Lecture Note: “Ayurvedic Management of Hepatobiliary Disorders” (Part-4)

“Ayurvedic Management of Hepatobiliary Disorders”
Part-4

 Prof. Muralidhara Sharma 

based on the lecture available at
 Ayurvedic Management of Hepatobiliary Disorders 

 Management of the patients of alcohol-induced conditions 

From a management point of view, when managing patients with alcohol-induced conditions, some people believe that there are drugs to prevent alcoholism. However, I do not prescribe or advise any medicines to prevent alcohol consumption. The only thing that matters is the patients’ willpower. Antabuse, which is very popular as an alcohol-preventing de-addicting drug, is very harmful. Although there are many de-addiction camps and de-addiction is a popular job source, I use the term “job source” in a specific context. Counseling is beneficial, but drugs used for preventing alcoholism can be very dangerous. They are a double-edged knife, so I do not suggest using any of them. Some people, including Ayurvedic practitioners, claim to have solutions like Shrikhandasava, but in my view, no drug can truly prevent a person from consuming alcohol except Antabuse, which is harmful. Regarding Ayurvedic drugs, I do not prescribe any to prevent alcoholism. I only advise individuals to have willpower. With willpower, we can definitely help. Withdrawal from alcoholism can lead to complications such as sleep loss, tremors, anxiety, etc., which can be effectively managed with Smritisagar Rasa. I do prescribe Smritisagar Rasa, Saraswatarishta, or occasionally Taildhara or Matrabasti to individuals who have withdrawn from alcohol but experience anxiety or similar symptoms. This management is not crucial for preventing alcoholism; it is merely symptomatic management of alcohol withdrawal symptoms. For alcohol-induced pathology ,Iusually prescribe the same Arogyavardhini, Kamdugha, depending on the presentations. Tremors are a common symptom of alcohol withdrawal and often indicate Vata Prakopa. In some cases, patients may experience dyspepsia and nausea, which are symptoms of Pitta Prakopa. In such situations, I may prescribe Kamdugha. The majority of alcohol withdrawal symptoms can be safely managed if the patient has the willpower. Alcohol withdrawal itself is not a risky issue, unlike drug addiction with substances like opium derivatives. It does not pose any critical risks and can be managed only if the patient has the willpower. In rare cases, alcohol withdrawal may result in hypoglycemia. However, it is not directly caused by alcohol withdrawal; it can be triggered when individuals who have been abstaining from alcohol suddenly consume large amounts. These patients may experience severe hypoglycemia due to acute alcoholism. They frequently visit hospitals in such conditions, and there is no other remedy besides administering immediate IV glucose, which becomes a life-saving measure. The incidence of such cases is increasing day by day. Nowadays, I have noticed more of these incidents compared to the past. They often occur during the first week of January, New Year’s Day celebrations, or sometimes during the third week of January, particularly after the Ayyappa Yatra. During the Ayyappa Yatra, individuals are forced to withdraw from alcohol, but on their return journey, they often consume excessive amounts, leading to complications of acute alcoholism-induced hypoglycemia. These complications are more frequent during festival seasons, such as Diwali, and also during wedding seasons. When a patient with altered consciousness is brought to the hospital, one of the important steps is to check their blood sugar level. If the blood sugar level is low, we start administering immediate glucose, and many times the patient recovers. This can help differentiate between a stroke, cerebrovascular pathology, or alcohol-related issues. This distinction is particularly important during festival seasons and even during other seasons when there is marriage at home.So these are the issues incidences where you’ll have that acute alcoholism binges.

 Key points 

 Management- 

Alcohol withdrawal, diet and exercise

 Symptomatic management of alcohol withdrawal symptoms 

Smritisagar Rasa, Saraswatarishta or occasionally Taildhara or Matrabasti.

 For alcohol-induced pathology 

Arogyavardhini, Kamdugha

 Non alcoholic fatty liver pathology: 

Singh, Divya & Das, Chandan & Baruah, Manash. (2013). Imaging of non-alcoholic fatty liver disease: A road less travelled. Indian journal of endocrinology and metabolism. 17. 990-995. 10.4103/2230-8210.122606.

