|Year : 2018 | Volume
| Issue : 2 | Page : 30-35
Management of Alcoholic Liver Disease through Ayurveda
Kiran Kumar V Mutnali, Rashmi Patil
Dept. of Kayachikitsa, KLE University’s Shri B M Kankanawadi Ayurveda Mahavidyalaya, PG Studies and Research Centre, Shahapur, Belagavi, Karnataka, India
|Date of Web Publication||13-Jul-2022|
Kiran Kumar V Mutnali
Dept. of Kayachikitsa, KLE University’s Shri B M Kankanawadi Ayurveda Mahavidyalaya, PG Studies and Research Centre, Shahapur, Belagavi
Source of Support: None, Conflict of Interest: None
Alcoholic Liver Disease (ALD) involves a process of progressive destruction and regeneration of liver parenchyma leading to fibrosis and cirrhosis. About 30% adult Indians use alcohol of which 4 - 13% are daily users. The commonest cause of ALD is use of excess alcohol in terms of quantity, duration and patterns of drinking. A 38 years old male visited OPD complaining of anorexia, distended abdomen after food, yellowish discoloration of eyes and yellow urine since five months. He developed distention of abdomen since three months and pedal edema since one month. Bilirubin, SGOT and Alkaline Phosphatase were elevated. USG showed hepatomegaly with fatty changes suggestive of chronic liver disease, moderate ascites and right sided minimal pleural effusion. Based on the history and clinical examination, the condition was diagnosed as Jalodara manifested due to Yakrddalyudara. The choice of treatment in this condition is Nitya virechana that eliminate accumulated Dosha from Koshtha and help in Agni deepana. Considering this, Virechana with Haritaki churna and Go-mootra arka and Shamana medications were administered in this case. At the end of the treatment; improvement was noticed in appetite, pedal edema and abdominal girth was reduced. Total bilirubin, direct bilirubin and SGOT were reduced and urine color became normal. These observations infer that Ayurveda treatment approaches are beneficial in cases where hepatic functions are altered and manifest in complications like ascites.
Keywords: Alcoholic liver disease, Ascites, Jalodara, Virechana, Yakriddalyudara
|How to cite this article:|
V Mutnali KK, Patil R. Management of Alcoholic Liver Disease through Ayurveda. J Ayurveda Case Rep 2018;1:30-5
Introduction: Alcoholic Liver Disease (ALD) involves a process of progressive destruction and regeneration of liver parenchyma leading to fibrosis and cirrhosis. Excess alcohol intake can lead to a spectrum of liver diseases collectively known as ALD. Quantity and duration of alcohol intake are the most important risk factors involved in the development of ALD. Alcohol intake of more than 60gm by men and 20gm by females per day will have high risk of ALD. Daily intake of alcohol for more than 6 to 8 years significantly increases the risk of ALD. Indians develop cirrhosis with relatively lesser quantity and duration of alcohol intake, which may be due to other factors such as Hepatitis B and C co- infection etc.
The patho-physiology of ALD involves three stages viz, lipogenic hit, inflammatory hit and fibrogenic hit. Fatty liver is the earliest change and is almost universally present in heavy alcoholics. It is generally a benign condition and usually reverses with abstinence. Alcoholic Hepatitis (AH) is a syndrome of necro-inflammation of liver due to heavy alcohol intake and occurs in 10 to 35% of such patients. Patients with more severe AH usually present with fever and signs of hepatocellular failure such as jaundice, ascites, encephalopathy and cirrhotic changes presents with jaundice, ascites and peripheral edema.
Jaundice is usually due to failure of hepatocytes to excrete bilirubin resulting into conjugated hyperbilirubinemia. The normal parenchyma of liver is replaced by scar tissue in cirrhosis thereby increasing resistance to blood flow and higher pressure in portal venous system finally resulting in portal hypertension. Ascites is accumulation of fluid in the peritoneal cavity, which is sequel of portal hypertension. The management of ascites in conventional science is by appropriate use of diuretics, paracentesis and other medications depending upon the cause and symptoms manifested.
