Lecture Note: “Ayurvedic Management of Hepatobiliary Disorders” (Part-3)

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 “Ayurvedic Management of Hepatobiliary Disorders”
Part-3

 Prof. Muralidhara Sharma 

based on the lecture available at
 Ayurvedic Management of Hepatobiliary Disorders 

Counseling about the patient for the possible risk to others also are the same issue.

  Incidentally identified cases  

This is about incidentally identified patients, and the incidence of such patients is quite high. Asymptomatic patients testing positive for HBsAg are now prevalent worldwide, not only in India. The total incidence is approximately 400 million people, which accounts for almost 5% of the global population. These individuals are at risk of developing the carrier state, where the source of infection may not be identified. It could be due to hospital transmission or their sexual behavior, among other factors. This has become a significant problem globally, and there is currently no definitive solution. There was another energetic treatment involving neutralizing immunoglobulins, but it has proven unsuccessful and is no longer practiced. The global recommendation, according to WHO, focuses on diet, lifestyle, and the restriction of disease spread. Counseling patients and advising their family members on measures such as physical separation, particularly in terms of sexual activity and the use of condoms, are suggested. However, there is currently no specific curative management available. Therefore, if we standardize our treatment and demonstrate improved results, there is potential to establish ayurvedic treatment as an effective approach.

 Inactive HbsAg carriers: 

De Franchis R, Meucci G. Vecchi M, et al. The natural history of asymptomatic hepatitis B surface antigen carners. Ann intern Med 1993;118:191-4,

As I mentioned before, there are inactive HBsAg-positive cases that can be of different varieties. Some may have HBeAg positive, while others may have HBeAg negative. The HBeAg positive cases carry a higher risk. This assessment is conducted in many patients to determine their risk of developing complications. In contrast, those who are HBeAg negative have a lower risk of complications. So, if there is a possibility, when a patient tests positive for HBsAg, the next level of processing involves assessing HBeAg and HBe status. HBeAg positivity suggests a more active pathology and higher risk for complications. There are no other advantages to this investigation. The cost of conducting HBeAg and HBe tests is around 2000 rupees. If the patient can afford it, it can be done to predict the likelihood of higher risk. However, beyond that, there is not much advantage in further investigations.

 Management 

Now, as I mentioned earlier, the management remains the same for many patients. However, I have observed that Virechana with Panchatikta Guggulu Ghrita has also been helpful in some cases. But again, the results are not very predictable or dependable. If the patient is otherwise healthy, I do try these treatments such as Panchatikta Guggulu Ghrita Snehana and Virechana. In approximately 30-40% of the patients, I have seen them test negative after this management. Occasionally, if the patient has symptoms like Jwara (fever) or weight loss, instead of Mritunjaya Rasa, I consider using Lakshminarayan Rasa, considering the possibility of Dhatugata Jwara. Some patients may present with such symptoms, and this alternative line of treatment can continue for several years, even up to three or four years. When a patient comes to me, I usually advise them to continue the treatment for three years. However, I do explain the possibility of no outcome at all. I have patients who have been under follow-up for more than 20 years. If the patient has not developed hepatocellular carcinoma even after 20 years, I can claim it is due to the treatment. But honestly, I don’t know whether the treatment has truly produced this advantage or not. So, the effectiveness of the treatment remains a significant area of uncertainty.

 Key points 

 Management: 

  • Screening of family members, Counselling, Diet and exercises
  • Virechan using Panchatiktaka Guggulu Ghrita for Snehana,

 Internal medication would include 

  • Arogyvardhini
  • Laxminarayan Rasa,
  • Kumari Asava                       3 years

 Hepatitis C- 

MJ Semin Liver Dis 1995; 15: Management of Hepatitis C NIH Consensus Statement 1997; March 24-26:15(3). 41

Now, Hepatitis C is not yet popular in usual clinical practice, but in the next few years, it will become a disease of the future. Every practitioner has to be aware of Hepatitis C, and Hepatitis C virus screening will become universal. The important variation with Hepatitis C is that it is transmitted through blood and blood products. As I initially mentioned, during our study, it was believed to be a complication of dialysis treatment only. However, it is now known that transmission can occur not only through dialysis treatment but also through short-duration exposure to infected body fluids. The clinical presentation of Hepatitis C is quite vague, and patients may not exhibit any symptoms for a long period. The total incubation period is quite long, and unlike other viral hepatitis types, the initial clinical presentation does not include features like fever or jaundice. The most common clinical presentation involves arthralgias, which are characterized by vague symptoms such as joint pain and numbness. These symptoms are usually categorized as neuritis-like conditions or pruritic skin manifestations. This is one of the important and misleading usual clinical presentations in that condition.

