Lecture Note: “Ayurvedic Management of Hepatobiliary Disorders” (Part-5)

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“Ayurvedic Management of Hepatobiliary Disorders”
Part-5

 Prof. Muralidhara Sharma 

based on the lecture available at
 Ayurvedic Management of Hepatobiliary Disorders 

 The description of Gomutra in Ayurveda Samhita: 

गोमूत्रं कटु तीक्ष्णोष्णं सक्षारत्वान्न वातलम् |
लघ्वग्निदीपनं मेध्यं पित्तलं कफवातनुत् ||२२०||

शूलगुल्मोदरानाहविरेकास्थापनादिषु |
मूत्रप्रयोगसाध्येषु गव्यं मूत्रं प्रयोजयेत् ||२२१||
( Su. Su. 47)

जयेदरिष्टगोमूत्रचूर्णायस्कृतिपानतः|
सक्षारतैलपानैश्च दुर्बलस्य कफोदरम्||७४|
(A.H.Chi.15)

सोपस्तम्भोऽपि वा वायुराध्मापयति यं नरम्||१७४||
तीक्ष्णैः सक्षारगोमूत्रैर्बस्तिभिस्तमुपाचरेत्|१७५|
( Ch. Chi. 13)

 The description of Gomutra in the text the same like you have all that the important is even if there is a “umstambhoapi va vayuraadhmaapyati yam narma tikshane skshaargomutrabastibhistupcharete”. Gomutra Basti is suggested in any of the patients even there is a Upstambha or obstruction symptoms mentioned in Samhita. but I don’t prescribe Basti there. I advise the patient to consume Gomutra daily.

Liver Transplantation in India:

https://www.mamcjms.in/viewimage.asp?img=MAMCJMedSci_2016_2_1_6_174841_f1.jpg

 Last part about the liver diseases and the liver transplantation. Though it’s not our area. What I would say is in initial stages, earlier stages liver transplantation was a myth. It was not practically existing. These days it is becoming popular and the incidence of liver transplantation increasing in India.

 Survival after liver transplantation 

Soin A S, Thiagarajan S. Liver transplant scene in india. MAMC J Med Sci 2016;2:6-11

The outcome is also increasing. Survival rate after liver transplantation in India is also increasing significantly. So, when a patient asks me whether they should go for a liver transplantation or not, some 15 or 20 years ago, I would have told them that there is no use. But now, I don’t use that statement. I say that they may try if they have the provision. So, it’s a costly issue. If a person can afford liver transplantation, the results have improved. I may not do it myself, but this is another part. As a responsible physician, we also have the responsibility of advising and suggesting the correct treatment options to patients. So, if there is a possibility of liver transplantation and the patient can afford it, it’s still an option for treatment. But I have seen many patients who have survived and are in a better condition for a significant period. The only thing is affordability, whether the patient can afford it or not. That’s the point where I don’t go beyond when discussing liver transplantation.

 Liver abscess: 

सर्वाङ्गप्रग्रहस्तीव्रो हृदि शूलश्च दारुणः |
श्वासो यकृति तृष्णा च पिपासाक्लोमजेऽधिका ||२२||

नाभेरुपरिजाः पक्वा यान्त्यूर्ध्वमितरे त्वधः |
जीवत्यधो निःस्रुतेषु स्रुतेषूर्ध्वं न जीवति ||२४||

हृन्नाभिबस्तिवर्ज्या ये तेषु भिन्नेषु बाह्यतः |
जीवेत् कदाचित् पुरुषो नेतरेषु कदाचन ||
२५||(Su. Ni.9)

Liver abscess has been described very clearly by Sushruta as Antarviddradhi. In the case of Yakritjanya or vidraddhi occurring in the liver, Sushruta has clearly mentioned “Swasoyakritatrishna cha pipasaklomaadhika”. The clinical features include Swasa due to the diaphragmatic strain. Liver abscess would affect the movement of the diaphragm, exactly as Sushruta has said. The outcomes of liver abscess are very clearly described by Sushruta. When the abscess bursts open, it bursts open to the superior side like “Nabheruprija pakwa yantyaurdhwamitre twadha, jiwatadho nishrutesu shrutesuurdhwa na jiwati”. If it bursts into the pleural cavity, the patient would not survive, and that statement is eternal. Even though the statement is true for a liver abscess, that the patient would not survive. However, if the liver abscess bursts into the peritoneum, the patient can survive. That’s the important part, and a better outcome is rare. If the abscess bursts open into the exterior, then the patient may survive. Sushruta has said the same. If the abscess bursts open, “Bhinnesu bahyata jiwete kadachita”. A person may survive if the abscess bursts open to the exterior and drainage occurs naturally. That’s the best possible termination. I think that would be the best description of the termination of a liver abscess, much better than any contemporary surgical text.

