|Year : 2022 | Volume
| Issue : 3 | Page : 97-101
Management of cholecystitis after endoscopic retrograde cholangiopancreatography through Ayurveda: An experience
Satya Smaran Adhikary1, Anil Kumar2, Asit Kumar Panja3, Geeta4
1 Government of West Bengal, West Bengal, India
2 Department of Samhita and Maulik Siddhanta, Keshav Ayurvedic Medical College, Aklera, Jhalawar, Rajasthan, India
3 Department of Samhita and Maulik Siddhanta, National Institute of Ayurveda (De-Novo), Jaipur, Rajasthan, India
4 Department of Shalya Tantra, Keshav Ayurvedic Medical College, Aklera, Jhalawar, Rajasthan, India
|Date of Submission||27-Dec-2021|
|Date of Acceptance||22-Aug-2022|
|Date of Web Publication||03-Oct-2022|
House of Sh. Rajnish K Sharma, Near Police Chauki, 56 Lakh Colony, Aklera, Jhalawar - 326 033, Rajasthan
Source of Support: None, Conflict of Interest: None
Gallbladder (GB) stones (~Pittashaya ashmari) are formed within the lumen of the GB and cause obstruction in the smooth flow of bile during physiological contraction of the bladder. The research backup for this study is based on the available knowledge of Ayurveda regarding the management of GB stones. Ayurveda may have the potential to offer practical inputs to this burgeoning area. An attempt has been made here to take a view of certain characteristic aspects of Ayurveda approaches with particular reference to their compatibility with modern needs. A patient diagnosed with Pittashaya ashmari (~calculus cholecystitis) has been treated with Ayurveda modalities. The clinical presentations of this case have been assessed based on classical signs and symptoms of Ashmari (~lithiasis) mentioned in Ayurveda classics. In modern medical science, no medicinal cure has been found yet to treat this disease. Only excision of the GB or destruction of the stones by lithotripsy through microsurgery is suggested. However, in Ayurveda, different medicines administered orally with some specific Anupana (~adjuvant) are effective. A case is being presented, which was treated as per the treatment principles of Samshodhana (~cleansing therapy) as Koshthashuddhi (~mild purgation) and Sukha-virechana (~purgation) with Pittashmaribhedana prabhava (~stone crushing effect) of some specific Ayurveda medications. Follow-up has been taken two times after treatment by assessing improvement in the classical sign and symptoms of Ashmari (~lithiasis) and ultrasonography report as well. A significant clinical and radiological improvement was noted in this case.
Keywords: Ashmari, Calculus cholecystitis, Gallbladder stone, Panchakarma, Pittashmari
|How to cite this article:|
Adhikary SS, Kumar A, Panja AK, Geeta. Management of cholecystitis after endoscopic retrograde cholangiopancreatography through Ayurveda: An experience. J Ayurveda Case Rep 2022;5:97-101
|How to cite this URL:|
Adhikary SS, Kumar A, Panja AK, Geeta. Management of cholecystitis after endoscopic retrograde cholangiopancreatography through Ayurveda: An experience. J Ayurveda Case Rep [serial online] 2022 [cited 2022 Dec 9];5:97-101. Available from: http://www.ayucare.org/text.asp?2022/5/3/97/357784
| Introduction|| |
Gallbladder (GB) is a small pouch-like structure that sits just beneath the liver. It stores the bile produced by the liver. In responding to the signal, GB squeezes stored bile into the small intestine through the bile duct. GB stone (~Pittashaya ashmari) is a condition in which stones are formed within the lumen of GB and cause obstruction in a smooth flow of bile during physiological contraction of the GB. They are a hardened accumulation of bile from the digestive fluid. They range in size and shape from the size of a speck of dust to the size of a golf ball. GB stones form when the chemical composition of bile becomes imbalanced, resulting in the accumulation of one or more of the constituents. GB stones are frequently regarded as a major ailment in modern medical science. GB stones, on the other hand, must have been recognized by human beings for a long time, as they have been discovered in the gallbladders of Egyptian mummies since 1000 BC. Despite geographical differences in GB stone occurrence, this ailment is a global health issue. GB stones are becoming more prevalent, they affect people of all ages, but the prevalence rises with age, and one-quarter of women over the age of 60 are affected by them. In major instances, they do not produce symptoms. Only 10% and 20% will become symptomatic within 5 and 20 years of diagnosis, respectively. An increase in fat, refined carbohydrates and a decrease in fiber content of the diet are significant risk factors for the production of GB stones. GB walls inflammation leads to severe abdominal pain, particularly in the right upper quadrant of the abdomen, radiating pain to the back and shoulder, Murphy's sign-positive, as well as vomiting, fever, and leukocytosis occurs. No medicinal cure has been found yet in modern medical science to treat this disease. Only excision of the GB or destruction of the stones by sound (lithotripsy) through microsurgery is suggested. In Ayurveda, GB stones can be understood as Pittashmari (~calculus cholecystitis), wherein “Ashmari” means “the stones” and “Pitta” denotes the imbalanced Pitta dosha of bile in the GB. This occurs from surplus Kapha dosha mixing with the Pitta features of the bile and turning into a dry hardened form. An attempt is being made here to show the efficacy of Ayurveda in the management of calculus cholecystitis.