 Initial extrahepatic symptoms 

  • Arthralgias
  • Paraesthesia
  • Myalgias
  • Pruritus

ततः शोणितजा रोगाः प्रजायन्ते पृथग्विधाः ।
मुखपाकोऽक्षिरागश्च पूतिघ्राणास्यगन्धिता||११||

गुल्मोपकुशवीसर्परक्तपित्तप्रमीलकाः।
विद्रधी रक्तमेहश्च प्रदरो वातशोणितम् ||१२||

वैवर्ण्यमग्निसादश्च पिपासा गुरुगात्रता ।
सन्तापश्चातिदौर्बल्यमरुचिः शिरसश्च रुक् ||१३||

विदाहश्चान्नपानस्य तिक्ताम्लोद्गिरणं क्लमः ।
क्रोधप्रचुरता बद्धेः सम्मोहो लवणास्यता ||१४||
|(Charak Sutrasthana 24/11,12,13,14)

 Secondary symptoms 

  • Hand signs: Palmar erythema, Dupuytren contracture, asterixis, leukonychia, clubbing
  • Head signs: Icteric sclera, temporal muscle wasting, enlarged parotid gland, cynosis
  • Fetor hepaticus
  • Gynecomastia, small testes
  • Abdominal signs: Paraumbilical hernia, ascites, caput medusae, hepatosplenomegaly, abdominal bruit
  • Ankle edema
  • Scant body hair
  • Skin signs: Spider nevi, petechiae, excoriations due to pruritus

Sushruta categorized this as Shonitaja Vyadhi, where the set of symptoms could include Mukhapaka, Akshiraga, Putighrana, and so on. These symptoms are quite vague, and the patient may have a general feeling of unwellness. The symptoms vary widely and are difficult to manage and assess. The current WHO guidelines state that every patient should be screened for hepatitis C. However, such guidelines have not yet been issued in our country. I expect that in the next one or two years, such guidelines will be developed at higher policy levels, and we will need to be more aware of hepatitis C. Another crucial aspect I follow in my clinical practice is when a patient presents with a clinical sign that is neither psoriasis nor eczema.

 Dermatological manifestation of Hepatitis C: 

There are signs of hyperkeratosis, with the skin being thickened, and there are itching rashes that suggest the need for hepatitis C screening. A good number of patients may be hepatitis C positive, based on what I have observed in my clinical practice. These patients exhibit skin manifestations that are difficult to categorize as either eczema or psoriasis, and they are often seen in areas with thickened keratin tissue, at the plantar or palmar areas. If you conduct a hepatitis C screening, it may yield positive results. I’m not saying every patient will test positive, but it is an important clue that can help us identify the condition. Currently, this practice is limited, but in the future, every patient may need to be screened for the Hepatitis C virus. These skin manifestations are significant in hepatitis C.

 Management

My treatment would consist of Kaishora Guggulu, Arogyavardhini, and Manjisthadi, considering this as a Vata-Pittaja Kustha variety. Virechana would also be included. Typically, Panchatikta Guggulu Ghrita is used for Snehana, which can provide symptomatic relief to patients. However, I am unable to screen the patient to determine whether the hepatitis C immunoglobulin has become negative afterward. Therefore, only a few patients may fall into the category of those treated for this condition. Nonetheless, this remains a critical issue in cases of Hepatic pathology.