Now, the other part is when the patient comes with a liver abscess, the clinical signs and assessment are the important issues. Actually, the history will include pain, fever, and possibly dyspnea. Respiratory excursion will be lesser, and there will be tenderness in the right hypochondrium. Don’t expect jaundice to be a clinical sign. Investigations will show that the transaminase level is higher in a moderate degree, around 300-400, not in the thousands as seen in hepatitis. In an abscess, the transaminase level will be moderately elevated. The important issue is how to identify whether it is a pyogenic liver abscess or an amoebic liver abscess. The incidence of amoebic liver abscess is more common in our coastal area. The majority of patients with a liver abscess have an amoebic liver abscess. If you go into the interior central areas like Madhya Pradesh, Andhra Pradesh, and so on, pyogenic abscesses are also more common, and the differentiation is based on the clinical course. Amoebic abscess would usually present as a single lesion. When you perform ultrasonography, it will show a single region. Whereas, in the case of pyogenic liver abscess, there will be multiple lesions.

 The USG finding of Amoebic and Pyogenic abscess: 

The USG finding, a single lesion which is the common feature which we see in the amoebic liver abscess. Whereas in Pyogenic liver abscess it will be multiple lesions.

 Management of Liver Abscess: 

I don’t say that we can manage the patients only with our treatment. Ayurvedic treatment alone might not be enough because the course is rapid, and the patient would be in a highly toxic condition. You’ll never have a patient with a leukocyte count less than 17,000. And, as I told you many times earlier, I consider that a leukocyte count of 17,000 is the critical level for Ayurvedic treatment. So, almost every patient requires Ayurvedic treatment, and interventional treatment like aspiration may also be necessary. The discretion about whether the patient requires aspiration or not is based on clinical outcome and detailed clinical assessment. I try to skip that part because that’s something you may not do in an OPD-level practice. But prevention of recurrence is definitely possible as the incidence of recurrence of amoebic liver abscess is quite high, and we can definitely prevent it. So, immediate management, I don’t say that we can manage only with our treatment. But once the patient has been treated with Triphala Guggula, Gandhaka Rasayana, Jeerakadyrishta given to them as Antarvidraddhi or the Gulma variant, treat that patient, and I can assure prevention of recurrence. That’s the important part.

 Key points: 

  • Antibiotics/Anti amoebic necessary
  • Aspiration/Exploration as per the condition

 Prevention of recurrence- 

  • Triphala Guggulu,
  • Gandhaka Rasayana,
  • Jeerakadyrishta

 Cholecystitis: 

तृष्णा दाहो मदो मूर्च्छा तीव्रं शूलं तथैव च |
शीताभिकामो भवति शीतेनैव प्रशाम्यति ||८४||

एतैर्लिङ्गैर्विजानीयाच्छूलं पित्तसमुद्भवम् |८५|
(Sushruta. Uttartantra 42/84,85)

Now the other condition which is related to the hepatobiliary system is the cholecystitis. Cholecystitis is described by Sushruta as the Pittaja Shoola. Pittaja Shoola is the exact description where you have all those clinical features of the cholecystitis.  Cholecystitis now has become a primary subject for surgeon.