| Patient Information|| |
A 52-year-old male businessman, diagnosed with calculus cholecystitis came to the outpatient department (OPD) of Govt. Ayurveda dispensary on April 8, 2020. He is a nonvegetarian (Northeast Bengali food habits), with an active lifestyle, and belongs to middle socioeconomic status. The patient was taking symptomatic allopathic treatment (namely, Pantocid D Capsule, Mebiz SR 200 mg capsule, Pankreoflat 170 mg/80 mg tablet, Orni-O tablet, Drotin-M tablet, Uliv-300 mg tablet, and Pegalup syrup 200 ml) under the supervision of specialist of modern medicine since March 7, 2020, but did not get relief. The patient denied a history of any type of addiction. No other systemic illness was observed and no significant family, medical, or drug history was found.
| Clinical findings|| |
The patient was presented with the Grade I (mild) symptoms of calculus cholecystitis like-colicky pain in the abdomen (~Udarashoola, Grade-03), radiating pain to the back and shoulder (~Prishtha and Ansa-shoola), Murphy's sign-positive, vomiting (~Chhardi, 2–3 times in a day), decreased appetite (~Aruchi), fever (~Jvara, rise of temperature during noon) for 7 days and abdominal distension (~Aadhmana), discomfort at the site of the liver, irregular bowel movements (~Vibandha, Atisara on/off), generalized weakness (~Balahani) and sometimes severe pain in abdomen with agony (~Udarashoola) for 2 months. On examination, the patient's blood pressure was moderately high at many times (140/90 mmHg), pulse rate – 82/m, RR – 18/min. No edema, pallor, and icterus were observed. Urine was light pale watery and stools were light yellow. The height of the patient was 5'7”, weight was 85 kg, and body mass index was 29.35. Per abdominal examination shows pain in the upper right quadrant of the stomach and some inflammatory mass with tenderness. The clinical presentations of this case have been assessed based on classical signs and symptoms of Pittashmari mentioned in Ayurveda classics.,
| Timeline|| |
The timeline of the case is placed in [Table 1].
| Diagnostic assessment|| |
On March 10, 2020, the patient had undergone his first ultrasonography (USG) test. The report shows that the GB and the bile duct are full of small calculi. The second USG report (on March 16, 2020) shows that the lumen is filled with calculi and sludge, whereas the third USG report (on March 23, 2020) shows that the lumen is filled with intraluminal sludge and tiny calculi (numbers and size are not mentioned), nondilated common bile duct with probable intraductal sludge, and bulky pancreas with minimal peripancreatic fluid. Complete blood counts were normal (in a report dated March 4, 2020). Liver function tests show borderline total bilirubin levels with an increase in the level of serum glutamic-oxalacetic transaminase and glutamic-pyruvic transaminase (report dated March 7.,2020). The lipid profile shows borderline serum cholesterol, decrease high-density lipoprotein, and an increase in low-density lipoprotein (dated March 4, 2020). The clinical presentations of this case have been assessed based on classical signs and symptoms of Ashmari (~lithiasis) mentioned in Ayurveda classics. The patient was suffering from Udarashoola associated with Aadhmana, Aruchi, Chardi, Avipaka (~indigestion), Jvara, Daurbalya (~debility), Balahani (~loss of physical strength), Raktagatavatavriddhi (~high blood pressure), Medadushti (~disorder of fat metabolism), Yakritvriddhi (~fatty liver). The patient was diagnosed with Pittashaya ashmari along with Yakrit (~liver and pancreas) Vriddhi. Ayurveda treatment was started on April 8, 2020, after explaining the prognosis clearly to the patient after his written consent. Koshthashuddhi (~mild purgation) by Gandharvahastadi eranda tailam, Samshodhana (~cleansing therapy) by Trivrit churna in the form of Sukha virechana (~purgation), and Shamana-aushadha (~alleviating therapy) in the form of oral medications have been administered for about 5 months. Improvement was assessed based on relief in the patient's symptoms along with observations found in USG reports. Significant improvement was found in both classical symptoms as well as USG study reports. Follow-up has been taken two times after treatment by assessing the USG report to evaluate the sustainability of the result.
