Lecture Note: “Ayurvedic Management of Hepatobiliary Disorders” (Part-6)

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“Ayurvedic Management of Hepatobiliary Disorders”
Part-6

 Prof. Muralidhara Sharma 

based on the lecture available at
 Ayurvedic Management of Hepatobiliary Disorders 

 Obstructive jaundice: 

  • Multiple causes
  • Jaundice with raised direct bilirubin
  • Dilatation of Biliary pathways
  • Clay-colored stools

Obstructive jaundice is an area where Ayurvedic treatment alone has virtually no role. We cannot effectively manage patients with obstructive jaundice through Ayurveda. It is important to identify patients with obstructive jaundice, and every case of obstructive jaundice requires surgical intervention. The type of surgery depends on the underlying cause, but I won’t elaborate on the specific conditions. The key point is to identify patients with jaundice and ensure they undergo investigation. It is crucial to rule out any obstructive causes of jaundice. In my experience, obstructive jaundice cannot be treated with any medical intervention, including Ayurveda or any other approach. There is no possibility of medical management. Therefore, every patient presenting with jaundice needs to undergo investigation. The usual clinical clues to diagnose obstructive jaundice include elevated direct bilirubin levels and clay-colored stools. Ultrasound confirmation is necessary. If ultrasonography shows signs of biliary tract dilation, I would consider it a limitation for Ayurvedic treatment. Surgical intervention is necessary in such cases. Whether I perform the surgery myself or refer the patient to another surgical specialist depends on the situation, as I mentioned earlier. However, it is not a condition that can be treated medically. So, intervention is absolutely necessary. Our responsibility is to recognize this, and Sushruta has described a similar condition called “Paanaki” in relation to “Pandu roga” (jaundice). The complications of Pandu roga are referred to as “Paanaki,” and “Kumbhkamala” is also the same.

Key points

Interventional treatment is necessary.

 स कामलापानकिपाण्डुरोगः कुम्भाह्वयो लाघर(व)कोऽलसाख्यः |
विभाष्यते लक्षणमस्य कृत्स्नं निबोध वक्ष्याम्यनुपूर्वशस्तत् [१] ||६||
… वक्ष्यामि लिङ्गान्यथ कामलायाः |
यो ह्यामयान्ते सहसाऽन्नमम्लमद्यादपथ्यानि च तस्य पित्तम् ||१०||
करोति पाण्डुं वदनं विशेषात् पूर्वेरितौ [१] तन्द्रिबलक्षयौ च |११|
भेदस्तु तस्याः खलु कुम्भसाह्वः शोफो महांस्तत्र च पर्वभेदः ||११||
ज्वराङ्गमर्दभ्रमसादतन्द्राक्षयान्वितो लाघर(व)कोऽलसाख्यः |१२|
तं वातपित्ताद्धरिपीतनीलं [१] हलीमकं नाम वदन्ति तज्ज्ञाः ||१२||
( Su. Utt. 44)

 Sushruta also has considered this as absolutely Asadhya incurable condition as such.

  Anemia:  

 Causes 

  • Gastritis
  • Gastric or duodenal ulcer
  • Liver or renal disease
  • Hypothyroidism
  • Sickle cell disease
  • Hypermenorrhea
  • Thrombocytopenia or blood coagulation disorders
  • Cancer or other chronic
  • Poor diet, especially iron deficiency

 Types of anemia based on clinical picture– 

  • Iron deficiency anemia
  • Megaloblastic anemia
  • Pernicious anemia
  • Hemorrhagic anemia
  • Hemolytic anemia-Thalassemia anemia,Sickle cell anemia
  • Aplastic anemia

Now, let’s discuss anemia, although I won’t delve into extensive details about its various causes and types. I’ll focus on the fundamental aspects to consider in clinical practice. It’s important to understand that anemia can have different underlying causes. Not all anemias are the same, so simply providing a tonic to an anemic patient is not the appropriate treatment approach. Each patient with anemia needs to undergo assessment, as approximately 80% of anemic patients will have an identifiable cause such as gastric pathologies, liver issues, thyroid problems, or menstrual abnormalities. Therefore, the treatment should be tailored to address those specific causes. Merely administering iron tonics or substances like Punarava Mandoor and Dhraaksharista to all anemic patients is not the correct treatment approach. The right approach involves identifying the root cause, as many times there will be a significant underlying cause that requires targeted treatment. Therefore, I cannot recommend a universal treatment plan for all types of anemia, except for iron deficiency anemia.