CholecystitisAcalculous

Salam H, Acute acalculous cholecystitis. Case study, Radiopaedia.org (Accessed on 21 Jun 2023) https://doi.org/10.53347/rID-18247DOI:https://doi.org/10.53347/rID-18247

So, almost many times, of course, the trend is changing, but maybe many times it happens. Like once the patient has cholecystitis, people may perceive that every patient has to be treated with surgery. But that’s not true. There is no need to treat every patient with cholecystitis with surgery. The issue is if the patient has acalculous cholecystitis, i.e., cholecystitis without the stones, I would have my own criteria, and those criteria are based upon the same universal guidelines only. It’s not only about the thickness of the gallbladder wall. If the gallbladder has not thickened beyond 5 mm, then surgery would not be required in acalculous cholecystitis. Whereas in calculous cholecystitis, the cholecystitis is accompanied by a stone, surgery is always a better option because there is a high risk of developing complications like pyemia or mucocele. So, my recommendation for a patient with cholecystitis is as follows: If the patient has a stone and cholecystitis, advise surgery. If the patient doesn’t have a stone but has developed cholecystitis, I would still continue with medical management. And only when the thickness is more than 8 mm, I would recommend surgery; otherwise, surgery is not required. It’s a universal guideline, and also, it is not required. Mucosal thickening is an important criterion to decide about that. In those patients who have biliary sludge, many times the patient may have cholecystitis, and in some cases, patients improve with medical treatment, but later they may tend to have biliary sludge. When you perform ultrasonography, you will see signs of bile stagnation, and in that condition, biliary sludge, you have to keep your fingers crossed. Some of the patients may respond, while others may not. If the patients do not respond to the treatment, again, surgery may be required. If the patient has developed complications like mucocele or a distended gallbladder, where the wall has become dissected, obviously it’s a surgical condition. There is no question of medical treatment. So, whether the patient can be managed medically or not would depend on these gray areas. If I consider them as medically managed conditions, my prescription would be Agnitundi, Arogyavardhini, Kumaryasava. Antibiotics supplementation would depend on the level of the leukocyte count. If the leukocyte count is not high, they can be effectively managed without antibiotics. There is no need for antibiotics with Agnitundi, Arogyavardhini, Jeerakadyaristha. The treatment of Pittaja Shoola would be sufficient. But if the count is higher and the patient shows toxic signs, an antibiotic course may be necessary. Selection of the antibiotic should be based on the antibiotic that will be secreted in the bile. It is not a random selection. That’s another point. I would not suggest which antibiotic it is because we are discussing in an Ayurvedic forum, but it may be necessary. You’ll have the issues. Very rarely, a patient may have gallbladder ischemia and perforation. That incidence is very low, but if there is any possibility of developing that, it’s a definite indication for surgery during the course of treatment. So, you have to be watchful about that. But at least for the first two weeks, if the patient develops that complication, it will be only in the first two weeks, like a perforation or ischemia, and the patient may have sudden severe toxemia. Rarely they occur, but it’s necessary that you have a Vata Shoola.

 Key points: 

 Management 

Antibiotics needed if total count is above 17000, IV fluids may be needed. Gall bladder ischemia, perforation and bile stasis- indication for surgery.

  • Agnitundi
  • Arogyavardhini
  • Jeerakadyarishta

 Gall stones 

कर्शनात्कफविट्पित्तैर्मार्गस्यावरणेन वा|
वायुः कृताश्रयः कोष्ठे रौक्ष्यात्काठिन्यमागतः||३९||

स्वतन्त्रः स्वाश्रये दुष्टः परतन्त्रः पराश्रये|
पिण्डितत्वादमूर्तोऽपि मूर्तत्वमिव संश्रितः||४०||

गुल्म इत्युच्यते बस्तिनाभिहृत्पार्श्वसंश्रयः|
(A.H.Ni. 11)

 Now gallstones are the other issue. Stones, the people considered is a Pittaja Ashmari. But again, it’s a theory part. I don’t consider this as Ashmari because Charaka and Sushruta have described Ashmari only in the urinary tract. But clinical symptoms of the gallstones are described in Pittaja Gulma. Pittaja Gulma is again, a point of academic debate I think will not waste much of the time on that issue. I would consider the patients of gallstones as the Pittaja Gulma.

 Management 

The management will be based on the indications. There are certain conditions where surgery is indicated. Surgery is indicated if cholecystitis is accompanied by gallstones. Asymptomatic gallstones need not be operated on immediately. The incidence of gallstones is increasing now. Earlier, it was lesser. In my practice, what I have seen is that the incidence of gallstones was higher in Northern India, particularly in Banaras. The incidence was very high. But in our area, when I started practice initially, the incidence was lower, but gradually, the incidence is increasing. Nowadays, the incidence is almost the same as that in Northern India. I don’t know the reason why, but probably what I guess is that it could be due to the universality of food habits. The food habits in southern India. Earlier, we had lesser protein consumption. But now, Chapati has become a universal diet. I’m not saying this with all the objective evidence, but my guess is that it could be due to that. But anyway, that’s another part.

