Jaundice With Alcoholic Liver Disease – A Clinical Case Presentation

Article by Dr Raghuram Y.S. MD (Ay) & Dr Manasa, B.A.M.S
Disclaimer: For the use of qualified Ayurvedic doctors only. Do not use this information for self treating yourself or others. 
In this article I am presenting a case discussion on Kamala i.e. Jaundice (associated with Alcoholic Liver Disease, ALD) which was a part of academic and clinical protocol. The patient was a chronic alcoholic addict but presented with body pains, leg pain, loss of appetite and tiredness.

During clinical examination he was diagnosed to have jaundice. Though we could figure out that it could be related with his alcoholism and erratic eating habits and living conditions (ALD), we had to treat the condition on the lines of Kamala vis-à-vis Kamala. This is because we do not have a direct reference for Alcoholic Liver Disease and its management in Ayurveda and Kamala is a closer condition which resembles the clinical picture of ALD (in this condition) and also that the patient had jaundice.
Read related: Kamala Roga Chikitsa: Liver Disorder Causes, Symptoms, Treatment

Preamble for case presentation

Case Presentation – Clinical Diagnosis and Treatment of Kamala vis-à-vis Jaundice

Case diagnosed and treated at – Out Patient Department and In Patient Department at Aroor Laxmi Narayana Rao Memorial Ayurvedic Medical College, Koppa, Kachgal Road, Koppa, Chikmagalur District, Karnataka State, South India.

Doctor In charge – Dr Keshav Rao, Associate Professor, Post Graduate Department of Kaya Chikitsa (General Medicine), ALN Rao Memorial Ayurvedic Medical College Koppa

Case Documented and Presented by – Dr Divya, II year Post Graduate Scholar, PG Department of Kaya Chikitsa, ALN Rao Memorial Ayurvedic Medical College, Koppa

Place of presentation – Audio Visual Room, Post Graduate Department of Kaya Chikitsa, ALN Rao Memorial Ayurvedic Medical College, Koppa
Read related: Fatty Liver: Symptoms, Ayurvedic Treatment, Remedies, Tips

The Case Presentation

Chief complaints at admission – A Hindu male patient named Praveen (name changed), aged 22 years, presenting with complaints of pain in calf muscles, body pain, weakness and loss of appetite since 1 month was admitted as an inpatient in the college Hospital of ALN Rao Memorial Ayurvedic Medical College on 20^th January 2018.

Brief history of illness – The patient reported that he was apparently healthy 1 month ago. He developed calf pain which gradually increased. The pain would vanish on rest. Later he developed loss of appetite. He could not eat much food or in appreciable quantity. This led to weakness and body pains. 15 days later he happened to note some color changes in his eyes. The eyes got yellowish. In a later period the body pains worsened. He also had fever with chills. He went to a nearby doctor and was symptomatically treated. The fever got reduced but the other complaints persisted. He came to the college OPD since he was told about Ayurvedic remedies by a close friend of his. When he was thoroughly examined by Dr Keshava Rao and his team in the OPD, the yellowish discoloration of the eyes (sclera), nails and palms were clearly evident. The patient was advised to get admitted as an inpatient so that he could be comprehensively addressed.

History of previous illness – The patient had suffered from Jaundice 8 years ago. There was no history of any other chronic or acute ailments.

Everyone in the family was reportedly healthy and the treatment details of the current illness couldn’t be procured.

Personal History –

• Ahara (food) – vegetarian and non vegetarian, more curds and pickles
• Agni (appetite, digestion, metabolism) – manda / alpa (sluggish appetite and weak digestion)
• Mala (bowel) – once a day
• Mutra (bladder, urination) – 2-3 times a day, slightly yellowish discoloration
• Nidra (sleep) – prakrita (normal)
• Vyasana (habits) – addicted to alcohol since many years, chews tobacco often, drinks lot of coffee (10-12 servings per day)

Professional history – The patient is a cook (chef) by profession

Rogi Pareeksha

Rogi Pareeksha (examination of the patient)

Dasha Vidha Pariksha (10 fold examination)

Prakriti (constitution) – Vata-Pitta
Vikriti (morbidity) – Pitta vitiation
Sara (essence of tissues) – Madhyama (moderate)

Samhanana (integrity, composure, compactness) – Madhyama (moderate)
Pramana (quantity, measurements, dimensions of tissues and organs) – Height: 175 cm, Weight: 56 Kg
Saatmya (suitability, compatibility of tastes, homologation) – Amla (sour), Katu (pungent) rasas (tastes)
Sattva (mind, psyche, mental faculties) – Madhyama (moderate)

Ahara Shakti (capacity of intake of food) –

• Abhyaharana Shakti (capacity of intake): Gunataha (quality) – Madhyama (moderate), Pramanataha (quantity of food) – Madhyama (moderate), Annakala (food servings) – 3 times in a day
• Jarana Shakti (capacity to digest the food) – Avara (less, minimal)

Vyayama Shakti (capacity to exercise, exercise tolerance) – Avara (less, minimal)
Vayaha (age) – Madhyama (middle aged)

