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| CASE REPORT |
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| Year : 2016 | Volume
: 35
| Issue : 4 | Page : 236-239 |
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Ayurvedic management of cirrhotic ascites
G Aswathy1, Prasanth Dharmarajan2, Ananth Ram Sharma1, VK Sasikumar1, MR Vasudevan Nampoothiri1
1 Department of Panchakarma, Amrita school of Ayurveda, Kollam, Kerala, India
2 Department of Panchakarma, All Institute of Ayurveda, New Delhi, India
| Date of Web Publication | 10-Aug-2016 |
Correspondence Address:
Ananth Ram Sharma
Department of Panchakarma, Amrita school of Ayurveda, Kollam, Kerala
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0257-7941.188183
Cirrhosis is the final stage of most of the chronic liver diseases and is most invariably complicated by portal hypertension resulting in ascites. A case of chronic liver disease with portal hypertension (cryptogenic cirrhosis), managed at Amrita School of Ayurveda is discussed in this paper. The clinical picture was that of an uncomplicated cirrhotic ascites. Snehapāna (therapeutic oral administration of lipids) followed by virecana (purgation) was done after an initial course of nityavirecana (daily purgation). Later Vardhamāna pippalī rasāyana [administration of single drug - pippalī (piper longum) in a structured dose pattern] was administered with an intention of rejuvenating liver cells. Ascites and lower limb oedema were completely resolved after the therapy. No recurrence of ascites has been reported after a follow up period of one year. Keywords: Ascites, chronic liver disease, cryptogenic cirrhosis, Nitya virecana, Vardhamāna pippalī rasāyana, Yakṛt udaraabout
How to cite this article:
Aswathy G, Dharmarajan P, Sharma AR, Sasikumar V K, Vasudevan Nampoothiri M R. Ayurvedic management of cirrhotic ascites. Ancient Sci Life 2016;35:236-9 |
| Introduction | |  |
In 2010 May world health organization declared liver diseases as a global public health issue.[1] Non- Alcoholic Fatty Liver Disease (NAFLD) is emerging as the commonest cause of chronic liver diseases. Among the liver diseases, NAFLD deserves special reference as it has been recognized as the prime cause of cryptogenic cirrhosis.[2] The importance of NAFLD is great because its prevalence is closely related to Type 2 diabetes mellitus and obesity which is alarmingly increasing.[2] The prevalence of NAFLD has doubled during last 20 years, whereas the prevalence of other chronic liver diseases has remained stable or even decreased.[1] In this scenario it will be relevant to think about the scope of an Ayurvedic approach to address NAFLD. The present case is a case of uncomplicated cirrhotic ascites with the written consent of the subject.
| Case Report | | |
A 63-year-old man who is an active full time social worker walked in with a well-established diagnosis of cryptogenic cirrhosis. The chief concerns were:
- Lower limb oedema - six months duration
- Distension of abdomen – one-month duration
- Loss of appetite and tiredness.
About six months before presentation, increased fatigue, lower limb oedema and an increase in blood sugar level were noticed. It was managed with oral hypoglycemic agent, diet and exercise. But the limb oedema was persistent and abdominal swelling also set in later. There was a rapid weight gain of about seven kg over a period of six months. The subject was physically, intellectually and socially active with a disciplined life style. There was no history of smoking, alcoholism or drug abuse nor was there any relevant history of past illness other than that of diabetes mellitus.
Clinical findings
The subject was pale, afebrile and emaciated with protruded abdomen. There was no icterus, asterixis, clubbing of fingers, leukonychia, or palmar erythema. There were no bruises, but a spider naevus spot was seen behind pinna. Abdomen was distended with umbilicus inverted. There were no dilated blood vessels over abdomen and no visible peristalsis. Bowel sounds were present. On palpation abdomen was soft and non-tender, with moderate hepatomegaly. Shifting dullness was found on percussion. Pretibial pitting oedema was detected on both lower limbs.
Investigations
CT scan abdomen:
- Morphological features suggestive of liver cirrhosis
- No focal lesions in liver
- Mild to moderate ascites
- Portal vein patent
- Multiple left gastric splenorenal and retroperitoneal collaterals noted.
Upper GI endoscopy
Grade 1 and grade 2 oesophageal varices and severe portal hypertensive gastropathy in the antrum of the stomach were detected.