But once the patient has a stone, my criteria would be if the patient has cholecystitis and multiple small stones, there is a high risk because the stone may migrate into the common bile duct and produce obstructive jaundice. The risk for surgery is highe in case of obstructive jaundice. So, it’s better to prevent the stone from moving. If the patient has multiple small stones, I would suggest surgery. As I said, if the gallbladder wall is thickened and, of course, if there are stones in the CBD, there is absolutely no question of trying medical treatment. It has to be surgical treatment because it produces an immediate complication of obstructive jaundice. Medical management is possible, particularly my preference would be if the patient is asymptomatic and has a single large stone. Single large stones are usually cholesterol stones, and cholesterol stones can be effectively managed medically. And it’s not only from an Ayurvedic point of view, even the current guidelines in the contemporary medical system also recommend the same, that medical management in cholesterol stones is suggested. So it’s not only Ayurvedic management, but there’s a condition where surgery is definitely not indicated. There is no need for surgery if it’s a single large stone, usually a cholesterol stone, and it can be effectively managed medically. And if the gallbladder is not thickened, I consider 8 mm as the criterion. The universal criterion is 5 mm, 3 mm for Ayurvedic treatment. So that’s another part.

A nonfunctioning gallbladder is definitely an indication for conservative management. Again, it’s a controversial issue. The contemporary medical system says that a nonfunctioning gallbladder with stones is high risk of malignancy. The incidence of malignancy, the time taken for the incidence of malignancy on average is 20 years, and the majority of the patients come in at the age of 50 or 60. So, 20 years after that, if the patient develops malignancy, I ask the patient the same question, How long do you want to survive? The selection of the patient, and if the patient is of a younger age, definitely those 20 years are precious. But when a patient is 60 years of age and thinking of possible complications after 20 years, the choice has to be given to the patient. In my OPD, those who I have seen, I ask the same question ‘How far do you want to survive?’ If you want to survive only up to 80 or older without disease, you can manage with our medicines. If you want to live longer, in the majority of the conditions, it will be one the later half. Rarely, you get such patients at a younger age where there will be  non-functioning gall bladder. If it’s a nonfunctioning gallbladder, in younger age of course surgery may be one of the options and my prescription in all that condition will be Arogyavardhini, Chandraprabha, Kumari Asava. Again consider this as either Pittaja Gulma or Pittaja Shoola. Pittaja Gulma is the better diagnosis.

 Key points 

 Surgical indications   

  • Cholecystitis
  • Multiple small stones
  • Thickened gall bladder
  • Stones in CBD

 Medical possibilities   

  • Asymptomatic single large stone
  • Gall bladder wall is not thickened [less than 8mm]
  • Non- functioning gall bladder

  My prescription would include following drugs-  

  • Arogyavardhini
  • Chandraprabha
  • Kumari Asava

  Post cholecystectomy syndrome  

1% of patients – Persistent symptoms
45% develop long term complications

  • Dyspepsia
  • Fat intolerance
  • Chest pain
  • USG evaluation to rule out surgical complications

Now, another area where we have some post-cholecystectomy syndrome. Patients, after cholecystectomy, almost all patients would develop one or other complications, and there is virtually no satisfactory solution in the contemporary medical system. So, one day or another, the patient has to come to an Ayurvedic practitioner. It’s mandatory, and the clinical symptoms tend to develop at a very high incidence. Though the universal statistic says that 45% develop long-term complications, I don’t say it’s 45%. It could be much higher than that. The most common symptom in all such patients who have developed these symptoms is fat intolerance. They may not be able to tolerate any fatty food, not even slightly oily contents. And virtually, there’s no other curative management in modern medical science. But with our medical management, my prescription would be Agnitundi, Arogyavardhini with Godanti, and Avipattikara or Jeerakadyaristha. If the patient has constipation, I would prefer Avipattikara. If the patient has relatively frequent stools, I prefer Jeerakadyaristha. Again, the treatment for Vataja and Pittaja Shoola will be very effective, and you will have a very satisfactory outcome. Post-cholecystectomy syndrome is an area where Ayurvedic treatment is definitely better than the other way, and the number of patients is also higher. So even if you refer a patient for surgery, there is still a scope for the patient to come back to you one day or another. That’s the point.