 Haemorrhagic Anemia: 

अत्युष्णेऽतिस्विन्नेऽतिविद्धेऽज्ञैर्विस्रावितमतिप्रवर्तत[१]
तदतिप्रवृत्तं शिरोऽभितापमान्ध्यमधिमन्थतिमिरप्रादुर्भावं धातुक्षयमाक्षेपकं दाहं पक्षाघातमेकाङ्गविकारं हिक्कां श्वासकासौ पाण्डुरोगं मरणं चापादयति ||३०||
(Su.Su. 14)

 Haemorrhoids: 

तेषां तु भविष्यतां पूर्वरूपाणि- अन्नेऽश्रद्धा कृच्छ्रात् पक्तिरम्लीका परिदाहो विष्टम्भः पिपासा सक्थिसदनमाटोपः कार्श्यमुद्गारबाहुल्यमक्ष्णोः श्वयथुरन्त्रकूजनं गुदपरिकर्तनमाशङ्का पाण्डुरोगग्रहणीदोषशोषाणां [१]
कासश्वासौ बलहानिर्भ्रमस्तन्द्रा निद्रेन्द्रियदौर्बल्यं च ||८||
( Su. Ni. 2)

  Renal Causes:  

हृत्पीडा सक्थिसदनं कुक्षिशूलं च वेपथुः |
तृष्णोर्ध्वगोऽनिलः कार्ष्ण्यं दौर्बल्यं पाण्डुगात्रता ||१५||

अरोचकाविपाकौ तु शर्करार्ते भवन्ति च |१६|
(Su. Ni. 3)

  GIT Pathology:  

तच्छीतवाताभ्रसमुद्भवेषु [१]
विशेषतः कुप्यति दह्यते च स चातुरो मूर्च्छति सम्प्रसक्तं पाण्डुः कृशः शुष्यति तृष्णया च ||१३||

प्रकीर्तितं [२] दूष्युदरं तु घोरं … |१४|
(Su. Ni. 7)

  Malignancy:  

दोषः प्रदुष्टो रुधिरं सिरास्तु सम्पीड्य सङ्कोच्य गतस्त्वपाकम् ||१५||

सास्रावमुन्नह्यति मांसपिण्डं मांसाङ्कुरैराचितमाशुवृद्धिम् |
स्रवत्यजस्रं रुधिरं प्रदुष्टमसाध्यमेतद्रुधिरात्मकं स्यात् ||१६||

रक्तक्षयोपद्रवपीडितत्वात् पाण्डुर्भवेत् सोऽर्बुदपीडितस्तु |१७|
(Su. Ni. 11)

 I think we can say that all the different causes of anemia are also mentioned in our text. It’s not that Ayurveda doesn’t mention them. The Pandu can be a complication of many of these conditions, of different varieties. It could be hemorrhoids, it could be Hritpeeda, and so on. The abnormality of the gastrointestinal tracts, or it could even be malignancy, which can be caused by the anemia. These causes are mentioned clearly in the Ayurvedic text, and the treatment also has to be accordingly. It’s not that a specific line of treatment for Pandu has to be used for all conditions of anemia. Assessment of the anemia is the important cause.

 Defieciency Anemia- Pandu Roga: 

व्यवायमम्लं लवणानि मद्यं मृदं दिवास्वप्नमतीव तीक्ष्णम् |
निषेवमाणस्य विदूष्य रक्तं कुर्वन्ति दोषास्त्वचि पाण्डुभावम् ||३||
(Su. Utt. 44)

Here we are discussing only deficiency anemia, which has become a national health program. There are critical issues to consider. One critical issue is identifying when a patient is anemic. The usual standard for hemoglobin level is considered as 14 g. However, if we screen our population, particularly the rural population, the majority of individuals will have hemoglobin levels somewhere between 11 to 12 g. Having 14 g of hemoglobin is a rare occurrence in rural areas. People believe they have iron deficiency anemia, and our national health program provides tons of iron supplements to such individuals. The reality is different. In areas with better oxygen availability in the air, the amount of hemoglobin required is lesser. The standard of 14 g hemoglobin is a Western standard based on lower oxygen availability in the environment due to low temperatures. In areas with better fresh air, the hemoglobin level does not need to be higher; it can be lower. The problem lies with the Indian Council of Medical Research, which has not established standards for Indian conditions. This issue applies not only to anemia or biological values but also to biochemical values that can vary according to the environment and living conditions. However, we continue to follow these Western standards even though the situation in our country is different. This is the real reason why rural individuals may have lower hemoglobin levels compared to urban areas like Delhi, where the hemoglobin levels are higher. It does not mean that a person in Delhi is healthier. In fact, living in Delhi poses a major problem due to lower oxygen availability, which requires a higher hemoglobin level. The perception of anemia needs to be changed, and I boldly state that this is not widely accepted by the medical field.

