Ayurvedic Management of Hepatocellular Jaundice - A Case Report

Introduction

Jaundice is characterized by yellowish discoloration of skin, sclera, mucous membrane due to excess bilirubin in the blood. The bilirubin level in the range of 0.5 to 1 mg/dL is considered normal. Clinical jaundice should become apparent when serum bilirubin levels increase by more than 3 mg/dL.

According to Charaka Samhitha, kamala is a more advanced form of Panduroga (anaemia).  It is classified as Pittaja Nanatmaja Vyadhi and Rakta Pradosaja Vyadhi.¹ It occurs as a result of contaminated drinks, street food and unclean food. Kamala and jaundice must be contrasted due to the similarity in their aetiology, symptoms and pathophysiology. Additionally the colour of the urine and faeces changes to red or yellow. Bhekavarna or frog-like complexion develops in the patient.² The patient becomes emaciated, experiences burning sensation, dyspepsia, weakness, anorexia and sensory impairment. According to Charaka Samhitha, there are two different types of Kamala Roga - Shakhashrita and Koshtashrita Kamala. The process of pre-hepatic jaundice or haemolytic jaundice and the condition is known as Koshthasrita Kamala.³  There is only symptomatic relief available in modern medicine for this condition. ‘Kamali tu virechane’ is chikitsa sutra of Kamala as is mentioned in Ayurvedic literature.⁴ The basic idea behind this is that Pitta and Rakta Dusti cause Kamala and Pitta and Rakta that have become vitiated can be eliminated by timely and regular Virechana.

Case Presentation

A 28 year old female N/K/C/O HTN, diabetes mellitus, anaemia reported to the OPD with complaints of Jwara, Agnimandya, associated with Dourbalya since four days. There was Peeta (yellowish discolouration) of Netra (eye), Nakha (Nails), Mutra (Urine), since ten days. Investigations including liver function test, ultrasound abdomen, complete blood count (CBC), HBsAG and urine routine were advised. CBC values were within the normal limits and other laboratory values were on the higher side, with bile pigment and bile salt positive in urine. Hepatocellular jaundice or Kosthashrita Kamala was the diagnosis made for this patient based on the clinical observations, physical examination and laboratory findings.

Discussion

Kamala is referred to as Pittaja nanaatmaja and Raktapradoshaja vyadhi in Ayurveda literature. Kamala is the advanced stage of Pandu Roga described by Acharya Charaka, but it was also mentioned by Acharya Sushruta as a complication of Pandu Roga as well as other diseases, while Acharya Vaghata mentioned it as a separate illness. The majority of signs and symptoms of jaundice are significantly more comparable to Kamala disease in Ayurveda in several ways. It primarily presents in the form of Koshtashakhashrita and Shakhashrita kamala. Koshtashakhashrita kamala is also known as Bahupittakamala as it increases pitta production and develops due to excessive erythrocyte breakdown. Shakhashrita kamala also known as Alpapitta kamala, is only caused by decreased excretion of bilirubin and develops as a result of intrahepatic cholestasis. Both forms of jaundice closely resemble haemolytic and hepatocellular jaundice as understood by contemporary medical science.⁵  Since liver is the largest gland and the major site of metabolism and detoxification, diet followed should be easily digestible and waste materials should be removed from the gut at the earliest during a jaundiced condition.

As a result, Ayurveda medicines include ingredients that help the kidney and gut remove the waste and provide immediate energy. Purgation therapy must be used as the first step in treating Kosthashakhashrita Kamala. The basic principle is that the liver should not be overworked, and for that reason, virechana treatment is advised. Increased stercobilin synthesis is due to excess bilirubin which occurs with the development of jaundice. In addition to removing extra stercobilinogen, the virechana procedure with preceding snehana aids in lowering hyperbilirubinemia and, ultimately jaundice. Increased bilirubin diffusion enhances the production of stercobilinogen as a result of excessive stercobilinogen elimination. Thus extra bilirubin can diffuse into stercobilin and urobilinogen before being eliminated once more by the virechana karma process. Thus nitya virechana aids in the removal of extra bile from the body in case of jaundice. As gallbladder calculus size is quite small, sonologist did not mention size and number. In obstructive jaundice, only the conjugated bilirubin levels are high. But in this case, both conjugated and unconjugated bilirubin levels were high.

A thirty-day course of treatment was recommended (Table 3). After three days of treatment with the medications, liver function tests were repeated and the patient started showing remission from both the reduced appetite and the related symptoms. The patient was strictly instructed to rigorously adhere to the pathya (wholesome). After sixteen days of treatment, all symptoms continued to diminish (Table 4). The Ayurveda formulations chosen for this case were developed to enhance liver function, which would then enhance digestion and metabolism. We utilized formulations with activities primarily on digestive system, as shown above in Table 3, for this purpose. The formulations were chosen in accordance to the Ayurvedic treatment principles, which calls for enhancing liver function and provide Rasayana (Rejuvenator) medications promoting Dhatu vardhana (nourish body tissues). Patola Katurohinyadi Kashaya contains Katuki (Picrorhiza kurora) as the main ingredient having tikta rasa and kaphapittahara dosha karma. Because of the presence of Katuki, which is Kamala Pittapradhana Vyadhi, it has purgative properties. The pitta virechana is the recommended course of treatment for this illness. So, this formulation can be used for liver detox, improves the digestion power and relieves anorexia.⁶ Nirocil tablet contains Bhumiyalaki, Amrita, Bhringaraja and Nimba. It is used to normalize the liver function, relieves fever, viral infection, jaundice, hepatitis.

Nimba (Azadiractha indica) provides protection against hepatic impairment. Despite being a key component of this Kwatha, Guduchi (Tinospora cordifolia) is shown to have immune-modulating properties.⁷

One of the best Ayurveda formulas for treating Pitta dosha imbalance-related health issues, such as acid reflux, indigestion, and heartburn, is Avipattikara Churna. These can be attributed to poor eating habits, a sedentary lifestyle, or lack of physical activity. Avipattikara Churna has a cooling impact on the body and aids in reducing excessive heat produced by an imbalance in Pitta dosha.

Low digestive fire (Mandagni) can cause food to not be fully digested, which can lead to the creation of Ama. This could result in Aruchi, the Ayurvedic term for anorexia or loss of appetite. It is a disorder that causes the doshas of Pitta, Kapha, and Vata to be out of balance. Because of its Deepana (appetiser) and Pachana (digestion) qualities, eating Avipattikara Churna on a daily basis can aid in meal digestion by breaking down the Ama. Additionally, it aids in the balancing of Vata, Pitta, and Kapha Doshas.⁸

There was a notable decrease in symptoms like the yellowish discolouration of skin, eyes and urine. Laboratory investigations showed significant reduction in the abnormal levels of various parameters tested. There were no observed adverse side effects from the therapy during the treatment and the follow-up period. The herbal medicines are highly effective in managing jaundice. However to establish this effect, further studies involving larger sample and long duration are needed.

Patient’s Informed consent

Yes

Conflict of interest

Nil

Acknowledgement

Sri Dharmasthala Manjunatheshwara College of Ayurveda and Hospital, Hassan.