Samanya Pareeksha

Samanya Pariksha (General examination, vitals)

• Built – lean
• Pulse – 70/minute
• BP – 110/80 mm of Hg
• Temperature – Normal
• Tongue – coated
• Conjunctiva – yellowish
• Nail – No clubbing or cyanosis
• Lymph Nodes – Not enlarged (not palpable)
• Thyroid gland – Normal (not enlarged)
• Icterus – Positive

Ashta Sthana Pareeksha

Ashta Sthana Pariksha (8 fold examination)

• Nadi (Pulse) – 70/minute
• Mala (feces, bowel) – once per day, sometimes constipated
• Mutra (urine) – 4-5 times per day, yellowish in color
• Jihwa (tongue) – Lipta (coated)
• Shabda (sound) – nothing significant
• Sparsha (touch) –Soshna (warm on touch)
• Drik (eye) – Peeta / haridra varna (yellowish / turmeric color)
• Akriti (built) – Madhyama (moderate)

Abdominal examination

Abdominal Examination

• Inspection – Absence of scars, dilated veins and abdominal distension (protuberance)
• Palpation – Normal findings, no organomegaly, no tenderness
• Percussion – Nothing significant, normal findings
• Auscultation – Normal findings

Roga Pareeksha

Roga Pareeksha (Examination of the disease)

Nidana

Nidana (probable etiological factors):

• Ahara (food) – Ruksha ahara (excessively dry foods), Sheeta (excessively cold foods), Katu (pungent and spicy foods), Amla (sour foods), Ati Madhyapana (excessive consumption of alcohol), Adhyashana (excessive consumption of food even when the previously taken food is not digested)
• Vihara (activities) – Ushna Maruta Sevana (constant exposure to hot air), Vega dharana (forcibly stopping the naturally indulging body urges or reflexes)

Purvarupa

Purvarupa (premonitory symptoms):

• Aruchi (tastelessness, anorexia, aversion to food)
• Angamarda (severe body pains)

Rupa

Rupa or Lakshana (current symptoms of the disease):

• Haaridra netra, nakha, mutra, varchas – Turmeric color manifestation (Yellowish discoloration, tinge) of eyes, nails, urine and stools (feces)
• Dourbalya – Weakness
• Avipaka – Indigestion

Upashaya

Upashaya (pacifying factors):

• Oushadhi – Medicines

Samprapti

Samprapti (Pathogenesis):
Samprapti Ghataka (participants or elements of pathogenesis):

• Dosha (morbidity) – Pitta Pradhana (predominant vitiation of pitta)
• Dushya (contaminated tissues) – Rakta (blood, blood cells), Rasa (plasma, lymph)
• Agni (status of metabolic fire) – Agnimandhya (sluggish digestion, low metabolism)
• Udbhava Sthana (origin) – Amashayottha (stomach, upper gastrointestinal tract, upper intestines)
• Srotas (channels which are contaminated) – Raktavaha Srotas (channels responsible for carrying blood)
• Srotodushti (type of contamination of conducting channels) – Sanga (obstruction)
• Adhishtana (localization of disease) – Twak (skin), Netra (eye), Nakha (nails), Mutra (urine)
• Swabhava (nature of disease) – Chirakari (chronic, slow developing)
• Sadhyaasaadhyata (prognosis) – Saadhya (curable)

Vyavachedaka Nidana

Vyavachchedaka Nidana (Differential Diagnosis)
Ayurveda

• Koshtashakashrita Kamala (Kamala or jaundice localized in koshta or visceral organs and also shakas i.e. tissues)
• Shakhashrita Kamala (Kamala or jaundice with involvement of shakas or tissues)
• Pittaja Pandu (Pandu or anemia or liver disorders caused by high pitta)

Modern

• Hepatitis B
• Hemolytic Jaundice
• Obstructive Jaundice
• Anemia
• Alcoholic Liver Disease

Vyadhi Vinischaya

Vyadhi Vinishchaya (Diagnosis of the disease)
Since we treated the condition on the lines of Kamala (since jaundice was essentially present in this condition / case), the diagnosis was Koshta Shakashrita Kamala (Jaundice located in visceral organs and tissues of the body). According to the modern medical science, we could consider it as Jaundice associated with Alcoholic Liver Disease.
Read related: Alcoholism: Ayurvedic Treatment, Medicines, Remedies

Chikitsa Taalika

Chikitsa Taalika (Treatment lineup chart)
First schedule (on admission)

• Kashaya or medicated decoction of Guduchi (Tinospora cordifolia), Katuki (Picrorhiza kurroa) and Musta (Cyperus rotundus), 20ml thrice daily half hour before food
• Paaneeyartha Siddha Jala – Water processed with Triphala (fruits of Haritakie. Terminalia chebula, Bibhitaki i.e. Terminalia bellirica and Amalaki i.e. Emblica officinalis), Katuki (Picrorhiza kurroa) and Vidanga (Embelia ribes) for drinking, this was advised to be taken whenever the patient felt thirsty or felt like drinking water. It was given in place of plain water.
• Syrup Kamilahar – 3 teaspoonfuls thrice daily after food
• Tab Arogyavardhini Vati – 2-2-2 after food with warm water
• Tab Liv 52 – 1-1-1 half hour after food with warm water