Ayurveda describes Jalodara as a condition characterized by accumulation of fluid in Udara that may also manifest in association with conditions like Yakridalyudara (~Hepatomegaly)., Excessive consumption of Ushna (~hot), Lavana (~salty), Kshara (~alkaline), Vidahi (~improperly baked foods), Amla (~sour), Ruksha (~dry), Viruddha ahara (~incompatible foods) etc. in persons with Mandagni (~decreased digestive functions) aggravates Pitta, Kapha and Vata that obstructs Udakavaha and Swedavaha srotas drawing fluid into the Udara by Upasneha nyaya (~osmosis and altered capillary pressure) leading to accumulation of fluid in Udara and manifesting different forms of Udara rogas., Nitya virechana, Agni deepana and surgical interventions are the recommended procedures in the management of Jalodara.,
| Case Report|| |
A 38 years old, non-hypertensive, non-diabetic, male patient approached the OPD with chief complaints of Kshudha alpata (~decreased appetite), Peeta netrata (~icterus) and Peeta mutrata (~yellowish urine) since five months. Udara utsedha (~distended abdomen) since three months and Pada shotha (~pedal edema) since a month. He is known alcoholic and consumes minimum 90ml alcohol daily since three years. The quantity was increased to 180ml during the last year.
Examination: General examination reveals Peeta netrata, Tandra (~drowsiness) and Ubhaya pada shotha (~bilateral pedal edema). On examination; weight was 56kg, pulse rate was 74/minute and blood pressure was 110/60 mm Hg. On inspection; Udara utsedha with transverse umbilicus was observed. On palpation, abdomen was Mridu (~soft and non-tender). On percussion, Udaka poorna druti sankshobha (~fluid thrill), shifting dullness and horse shoe dullness were observed. USG abdomen revealed hepatomegaly with fatty changes suggestive of chronic liver disease, moderate ascites and right sided minimal pleural effusion. Liver function tests presented with elevated Bilirubin, SGOT and Alkaline Phosphatase. The Satva and Samhanana of the patient were of Madhyama. Prakriti was Vata pradhana pittaja, while Sara was Rakta.
Diagnosis: Based on the clinical presentation and examination with radiological and laboratory tests; the patient was diagnosed with chronic liver disease with moderate ascites. This manifestation is compared with Jalodara due to Yakriddalyudara.
Treatment adopted: Nitya virechana with 10ml Go-mootra arka (distilled Cows urine) added with 5gm of Haritaki churna (fine powder of Terminalia chebula) and 50ml of warm water was administered on empty stomach. Udara lepa (~application of a herbal paste over the abdomen) made up of fine powders of Palasha beeja (seeds of Butea monosperma (Lam.) Taub.), Arka moola twak (root bark of Calotropis procera (Aiton) W.T.Aiton), Shigru moola twak (root bark of Moringa oleifera Lam.), Ashwagandha (Withania somnifera (L.) Dunal), Pippali (Piper longum Linn.), Devadaru (Cedrus deodara (Roxb.) G.Don), Vacha (Acorus calamus Linn.) triturated with quantity sufficient of Go-mootra arka. Shamana medications include 50ml Swarasa (~fresh juice) extracted from equal parts of Nimba patra (leaves of Azadirachta indica (A. Juss.) Brandis), Guduchi (Tinospora cordifolia (Thunb.) Miers), Bhringaraja (Eclipta prostrata Linn.) and Bhumyamalaki (Phyllanthus niruri Linn.) added with 3gm powder of Katuki (Picrorhiza kurroa Royle ex Benth.), Cap. Cytozen (a proprietary formulation of Charak Pharma Pvt. Ltd.), Tab. Silybon-70 (extract of Silybum marianum) and Syrup Kalamegha strong [Table 1] for 15 days. The observations in the changes of abdominal girth and Liver Function Tests during and after the treatment are mentioned at [Table 2], [Table 3].
Discussion: Ayurveda considers Yakriddalyudara under Udara roga comparable to hepatic enlargement in conventional system. In cirrhosis, liver is palpable in early stages, but as the condition progresses, it starts to shrink and cannot be palpable in advanced stages. Excess alcohol consumption, as seen in the current case leads to vitiation of Pitta and Vata dosha, Rasa and Rakta dushya that in turn leads to accumulation of toxins in liver. The deranged Rakta dhatu gets accumulated in liver and spleen that are the Raktavaha sroto moola leading to their Vriddhi (~hepato-splenomegaly). When the Kapha dosha blocks the vitiated Rakta in liver and spleen, hyperactivity of these organs results in altered blood profile leading to the manifestation of Pandu (~anaemia), Kamala (~jaundice) etc. Persistent vitiation of Dosha get mobilized to the skin, where it get obstructed by Vata dosha producing Shotha (~inflammation).