Tolman KG, Dalpiaz AS. Treatment of non-alcoholic fatty liver disease. Ther Clin Risk Manag. 2007;3(6):1153-1163.

This is another critical problem we face, as the incidence is increasing quite rapidly. Although I haven’t mentioned it yet, the cause is often the excessive use of drugs by the patients who are dependent on them. Patients rely on medications for every little thing, resulting in multiple pages of prescriptions. Such patients are prone to developing complications due to the combination of contemporary drugs they take. Individually, these drugs may not be hepatotoxic, but when taken together, they can lead to various unexplained conditions, including hepatic damage. Many times, there may be no clinical symptoms, and the symptoms that do appear can vary widely, encompassing a range of conditions. The patient may appear to be healthy, or they may exhibit general symptoms such as weight loss or sudden weight gain. These symptoms can be attributed to fatty degeneration, and upon palpation, no abnormal findings may be detected. However, an ultrasound (USG) may reveal the presence of abnormalities. Additionally, biochemical tests may show normal results in a large number of patients, making these conditions quite challenging to diagnose. Among the various critical causes, obesity stands out as a significant factor. Patients who are obese have a high likelihood of developing fatty degeneration. Additionally, patients with intestinal disorders or chronic colitis-like conditions are also at risk. Another contributing factor to fatty liver is pregnancy, especially multiple pregnancies. These are crucial conditions that require careful treatment. One of the notable drugs known to cause fatty degeneration is Valproic acid, commonly used for treating seizure disorders. The incidence of fatty degeneration due to Valproic acid is significant, and considering the long duration of treatment, dosage review becomes crucial. It is necessary to regularly monitor liver functions and adjust the dosage if needed. Discontinuing the drug abruptly is not easy as it can worsen seizures. In such cases, I review the dosages and supplement the patients with Smritisagar, Arogyavardhini, and Saraswatarista. With this approach, many patients can be effectively managed, and complications can be avoided. This area poses a critical challenge in clinical practice. While all drugs are important, this particular aspect often leads patients to seek Ayurvedic management, which is how I approach it.

 Cirrhosis 

Cirrhosis is a common complication of the liver. Traditionally, cirrhosis has been considered a reversible pathology characterized by necrosis, fibrosis, and regeneration. According to guidelines, the diagnosis of cirrhosis should be confirmed through a biopsy. However, I believe that biopsy is not always mandatory, as ultrasonography alone can often reveal the presence of cirrhosis. One of the most significant indicators is a reduced level of albumin in the patient, even in the absence of other obvious evidence of cirrhosis. In such cases, we can reasonably assume that the patient has cirrhosis. I do not consider biopsy as an essential requirement for diagnosis. Although it is universally recommended that cirrhosis should be diagnosed through biopsy, liver biopsy carries multiple risks, especially in patients with existing cirrhosis. The risks associated with liver biopsy are considerably higher. Therefore, I do not recommend biopsy for all patients, unless they have already undergone the procedure. However, my recommendation regarding biopsy may deviate from the usual guidelines

 Radiological evidence of Cirrhosis: 

The radiological evidence of ultrasonography that changes is enough to make the diagnosis and the most crucial part is whether there is evidence of the portal hypertension or not. The blood flow in the portal circulation is the crucial issue.

 Causes for cirrhosis- 

 The causes of cirrhosis are numerous, and it is often challenging to identify the specific cause. Viral hepatitis, especially B and C, can lead to cirrhosis over time, making it a crucial concern. Additionally, drug-induced pathologies and autoimmune disorders are significant contributors. Patients with autoimmune pathologies like sclerosing cholangitis or rheumatism can rarely develop cirrhosis, although this is not frequently reported. I have observed cirrhosis in many patients with rheumatism, whether it is due to the condition itself or the treatment, such as hydroxyquinoline, which is commonly prescribed for rheumatism. However, determining the exact cause remains uncertain. The causes of cirrhosis are diverse, and in most cases, the exact cause cannot be identified. The question arises whether it is necessary to emphasize identifying the cause or not. While there may be extensive efforts to identify the cause, effective management may still be lacking. I don’t mean to suggest that the causes should not be considered, but it depends on the patient’s financial status. If a patient has limited resources, I won’t prioritize identifying the cause, as the ultimate outcome and treatment would remain the same. Therefore, I have treated many cirrhosis patients without precisely knowing the exact cause. Although this approach may go against ethical guidelines, it is possible to manage and achieve satisfactory outcomes for patients even without strict adherence to those guidelines.

