoides. Yeh et al3 reported a case of IMP that was associated with longterm use (8 years) of Chinese medicine, which contained extracts of Gardenia jasminoides. While mechanisms are not entirely clear, it is possible that geniposide, which is the main component of Gardenia jasminoides, may be transferred to genipin, which is absorbed into the mesenteric veins and causes intimal hyperplasia, venous wall thickening, and fibrosis, resulting in “mummification.”4 Subsequently, the obstruction of venous lumen produces inadequate venous return, intestinal wall thickening and edema, gliosis, and sclerosis and eventually mesenteric phlebosclerosis.4 In addition, it is not clear if the disease is impacted by the amount of ingested doses of the Gardenia jasminoides. Our case report provides evidence of the daily ingestion of geniposide with the occurrence of IMP.


Dear editor,
We read with interest the manuscript by Chou et al 1 titled "Idiopathic Mesenteric Phlebosclerosis: A Single-Institute Experience in Taiwan," which was published on February 25, 2023.Idiopathic mesenteric phlebosclerosis (IMP) is a rare form of ischemic bowel, commonly involving the proximal ascending colon, and characterized by wall thickening and serpentine calcifications of mesenteric veins.Asian descents with long-term Chinese herbs ingestion seem to be the most susceptible etiology.Chou et al 1 reported that 36.1% of 38 patients with IMP had a history of using Chinese medicine.Which Chinese herb is the culprit is often unclear, but extracts of Gardenia jasminoides have been reported to be responsible.For example, Hiramatsu et al 2 showed that 70.4% of IMP patients have exposure to sanshishi, which is an extract of Gardenia jasminoides.Yeh et al 3 reported a case of IMP that was associated with longterm use (8 years) of Chinese medicine, which contained extracts of Gardenia jasminoides.
While mechanisms are not entirely clear, it is possible that geniposide, which is the main component of Gardenia jasminoides, may be transferred to genipin, which is absorbed into the mesenteric veins and causes intimal hyperplasia, venous wall thickening, and fibrosis, resulting in "mummification." 4Subsequently, the obstruction of venous lumen produces inadequate venous return, intestinal wall thickening and edema, gliosis, and sclerosis and eventually mesenteric phlebosclerosis. 4In addition, it is not clear if the disease is impacted by the amount of ingested doses of the Gardenia jasminoides.Our case report provides evidence of the daily ingestion of geniposide with the occurrence of IMP.
A 58-year-old female patient was suffering from dull abdominal pain for a week.She went to our emergency department for evaluation.The physical examination was unrevealing and likewise her blood tests.Her pelvic x-ray showed thread-like calcifications (Figure 1A).Bowel thickening and calcifications were also seen in a later computed tomography of the abdomen (Figure 1B).Upon tracing back her drug history, she had been taking a Chinese herbal medicine, Jia Wei Xiao Yao Shan, which contained 95 mg of geniposide (山梔子) (Figure 2, red box) per 1 g in a 3 g powder packet, consistently since January 1, 2000, for 1 pack 1 time per day.Based on the calculation of 1 pack Jia Wei Xiao Yao Shan Chinese medicine per day, a total amount of 2110 g of geniposide had been ingested before the diagnosis of IMP was made on April 13, 2021.
Our case iterates the potential harms of geniposide in the causation of IMP after a prolonged period of time of ingestion before the occurrence of clinical manifestations and the lack of concerns of patients towards such practices.
Informed Consent: Written informed consent was obtained from the patient who agreed take part in the study.

Figure 1 .
Figure 1.(A) Pelvic X-ray showed thread-like calcifications at ascending colon (blue arrows).(B) Multiple calcifications (blue arrows) are depicted along the thickened wall of ascending colon (white arrow).