The treatment principle of Udara roga is Nitya virechana and Dipana chikitsa. Nitya virechana was planned to eliminate the Sanchita dosha (~accumulated toxins). As the patient is of Madhyama bala, Vatapitta prakriti, Madhyama satva; Go- mootra arka added with Haritaki churna was used for Nitya virechana. The patient was presented with bilateral pitting pedal edema, where Kapha plays a predominant role, demanding Rukshana chikitsa. A combination of Haritaki and Go-mootra arka also suits and can pacify this condition. 50ml Swarasa of Guduchi, Nimba, Bhringaraja and Bhumyamalaki mixed with 3gm of Katuki churna was administered twice daily on empty stomach for 15 days. Guduchi pacifies vitiated Tridosha and additionally it has Rasayana effect. Guduchi also has hepato-protective properties that prevents fibrous changes and promotes regeneration of parenchymal tissue. Punarnava is preferred in the management of Shotha and Pandu. It also has hepato-protective properties and help in decreasing albuminuria and increasing serum protein. All these herbs being Tikta rasa pradhana, pacify aggravated Kapha and Pitta dosha that play major role in disease manifestation. Bhringaraja is also an hepato- protective drug and is indicated in Kaphaja shotha and Pandu.,
Bhumyamalaki is Yakriduttejaka (~hepato-stimulant), Rakta shodhaka (~blood purifier) and Pitta rechaka (~eliminates exacerbated Pitta). Cap. Cytozen contains 56.25mg of Mandura bhasma, 112.5mg of Arogyavardhini ras, 67.5mg each of Kakamachi (Solanum nigrum Linn.) fruit and Chitraka (Plumbago zeylanica Linn.) root, 112.5mg each of pericarp of Triphala (Terminala chebula Retz., Terminalia belerica (Gaertn.) Roxb. and Emblica officinalis Linn.), 337.5mg each of Punaranava (Boerhavia diffusa Linn.) root, Kumari (Aloe barbadensis (L.) Burm.f.) leaf, Kasni (Cichorium intybus Linn.) seed, Katuki (Picrorhiza kurrooa Royle ex Benth.) rhizome, Bhunimba (Andrographis paniculata (Burm.f.) Wall.) whole plant and Sharapunkha (Tephrosia purpurea (L.) Pers.) whole plant. Katuki possesses hepato-protective, anti-viral and anti- oxidant activities. Punarnava exhibits anti-inflammatory activity, thus help in modulating inflammatory responses and is advised in the management of Shotha and Pandu. Amalaki is potent antioxidant and protects liver cells from free radical damage. In Kalamegha strong, Bhunimba is the potent drug, which reverses the altered hepatic biochemical parameters. Tablet Silybon is made-up of Silybum marianum seed extract. It provides hepatocellular protection by stabilizing hepatic cell membranes. It alters the structure of the outer cell membrane of the hepatocytes in such a way as to prevent the penetration of the liver toxins into interior of the cell, and helps in normalizing hepatic functions.
500ml of boiled milk per day in divided doses is advised in diet as it is Sadya santarpaka, Snigdha virechaka and is a good source of protein. 250ml of Mudga amalaka yusha twice daily is indicated as Mudga also is rich source of protein and light for digestion, thus compensates albumin depletion. Amalaki has hepato-protective activity and helps in elevating the serum protein levels.
With the intervention of all these Shodhana and Shamana procedures; liver function tests showed marked improvement [Table 3], appetite was improved, abdominal girth at one inch above the umbilicus was reduced from 36.5 inches to 31.5 inches [Figure 1],[Figure 2]. Pedal edema was also reduced significantly.
On discharge; the condition of the patient was good. Appetite and general health were improved. Direct, Indirect bilirubin and SGOT and Alkaline phosphatase levels were reduced considerably. Icterus was reduced slightly, pedal edema was completely reduced, urine color was changed from dark yellow to light yellow. On discharge, patient was prescribed with Syrup Kalamegha strong (15ml thrice in a day before food), Cap. Cytozen (two capsules twice a day) and Punarnavadi kashaya (15ml twice a day) for next 15 days. He has advised to avoid all precipitating etiological factors and follow dietary restrictions at least for three months. On the next follow-up visit, he was free from any of the complaints.
Conclusion: Mandagni and Vaatadi dosha prakopa is the main cause for Udara hence the basic principle to treat the Udara is Deepana, Pachana and Tridosha shamaka kriya along with Nitya virechana. Results observed in this case are encouraging and reveal importance of Ayurveda treatment modalities in the management of manifestations like Alcoholic Liver Disease.
Source of support: Nil
Conflicts of Interest: None declared
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]