 Key points for medical management: 

  • Kaishora Guggulu
  • Arogyavardhinni
  • Manajisthadi
  • Virechana

 Alcoholic liver disorder: 

on 30/06/2023)

According to the WHO, alcoholism is highly prevalent, accounting for 3.8% of global mortality. For every 100 deaths, 3.8 deaths are attributable to alcohol-related issues, and these fatalities occur almost daily. Liver disease represents 9.9% of deaths related to alcohol consumption. However, it’s important to note that alcoholism does not solely affect the liver but can impact other organs as well. While I won’t delve into those details, it’s crucial to understand the liver pathology induced by alcoholism and its overall prevalence. The best approach to preventing such issues is to avoid alcohol altogether, although it can be challenging for individuals accustomed to its consumption. Additionally, the onset of liver disease due to alcoholism is unpredictable; initially, for many years, everything may appear normal.

Lazo, M., Mitchell, M.C. (2016). Epidemiology and Risk Factors for Alcoholic Liver Disease. In: Chalasani, N., Szabo, G. (eds) Alcoholic and Non-Alcoholic Fatty Liver Disease. Springer, Cham. https://doi.org/10.1007/978-3-319-20538-0_1

You may not find anything abnormal. The other factors may increase the risks. When conducting liver function tests, every other test may appear normal, except for marginally raised transaminase levels. Instead of being 35 or 40, they may be 80 or 90, which is not extremely high. Many times, these elevations can go unnoticed. Additionally, alkaline phosphatase levels being raised is an initial sign of increased risk. The rest of the parameters are normal, with only a marginal increase in alkaline phosphatase. In such cases, we can treat the patient who has a high risk of alcohol-induced pathologies. However, the next stage is fatty liver, which can be identified through ultrasound imaging. Fatty liver pathologies are now prevalent, even among non-alcoholic patients. The causes of fatty liver can vary, including factors such as diet and lifestyle choices. Interestingly, a well-known hepatologist from Kerala has mentioned that Ayurvedic medicines can contribute to fatty liver. He presented a paper with a history of patients who had taken Ayurvedic medicines and developed fatty liver. So, almost every patient with fatty liver pathology would have consumed these Ayurvedic drugs at some point in their life. Contextually, I would like to mention another issue. Three months ago, there was a broadcast on India Today TV discussing the initiatives in Ayurvedic treatment by the central government. During the discussion, a hepatologist from the All-India Institute of Medical Science mentioned four cases of acute hepatic failure linked to Ayurvedic medicines. This led to a lot of criticism of Ayurvedic medicine. I wrote an email to him, stating that I had treated 400 cases of hepatic failure due to contemporary medications. He had the courtesy to accept and issue an apology. The situation eventually cooled down. However, such incidents of negative publicity do exist, and at times, we may have to defend ourselves .

We encounter this risk frequently. Many times, patients may not have been aware of their fatty liver condition before seeking treatment for other reasons at different hospitals. And when they mention having received Ayurvedic treatment, some people may attribute the fatty liver to Ayurvedic medicine. So, in such situations, we may need to be assertive. That’s the main point I want to emphasize. I understand that fatty liver is not always caused by alcohol. However, once a patient has fatty liver changes and alcohol is the cause, it is crucial for the patient to withdraw from alcohol. A fatty liver patient can be managed throughout their life without significant events, and it is possible to prevent the progression of fatty liver with our treatment. This would be a major contribution achievable through our treatment. However, once it progresses to the next stage of fibrosis, avoiding alcohol does not have a significant impact in the long run. So, when fibrosis occurs, whether the patient avoids alcohol or continues to consume it, the outcome is almost the same. At that point, the choice is left to the patient because, at times, the patient may be so addicted that they are unable to stop. Moreover, there is not much advantage in stopping alcohol consumption at that stage. I don’t directly counsel patients about this, but I may indirectly suggest the same. Once the patient has developed cirrhosis, it is an irreversible condition, and there is no question of any treatment. The progression of cirrhosis is gradual, and the time taken for progression is unpredictable. It may progress rapidly in some cases and slowly in others. Again, I don’t have concrete statistical data, but based on my observations, patients with Pitta Prakriti are highly sensitive to alcohol and tend to develop alcohol-related complications earlier. On the other hand, patients with Kapha Prakriti tend to tolerate alcohol better. However, this does not mean that people with Kapha Prakriti can consume more alcohol. It is always better to avoid it altogether. But this is what I have observed personally, and I don’t have obvious statistical or structured data. Nevertheless, it is an area where we can make observations and potentially achieve positive outcomes. That covers the other aspect.