Therapeutic intervention
Therapeutic intervention was based on the principles of udara cikitsā (management of ascites) as the clinical picture of uncomplicated cirrhotic ascites was comparable with yakṛt udara . The two phases of treatment were laṅghana (thatwhich promotes catabolicactivity in the body) and Vardhamana Pippalī rasāyana . Considering the initial Bahudoṣāvasthā [3] (high level of morbid humours) and doṣa predominance, nityavirecana [4] (daily purgation) was the laṅghana strategy adopted.
First phase of management
Nityavirecana
The patient was hospitalized and 25 ml Hiṅgutriguṇa taila [5] (castor oil processed in Ferula asafoetida, Allium cepa etc.) along with 75ml milk was given on empty stomach for 10 days.
Internal medicines
- Punarnavādi kaṣāyam [6] (Decoction of Boerhavia diffusa, Melia azadirachta etc.) – 60 ml thrice a day before food
- Pañcakola cūrṇam [7] (powder of Piper longum, Zingiber officinale etc.) – 5 g twice a day before food
- Gomūtra harīthaki [8] (a preparation of Terminalia chebula in cow's urine) – 15 g at bed time.
Diet
- Āviltolādi bhasma kaññi [9] (Medicated gruel with diuretic property-prepared using ash preparation of Holoptelia integrifolia, Baliospermum montanum , etc.)
- Mudga yūṣa (green gram soup)
- Pāna (medicated drinking water): Ardhavilva toyapākam [10] (water processed in Zingiber officinale, Solanum indicum etc.).
Marked relief was obtained in ascites and limb oedema after ten days. After the initial course, the patient was discharged with the advice of oral medication and pathya āhāra (diet) of pancakola yavāgu (gruel) for improving agni (digestive and metabolic ability).
Second phase of management
Vardhamāna pippalī rasāyana was planned about one and a half month later, i.e., after gaining strength and moderate digestive and metabolic efficiency (agnibala). Subject was on Pancakola yavāgu and follow-up medicines during this period. Rasāyana therapy (rejuvenation) requires preparatory purification of the body. Hrasva mātrā snehapānam (internal administration of medicated ghee in small doses) with Indukānta ghṛta [11] (ghee processed in decoction of Holoptelia integrifolia, Cedrus deodara etc.) followed by virecana (purgation) with Hiṅgutriguṇa taila was done. Doses were fixed according to the daily fluctuations in agni (digestive ability) and bala ( strength or general health) of the patient.
In Vardhamāna pippalī rasāyana 1000 pippalīs are administered to the patient in a structured dose pattern over a specific duration of time. It was administered as powder with milk as the anupāna (liquids taken along or after medicines which may act as vehicles). Half kg of Pippalī fruits was dried in shade and powdered. Ten number of Pippalī fruits were standardized as approximately three grams.
Dosage pattern
Three grams of pippalī cūrṇa (~10 dry pippalī fruits) was administered on the first day. The dose was increased by three grams every day to reach up to 30 grams on the tenth day (a total of 550 pippalī fruits). Eleventh day onwards the dose was tapered by reducing three grams every day until it came back to the starting dose. It took 19 days to administer 1000 pippalī fruits. The exact dose pattern is shown as [Table 1].
Administration
Every day in the morning a quarter glass of milk was given on empty stomach. After ten minutes, pippalī cūrṇa was given with 100–150 ml of milk, followed by half a glass of milk. Diet was restricted to milk gruel and diluted milk was provided for drinking whenever patient felt thirsty. Approximately two litres of milk was administered every day.
| Results | | |
Ascites and lower limb oedema were completely resolved. The patient is back to his normal routine. Some improvement in the liver panel work up was also noticed, as shown in [Table 2]. After a regular follow-up of one year, it was found that there was no recurrence of ascites. Serum bilirubin value (total) is maintained around the upper normal limit. Even if a significant increase in total protein and serum albumin cannot be claimed, the values are almost stable without further deterioration. | Table 2: Comparing the values of liver panel work up at different stages
Click here to view |
Timeline
Timeline of the case report is shown in [Figure 1].
| Discussion | | |
During rasāyana treatment patient occasionally complained of burning stomach, gaseous abdomen, increased bowel frequency, weakness and sleeplessness. Despite all these, overall tolerability of intervention was fairly acceptable.