 Pugh scoring technique 

The most common cause of cirrhosis is considerably alcoholism, but it’s important to note that non-alcoholic cirrhosis is also quite common. Therefore, when asking patients about their alcohol intake, practitioners should not assume that the patient is hiding an alcoholic habit. The grading of cirrhosis is crucial when selecting patients for treatment. Some patients may be critical and cannot be managed with medicines alone. To determine this, I use the popular Pugh scoring technique.

The Pugh scoring technique is a simple method of assessing clinical factors. For example, when there is no encephalopathy, one point is given, while significant encephalopathy warrants three points, increasing the grade accordingly. Ascites also contributes to the grading. If a patient with cirrhosis develops hyperbilirubinemia with a total bilirubin level exceeding three or four, it is considered a high-risk case. Additionally, the levels of bilirubin in both urine and total bilirubin are important factors.

However, one critical indicator is the level of albumin. A lower albumin level indicates greater severity. Grade three conditions have a very poor outcome with our management, often resulting in fatal complications. On the other hand, grade one conditions are more easily managed. Therefore, I always prefer to treat patients in grade one. While I don’t refuse treatment for grade three patients, the prognosis can be predicted as poor, with hepatic transplantation being the only possible curative option.

 The course of the disease and the development of the complications 

Hepatitis, the cirrhosis can even result in the hepatocellular carcinoma or even it can result in a fatal complication. The time taken for that disease and the incidence of the disease also is increasing these days. Hepatic cell carcinoma incidence is somewhat now lesser. But cirrhosis is resulting in a fatal complication. Otherwise in India is increasing rapidly these days. Again, the causes will not go into that issue of the causes but cirrhosis is a burning problem.

 Description of cirrhosis in our texts 

कोष्ठादुपस्नेहवदन्नसारो निःसृत्य दुष्टोऽनिलवेगनुन्नः ||६||

त्वचः समुन्नम्य शनैः समन्ताद्विवर्धमानो जठरं करोति |७|

यच्चोषतृष्णाज्वरदाहयुक्तं पीतं सिरा भान्ति च यत्र पीताः ||९||

पीताक्षिविण्मूत्रनखाननस्य पित्तोदरं तत्त्वचिराभिवृद्धि |१०|

दकोदरं कीर्तयतो निबोध |

यः स्नेहपीतोऽप्यनुवासितो वा वान्तो विरिक्तोऽप्यथवा निरूढः ||२१||

पिबेज्जलं शीतलमाशु तस्य स्रोतांसि दुष्यन्ति हि तद्वहानि |

स्नेहोपलिप्तेष्वथवाऽपि तेषु दकोदरं पूर्ववदभ्युपैति ||२२||

स्निग्धं महत् सम्परिवृत्तनाभि भृशोन्नतं पूर्णमिवाम्बुना च |

यथा दृतिः क्षुभ्यति कम्पते च शब्दायते चापि दकोदरं तत् ||२३||
(Su. Ni 7/21,22,23)

Though cirrhosis is not directly described in our text, the complications of ascites formation are discussed in the context of Jalodara. Jalodara is an exact manifestation of portal hypertension, which leads to the accumulation of fluid in the abdomen, resulting in complications. The verse ‘kosthaupsnehaavdnnaasaro nrisatya dustoanilavegaunaah’ suggests that it causes the accumulation of fluid in the abdomen and leads to complications. Additionally, cirrhosis can also present with the clinical features of Pittodara, where the patient may experience jaundice. Therefore, cirrhosis may manifest with either ascites formation or ascites with associated jaundice, referred to as Jalodara or Pittodara respectively. Both Jalodara and Pittodara are considered as Asadhya conditions in Sushruta. Hence the outcome would be always poor.