  Description of the Panatya and the complications of alcoholism:  

पानात्ययं परमदं पानाजीर्णमथापि वा |

पानविभ्रममुग्रं च तेषां वक्ष्यमि लक्षणम् ||१७||

ऊष्माणमङ्गगुरुतां विरसाननत्वं श्लेष्माधिकत्वमरुचिं मलमूत्रसङ्गम् ||१९||

लिङ्गं परस्य तु मदस्य वदन्ति तज्ज्ञास्तृष्णां रुजां शिरसि सन्धिषु चापि भेदम् |२०|

आध्मानमुद्गिरणमम्लरसो विदाहोऽजीर्णस्य पानजनितस्य वदन्ति लिङ्गम् ||२०||

ज्ञेयानि तत्र भिषजा सुविनिश्चितानि पित्तप्रकोपजनितानि च कारणानि |२१|

हृद्गात्रतोदवमथुज्वरकण्ठधूममूर्च्छाकफस्रवणमूर्धरुजो विदाहः ||२१||

द्वेषः सुरान्नविकृतेषु च तेषु तेषु तं पानविभ्रममुशन्त्यखिलेन धीराः |२२|

हीनोत्तरौष्ठमतिशीतममन्ददाहं तैलप्रभास्यमति(पि)पानहतं विजह्यात् ||२२||

जिह्वौष्ठदन्तमसितं त्वथवाऽपि नीलं पीते च यस्य नयने रुधिरप्रभे च |२३|
( Sushruta Uttartantra 47/19-23)

Our text provides a comprehensive description of the possible complications of Panatya, including all varieties starting from simple conditions like Virsananatwama and Angaguruta, which fall under general heaviness and so on. Towards the end, the text covers even more severe complications like deep jaundice and Halimaka. In such cases, the patient may exhibit various other symptoms, such as urine with an oily appearance (Tailaprabhasyama) and even reddish eyes (Pittam nayana rudhira prabhe). Sushruta did not mention ultrasonography findings because it was not available during that period.

The other part bit of the other issues the statistics issue prevalence of alcohol use is quite high and generally, a general notion is the incidence is not common among women.

 Burden of disease in India 

But the recorded incidence of alcoholism among women in India is 9%. I underline the word “recorded” because there are many unreported cases. Usually, wives complain about their husbands’ alcoholism, but they may not reveal their own discreet alcohol consumption, such as consuming the leftover bottle. So, that’s not the point. The important point is that when a female patient comes in, we may not always consider alcoholism as a cause, but that’s not always true. However, it is true that the incidence is higher among males than females.

 Alcohol consumption in India 

The alcohol consumption in India is rapidly increasing and this is the data of 2011. Now, if you collect the data beyond 2011, the graph is still vertical and it’s throughout the country. It’s not only in one state.
It’s not a very important issue, but still, you have to be aware of that. While alcoholism has become so prevalent and is rather encouraged, it’s a major source of revenue for all governments. I have collected data from some authentic sources regarding the revenue sources for each state. Tamil Nadu has the maximum revenue based on data from 2015-16. The trend has remained the same throughout the years. Interestingly, Punjab has a lower financial outcome despite having the highest incidence of alcoholism. The reason is that tax rates are lower in Punjab, while they are higher in Tamil Nadu. However, there is another important issue   that is the allocation of revenue for the prevention and treatment of alcoholism. It is part of our health program, the Prevention and Management of Alcohol-Induced Diseases, which is one of the National Health Programs. The budget allocated for this program is gradually reducing. These are the issues we need to be conscious of as taxpayers. Regardless of whether you consume alcohol or not, a portion of the taxes you pay goes towards this. Therefore, we naturally have the right to ask about this issue. The budget allocated for alcohol prevention or the management of alcohol-related conditions has been gradually diminishing from 2014 to 2017. All this data is authentic. The number of beneficiaries has markedly reduced. For example, in 2017, the total number of beneficiaries in India was only 49,000, despite there being crores of alcoholics. I’m not suggesting any remedy or anything like that, but it’s an issue we need to be aware of, even if it’s not directly related to our day-to-day activities. However, I believe we should be aware of these policy issues and, whenever there is an opportunity, we should highlight these policy errors. If the policy errors are corrected, it could potentially benefit the common man.

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