The problem with herbal medicines is the unknown quantities of active ingredients they have. The hemorrhagic complication is a well-known problem caused by dietary supplements such as ginkgo biloba and ginseng. Postoperative bleeding due to cinnamon is quite new data.
In 2022, Dr. Courtenay Chase et al from Barbados published a case of a postoperative hemorrhage due to cinnamon consumption/abuse. A male patient was diagnosed with a differentiated adenocarcinoma 45 cm from the anal verge. He was not on any medication. Pre-operative hemoglobin was 17.4 g/dL. No preoperative coagulation status was available. The patient was proposed for a laparoscopic left hemicolectomy. However, because of a short mesocolon, a tension-free anastomosis was impossible. In that setting, the authors decided on a subtotal colectomy with an ileo-sigmoid anastomosis. In my opinion, an anastomosis to the sigmoid is a mistake because there is no marginal artery in this colonic segment, making all anastomosis potentially ischemic. My option would have been an ileorectal anastomosis.
On postoperative day one, the patient developed generalized peritonitis, and a Fox sign was evident. A laparoscopy was performed to manage a postoperative hemorrhage. Although no active bleeding was found, there was a clot around the area of the middle colic vessels, extending to the retroperitoneum and to the space of Retzius. Hemoglobin dropped to 9.3 g/dL. On the day after, the patient had flank ecchymosis and scrotal swelling. A bleeding diathesis was considered. Prothrombin time (PT) was 22.5s and International Normalized Ratio (INR) was 1.59. Liver function was normal. The authors asked the patient about dietary habits. He was taking one tablespoon of cinnamon a day for the past ten months. Why? Keep reading to find out some healthy properties of cinnamon. Six hours later hemoglobin decreased from 9.3 to 8.0 g/dL. He was then transfused with red blood cells and fresh frozen plasma. On the next day, hemoglobin was 11.6 g/dL, PT was 19.2s, and INR was 1.32. There were no more signs of hemorrhage. Meanwhile, the patient was diagnosed with anastomosis stenosis (vomiting). Through a laparotomy, the anastomosis was resected, and an ileorectal anastomosis was performed. The patient was discharged home free of symptoms. One week later INR was 1.2. He was not on cinnamon anymore, I think.
According to Dr. Courtenay Chase et al, the patient had a reactive postoperative hemorrhage (e.g. failed ligation) aggravated by impaired coagulation (for which cinnamon consumption was responsible). Why did cinnamon cause those coagulation changes? Because coumarin is one of the biological compounds of cinnamon. As we all know, coumarin has anticoagulation properties by antagonizing vitamin K epoxide reductase complex 1. So, coumarin (and cinnamon) decrease the function of clotting factors II, VII, IX, and X. However, coumarins can also have some healthy properties such as anti-inflammatory and antimicrobial. Additionally, coumarins are believed to have anti-cancer properties by inhibiting the beta-catenin pathway which is linked to APC gene mutation (an important role in colonic adenoma to carcinoma progression). These were probably the reasons why the patient was eating huge amounts of cinnamon. Unfortunately, the patient not only failed to avoid cancer but also promoted the postoperative bleeding scenario.
As doctors (and patients), we must be cautious when using herbal medicines. Many believe herbal remedies have no side effects because “they are a natural product”. Remember that many medications come from natural herbs. Also, some aggressive poisons are found in animals, herbs, and berries. Because of the potential unknown side effects of herbal medicines, the American Society of Anesthesiologists recommends stopping them two weeks prior to surgery.
To avoid unpleasant surprises, you should always promote a good clinical interrogation, including a detailed dietary history. You must always ask your patients to stop any kind of herbal medicines for two weeks or you must postpone the surgery if they did not. Do not ever perform elective surgery on a patient who is on herbal medicines. This rule will keep you and your patient safe.
Link to PubMed:
Dr. Carlos Eduardo Costa Almeida
General Surgeon
#colorectal #cancer #colon #rectum #sigmoid #cinnamon #bleeding #hemorrhage #haemorrhage #bleeding #postoperative #complication #side_effects #coumarin #vitamin_K #clotting
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