 Risk assessment and management 

The most important issue in the management is if there are esophageal varices. The patients who have esophageal varices with cirrhosis are high-risk conditions. Nobody can predict when the patient would develop bleeding, and bleeding from the esophageal varices is very acute and life-threatening. It has to be an emergency condition, so when a patient presents with varices, I would suggest the patient go for interventional treatment, either clipping or sclerosing therapy. I don’t perform clipping for varices even though I have an endoscope because it’s a high-risk procedure. Placing a clip slightly out of the area can result in bleeding right on the table, making it a high-risk potential condition.

So, if a patient with cirrhosis and varices comes in, I do perform an esophagus scope. If varices are present, I would not negotiate going beyond that area with the esophagus scope. Once there are varices, I withdraw my esophagus scope, refer the patient to another hospital, and only after clipping has been performed, I may treat the patient. Now, once the patient has had this clipping to prevent the recurrence of bleeding, and of course, prevent the recurrence of varices, my choice of treatment is Arogyavardhini, Kamadugha, Usheerasava. It’s a variant of Raktapitta, managed along the lines of Raktapitta variation, and it’s not a treatment for esophageal varices. I consider this as a prevention of the recurrence of varices. If a patient has varices, I would always recommend the patient for primary treatment elsewhere, and then to prevent the recurrence, which can be done. And with this, effectively, we can prevent the condition as such. Of course, varices tend to recur quite frequently even after the interventional treatment. When a patient has fluid accumulation in the abdomen, such as ascites, the primary treatment will be Arogyavardhini and Kumaryasava. But along with that and following the principles of Jalodara Chikitsa, I would add Punarnava Mandura and Punarnavasav.

One of the very significant advantages or significant beneficiary lines of treatment that I use is Gomutra with Triphala Churna. Fresh Gomutra collected daily with Triphala churna is what I prescribe. Gomutra Arka, which is available in the market, will not have the same results. I have observed both.Many times, the Gomutra Arka would produce more irritation, whereas fresh collected Gomutra would definitely be beneficial. So, we have Gomutra provision in our hospital. They have established that part, but the problem arises when the patient goes home, and in urban conditions, the patient may not be able to have that Gomutra. So, it depends on whether the patient is able to do that or not. With the Gomutra and Triphala, one of the important issues is the first week. I keep the patient in the hospital. I don’t advise the patients to take Gomutra at home because I have observed a good number of patients who, when we start with the Gomutra, there is a possibility of widespread peritonitis within one week.If the patient has tolerated Gomutra for one week, the chances of peritonitis developing are lesser. Maybe it could be one of the possibilities of tests like whether the outcome would be poor or not.If a patient develops peritonitis, the outcome would be very poor, and the complications will be very serious. So, I do keep it as a rule that when I start with the Gomutra in a patient with cirrhosis, for the first week, I keep the patient in the hospital, observe daily, and only when I’m sure that the patient has not developed peritonitis, I discharge the patient and allow them to take it at home.Rarely do I advise the patient to take Gomutra at home as this is another crucial issue. Gomutra may not be a universally safe prescription, but once the patient has become accustomed to it, the results will be dramatically good.I have many patients where the results are dramatically good, including huge ascites completely resolving, patients looking normal, and even having to change their pants and shirt.Such incidents are not rare. We have plenty of cases, but the major problem is the predictability to exactly predict in which patients the outcome would be very difficult. But I have already discussed some of those issues which I consider as the possibility of predicting the prognosis.

  Key points

 Esophageal varices and bleeding-  Acute emergency, interventional treatment necessary

  Prevention of recurrence-

• Arogyavardhini
• Kamdugha
• Usheerasava

 Symptomatic management of fluid accumulation 

• Punarnava Mandoora
• Punarnavasav
• Gomutra with Triphala Churna (Risk of peritonitis)