| Therapeutic interventions|| |
The therapy was started at the OPD level with a prior treatment USG dated March 23, 2020, to keep track of the record of progress. The treatment is given in the form of Koshthashuddhi (Gandharvahastadi eranda tailam, [20 ml] once in a week with warm milk on empty stomach in the morning [6 a.m.] for 1 month). About 4–5 bowel movements/purgations were noticed with this. Shodhana chikitsa (Trivrit churna [5 g] once in a day after meal with lukewarm water at bedtime at 9 p.m. daily for the next 4.5 months), Shamana chikitsa (Yakridari lauha [250 mg] twice in a day after meal with Badarasvarasa anupana [20 ml], Varunadi kasaya vati (500 mg) twice in a day after meal with water for 3.5 months) and Pachana (Phalatrikadi pachana [20 ml] twice in a day before the meal with water at 8 a.m. and 5 p.m. for 1 month) were prescribed. Pathya-apathya, aahar-vihar (~wholesome-unwholesome diet and lifestyle) mentioned in Virechana karma (~purgation therapy) was followed for 1 month after completion of treatment. During this period no concomitant medication was used [Table 1].
| Follow-up and outcome|| |
Follow-up has been taken two times after treatment by assessing improvement in the classical signs and symptoms of Ashmari and observations in the USG report as well, where a significant improvement was noted [Table 2]. He was advised USG of the upper abdomen two times after treatment to observe the response to the treatment. No other adverse or unanticipated events were observed during the treatment or follow-up period.
| Discussion|| |
The endoscopic retrograde cholangiopancreatography (ERCP) done with the coverage of antibiotics to check the infection of the pancreas has given relief to the patient in the symptoms of pancreatic infection to some extent. However, significant relief from the symptoms of cholecystitis with cholelithiasis was not achieved. Thus, to encounter this situation, Ayurveda interventions were started. In classics, it is mentioned that the Samprapti or Dosha-dushya sammurchchhana (~pathophysiology) of any type of Ashmari is Kapha dosha that is thickened due to the influence of Vata and Pitta dosha. The formation of any type of Ashmari (~lithiasis) occurs at the site of “Kha-vaigunya.” In Pittashmari, the involvement of Vata and Pitta dosha exists. It is clear that, in the process of dryness, the involvement of Vata (Vayu) and Pitta (Agni) is necessary. Due to consuming Vata-pittaja aahara-vihara, accumulated Malabhuta kapha, i.e., Kleda (~stickiness) gets hardened at the site of GB and Pittashmari formation occurs. Medication which has the Prabhava (~special effect) of Pittashmaribhedana (~stone crushing) can be used in this condition. This Ayurveda modality may offer a promising and scalable treatment option for calculus cholecystitis. A case series or a suitably designed randomized controlled trial is needed to assess its efficacy.
Probable brief mode of action of treatment
Gandharvahastadi Eranda Tailam is used alone for Koshthasuddhi (~mild purgation) in the initial stage of treatment for encountering the condition of Rukshakoshthata (~dryness of gastrointestinal tract organs). Then, Trivrit churna is used for Sukha virechana (~purgation). It mitigates Pitta and Vata without aggravating Kapha due to its Tridoshahara property. Hence, it is effectively used for Sukha-virechana (~purgative) in this case of Sukumara (~delicate) person. In this way, Srotosodhana (~opening of body channels) of the middle to the lower part of the body is done successfully by neutralizing the imbalance of Vata. After that, oral medications that have Ashmaribhedana Prabhava (~stone crushing effect) are administered such as Phalatrikadi pachana, Yakridari lauha, and Varunadi kashayam vati. In food, boiled Shali-tandula (~rice) in Yavagu (~medicated gruel) form is used that contains mainly Shalidhanya and Trikatu in small quantities. It is having Laghu (~lightness) property and helps in removing Avarana (~occlusion) in Strotas (~channels) to some extent.
| Conclusion|| |
This Ayurveda therapy was found to be effective in mitigating the symptoms of calculus cholecystitis in this patient with comorbidity of the bulky pancreas. Moreover, a significant improvement was achieved in the USG findings regarding GB stones.
Disclaimer: Initially, the patient was treated with ERCP, and antibiotics and later Ayurveda treatment was given.
Patient perspective section
Having recovered from symptoms of cholecystitis with cholelithiasis, the patient was asked for his feedback on the intervention. The patient expressed immense satisfaction and a sense of confidence. The patient was so convinced about the efficacy of Ayurveda that he suggested his friend to seek Ayurveda treatment. Most importantly, he decided to adopt Ayurveda into his lifestyle.
Declaration of patient consent
Authors certify that they have obtained patient consent form, where the patient has given his consent for reporting the case along with the images and other clinical information in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.
The authors convey sincere thanks to the authority of Jhalda Block Hospital, to the staff of State Ayurvedic Dispensary, Jhalda, Purulia, and are highly grateful to the District Ayush Medical Officer, Purulia for every cooperation.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]