 Key points 

  • USG evaluation to rule out surgical complications

 Medical management 

  • Agnitundi
  • Arogyavardhini
  • Godanti+Avipathikara /Jeerakadyarishta

  Biliary dyskinesia: Udavarthar Basti  

जलद्विकंसेऽष्टपलं पलाशात् पक्त्वा रसोऽर्धाढकमात्रशेषः|
कल्कैर्वचामागधिकापलाभ्यां  युक्तः शताह्वाद्विपलेन चापि||४४||

ससैन्धवः क्षौद्रयुतः सतैलो देयो निरूहो बलवर्णकारी|
आनाहपार्श्वामययोनिदोषान् गुल्मानुदावर्तरुजं च हन्यात्||४५||
(Ch. Si. 3)

Now, it’s not a frequent incidence, but I always feel like explaining one of my clinical experiences. It was in 2002, and I still remember this very important issue. I had a patient with all the clinical symptoms of obstructive jaundice. This patient was initially diagnosed with CBD stone at KMC Manipal. However, when I looked at the MRI scan, which was done in another hospital, the patient came to us because they couldn’t afford surgery. Interestingly, an astrologer had suggested to the patient that they would die in Manipal but survive if they went to M Sharma. It was a single episode, but a very interesting one. The scan showed a diagnosis of a growth in the biliary tract, specifically the CBD growth. However, upon examining the image, I felt that it may not be a growth but rather a soft stone. So I proceeded with the cholecyststomy. Trust me, when I opened the abdomen, the CBD was open, and to my surprise, I found a live roundworm inside. I picked it up from the table, and it remained alive for about 15 minutes. Naturally, I was quite happy because we had a case where the outcome would be excellent since there was no malignancy growth as suspected. If we had a roundworm instead, the outcome would be very good. The usual procedure was followed, and a T-tube was inserted. The patient recovered very well in the postoperative period, except for CBD dyskinesia, the patient was absolutely normal. As long as the T-tube was intact and kept open, everything was normal and healthy. However, when I tried to close the T-tube after the 5th or 6th day, the patient would experience problems such as bile leakage or severe pain. This issue continued. If I kept the T-tube open, the patient would be happy with no complaints and overall good health. The only observation I made was that the pressure required for bile to flow in the CBD was higher. Typically, it’s 14 cm of water, but in this patient, it was about 40 cm of water. So, if I connected a drip bottle to the T-tube to maintain it at 40 cm of water, bile would flow easily, but at a lower pressure, it wouldn’t flow. It was diagnosed as a case of biliary dyskinesia, and the only treatment option was to dilate the sphincter through an endoscope. However, the patient was not willing to go to another hospital for treatment as I had suggested. This continued for almost 140 days, and I tried various experiments and treatments, injecting antibiotics and advising the patient to consume chicken and other things. But nothing really helped, and the situation remained the same every time, which became frustrating. It was probably one situation where I lost sleep for many days due to a patient. I felt that if the patient had died, it would have been better, but now, more than 40 years after the surgery, the patient still had the T-tube. It was a very frustrating and discouraging situation, especially because the patient was not willing to go to another hospital.

One night, I had a dream of opening Charak Samhita, Siddhi Sthana Chapter 8, where I read about Udavartdhara Basti. The very next morning, I copied that sentence and gave it to Doctor Shrikant. We prepared a simple Udavartara Basti and administered it to the patient. Within three days, the pressure of 40 centimeters decreased to 14 centimeters, and on the fourth day, I was able to remove the T-tube. The patient’s condition became absolutely normal. Now, I share this example to highlight its significance. It’s not a universal solution, but an important issue nonetheless. Biliary dyskinesia is not a very frequent occurrence, and the Udavartara Basti produced dramatic results in this particular case. The patient survived for about five years without any other complications. After five years, unfortunately, the patient met with a road accident and passed away at Manipal. However, that’s the story related to biliary dyskinesia. Additionally, Udavartara Basti has been used in many other cases of dyskinesia. While dyskinesia is a rare condition, we may encounter frequent incidences of dyskinesia in the ureter. I have personally witnessed significant results using Udavartara Basti in patients with ureteric dyskinesia and it has produced significant results.

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