The outcome was a combined effect of śodhana ( purificatory therapy) and rasāyana ( rejuvanative therapy). Pippalī has kaṭu rasa (pungent taste) , uṣṇa vīrya (hot potency), madhura vipāka (sweet after digestion); tīkṣṇa (sharp and potent) and laghu guṇa (light to digest). [12] Pippalī acts as hetu viparīta (against cause-dīpana), vyādhiviparīta (against disease-Yakṛt plīhāmayahṛt), doṣa viparīta (kapha vāta hara , tridoṣahara , pittāvirodhi) and as rasāyana . The mode of administration is also important as the action of drug varies according to it. Hepatoregenerative property of pippalī has already been established in an animal study.[13]
| Conclusion | | |
Uncomplicated cirrhotic ascites can be managed with Ayurvedic protocol. Outcomes of the treatment suggest that reversal of liver pathology at cellular level can happen when pippalī is administered as a rasāyana . The extent of alteration of the pathophysiology, in terms of biomedical science, needs to be ascertained. Apart from the improvement in the quality of life of the subject, this case study opens the scope for clinical trials to evaluate the treatment protocol.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | LaBrecque D, Abbas Z, Anania F, Peter F, Khan AG, Lee Goh K, et al . World Gastroenterology Organization Global Guidelines. Nonalcoholic Fatty Liver Disease and Nonalcoholic Steatohepatitis; June, 2012. Available from: http://www.worldgastroenterology.org/guidelines/global-guidelines/nafld-nash/nafld-nash-english. [Last accessed on 2016 Jul 11].  |
| 2. | Duseja A. Nonalcoholic fatty liver disease in India – A lot done, yet more required! Indian J Gastroenterol 2010;29:217-25. |
| 3. | Agnivesha. Chikitsaprabhrteeyam adhyaya. In: Acharya VY, editor. Caraka-samhita. 1 st ed. Varanasi: Chaukhambha Surbharati Prakshan; 2013. p. 97. |
| 4. | Vagbhata. Udara chikitsitiyadhyaya. In: Paradakara PH, editor. Astangahridayam. 15/1. 9 th ed. Varanasi: Chaukhambha Orientalia; 2002. p. 693. |
| 5. | Vagbhata. Gulma chikitsitadhyaya. In: Paradakara PH, editor. Astangahridayam. 14/39. 9 th ed. Varanasi: Chaukhambha Orientalia; 2002. p. 687. |
| 6. | Kashaya Yogas. In: Vaidyan KVK, pillai SG, editors. Cikitsa Sarasarvaswam. 31 st ed. Alappuzha: Vidyarambham Publishers; 2012. p. 121. |
| 7. | Vagbhata. Annaswarupa vijnaniya adhyaya. In: Paradakara PH, editor. Astangahridayam. Su 6/166. 9 th ed. Varanasi: Chaukhambha Orientalia; 2002. p. 120. |
| 8. | Vagbhata. Arsas chikitsitiyadhyaya. In: Paradakara PH, editor. Astangahridayam. 8/55. 9 th ed. Varanasi: Chaukhambha Orientalia; 2002. p. 647. |
| 9. | Kashaya Yogas, Pillai SG, editors. Chikitsa Sarasarvaswam. 31 st ed. Alappuzha: Vidyarambham Publishers; 2012. p. 111. |
| 10. | Kashaya Yogas, Pillai SG, editors. Chikitsa Sarasarvaswam. 31 st ed. Alappuzha: Vidyarambham Publishers; 2012. p. 109. |
| 11. | Kashaya Yogas, Pillai SG, editors. Chikitsa Sarasarvaswam. 31 st ed. Alappuzha: Vidyarambham Publishers; 2012. p. 322. |
| 12. | Agnivesha. Rasavimana. In: Acharya VY, editor. Caraka-samhita. Vimanasthana 1/16. 1 st ed. Varanasi: Chaukhambha Surbharati Prakshan; 2013. p. 234. |
| 13. | Patel JA, Shah US, Hepatoprotective activity of Piper longum traditional milk extract on carbon tetrachloride induced liver toxicity in Wistar rats. Boletín Latinoamericano y del Caribe de Plantas Medicinales y Aromáticas 2009;8:121-29. Available from http://www.redalyc.org/pdf/856/85611769008.pdf. [Last accessed on 2016 Jul 12]. |
[Figure 1]
[Table 1], [Table 2]
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