 There is a need to review this situation. The World Health Organization (WHO) is aware of this, which is why the criteria for anemia according to the WHO consider a range of 9-11 gm as normal. However, the Indian Council of Medical Research (ICMR), after considering the situation, has stated that 10-11 gm can be considered as moderate anemia without requiring treatment. The ICMR still maintains a higher level. This is an important issue that society is not fully aware of, and we need to be mindful of it. So, if a person has a lower hemoglobin level, we should not automatically consider them as anemic. Instead, try to understand their level and live accordingly when assessing anemia. By adjusting to their level, even anemia can be corrected to that specific level. It is not a universal standard. Therefore, I consider 9 grams as the criterion for anemia. Only patients with less than 9 grams would be considered anemic. If a person has more than 9 g but no other obvious clinical evidence, such as a patient with hypothyroidism having 9 g, then they need not be considered anemic. This is a significant issue, and addressing it can reduce the possibility of unnecessary medications being prescribed to a large number of patients. It is a crucial matter to consider.

 Global data about the incidence of anemia-  

 According to global data on the incidence of anemia, India stands out in comparison to other countries. The statistics clearly indicate that almost every Indian is categorized as part of the anemic population. The difference in the length of the line further accentuates this distinction, making it unnecessary to delve into specific figures. These statistics are sourced from authentic data on epidemiology provided by the World Health Organization (WHO). Hence, it can be concluded that the entire Indian population is categorized as anemic. The underlying reason for this categorization is attributed to the availability of better oxygen, emphasizing this crucial point.

 Classification:  

Now, when a patient presents with anemia, particularly iron deficiency anemia, it is essential to determine whether the patient truly requires an iron supplement or not. This decision is based on the patient’s reduced serum ferritin content. Only patients in this category require iron supplementation. In the first two categories, iron supplementation is not necessary. Instead, efforts can be made to improve their iron metabolism and enhance iron absorption. By doing so, the anemia can be corrected without the need for iron supplements. Therefore, iron supplementation is only required for patients with microcytic anemia, where the cell size and mean corpuscular hemoglobin concentration have decreased to less than 20%. These patients have a genuine deficiency of iron stores in their bodies and exhibit specific cellular changes. However, such patients constitute only around 15% of the population requiring iron supplementation. This means that 85% of the individuals receiving iron supplements do not actually need them. It is crucial to identify and prescribe the appropriate medication for those deserving patients, which would significantly reduce the burden on patients and healthcare resources. Unfortunately, this aspect is often overlooked. Personally, I have no hesitation in discontinuing iron tonics for any patient who comes to me with multiple prescriptions, as most of them include iron content tonics in various forms such as round blue bottles or red bottles. Instead, I emphasize the importance of providing them with a balanced diet and regular exercise to address their anemia.

 Current global data, Indian data, The National Health Program:  

Based on the current global and Indian data, as well as the National Health Program spanning from 2005 to 2015, there have been changes in the incidence of anemia. In Karnataka, there has been a notable reversal in the incidence of anemia, with a reduction of around 10%, despite the provision of tons of iron supplementation. However, in many other states, despite the substantial iron supplementation, the incidence of anemia continues to increase. This supports my argument that simply supplementing iron is not a solution for anemia. Instead, it is crucial to assess the underlying causes and provide better nourishment and dietary interventions. This highlights the futility of investing millions of rupees in the National Health Program for iron supplementation, as the impact has been minimal. While there are significant results in certain states, overall, the impact is not significant. The figures for expenditure are increasing each year, but the study over the course of 10 years shows limited effectiveness.

 Management:  

My management in a patient of anemia, as I told you in the that category where there is not much of iron deficiency. My prescription will be only Agnitundi, Arogyavardhini, Kumariasava as a Deepan, Paachan treatment. Improving the metabolism or Agni of the patient. If the Agni is improved anemia would be corrected. Rarely in those patients who have a real iron deficiency my prescription would be Punarnava Mandoora, Chandprabhavati, Draksharishta. I have in my practice. I have never prescribed iron supplemented any of the patients. But of course, if the patient is taking a real iron supplement and the patient is really of iron deficiency category, I may not withdraw the prescription only in such patients as I told you, it’s around 15% of the patients who really, they are provided with iron prescriptions. Otherwise not necessary and such a deficiency anemia can be managed effectively with our approach of the Agnimandya and treatment of the Agnimandya.

 Key points-  

  • Agnitundi
  • Arogyavardhini      for Deepan, Pachana
  • Kumari Asava

 Management for iron deficiency anemia  

  • Chandraprabhavati
  • Punarnava mandora
  • Draksharishta

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