Virechana (therapeutic purgation) – with Trivrit Leham

Added medicines (after Virechana)

• Bhumyamalaki Swarasa (Juice of Phyllanthus niruri) – 1 teaspoon full dose on empty stomach at 6am and 6pm
• Vasaguluchyadi Kashayam – 15ml with 30ml hot water at 8am and 8pm
• Tab Chandraprabha Vati – 1-1-1 after food with warm water
• Drakshadi Ghritam – 10ml – 0 – 10ml before food (prescribed in follow up, after discharge)

Other advices – The patient was advised to keep away from alcohol, tobacco and too much coffee. He was advised not to take oily and fried foods, to avoid pungent, spicy, sour and salt rich foods and corrosive foods.

Prescription on discharge

Prescription on discharge:

• Tab Arogyavardhini Ras – 1-1-1 half hour after food with warm water
• Syrup Kamilahar 2-2-2 teaspoon full half hour after food
• Tab Liv 52 – 1-1-1 half hour after food with warm water

The patient was asked to come back for follow up review after 10 days
Read related: Autoimmune Hepatitis: Causes, Symptoms, Diagnosis, Treatment

Treatment chart

Treatment Chart
20/01/18
1. Triphala + Katuki + Vidanga siddha Jala – Paaneeyartha
2. Guduchi + Katuki + Musta siddha Kashayam – 20ml-20ml-20ml half hour before food
3. Syrup Kamilahar – 3tsf-3tsf-3tsf
4. Tab Arogyavardhini Ras – 2-2-2
5. Tab Liv 52 1-1-1

Observations:
Medicines started
Investigations done – LFT, Hb, TC, DC, ESR, BS/BP
Read related: Liver Diseases: Causes, Symptoms, Treatment, Home Remedies

21/01/18
Same treatment continued.
No improvements noted.

22/08/18
Same medications continued.
Slight reduction in the yellowish discoloration of the sclera is seen

23/01/18
Sadhyo Virechana (instant purgation) is given by administering Trivrit Leham in a dose of 50 grams stat, with Ushnodaka anupana (hot water as vehicle)

Observation:
10 vegas of virechana occurred (10 purges)
Patient was stable
The above said investigations were repeated

24/01/18
The medicines prescribed on Day 1 of treatment i.e. 1-5 were repeated. The below mentioned medicines were added to the list of prescription –

6. Vasaguluchyadi Kashayam – 15ml+30ml hot water before food, @ 8am and 8pm
7. Bhumyamalaki Swarasa – 1 tsf on empty stomach @ 6am and 6pm
8. Tab Chandraprabha Vati – 1-1-1

Observations:
Gross changes in sclera discoloration seen, yellow color was significantly reduced
Urine discoloration (yellowness) had decreased notably
Coating of tongue was reduced

25/01/18
Same medications continued
Appetite had increased, patient was feeling hungry

26/01/18
Same medications continued
Strength and energy levels improved

27/01/18
Sadhyo Virechana (instant purgation), 2^nd course is given by administering Trivrit Leham in a dose of 50 grams stat, with Ushnodaka anupana (hot water as vehicle)

Observations –
08 vegas of virechana occurred (08 purges)
Patient was stable
The above said investigations were repeated

Investigation chart

Investigation chart with ‘after treatment’ changes
On admission (20/01/18)
Urine analysis

• Sugar – Nil
• Albumin – Traces

Microscopy

• Pus cells – 3-4
• Epithelial cells – 4-5
• RBC – 1-2

Bile Salts / Bile Pigments – Present (+++)

Blood Investigations

• Hb – 13.1 gms%
• TC – 6,500
• DC – N-78%, L-19%, E-02%, M-01%

ESR – 46 mm/hr
RBC – 3.98 mil / mm³
PCV – 39.28%
MCV – 99 µm³
MCHC – 33.4 g/dl
PLT – 1.38 lakhs
RBS – 92.39 mg/dl

Discharge Notes

Prescription at Discharge

• Drakshadi Ghritam – 10ml – 0 – 10ml before food
• Syrup Kamilahar – 3tsf-3tsf-3tsf half hour after food with warm water
• Tab Arogyavardhini Ras – 1-1-1 half hour after food with warm water
• Tab Chandraprabha Vati – 1-1-1 half hour after food with warm water
• Tab Liv 52 – 1-0-1 half hour after food with warm water

Observations at discharge

• Yellowish discoloration of the sclera had reduced by 90% (prakrita netra)
• Coating of tongue had reduced (cleared), tongue was looking at its normal pink (nirlipta jihwa)
• Patient was appreciating hunger (kshudha vriddhi)
• The strength of the patient had improved (bala vriddhi)
• Body pains, fatigue had decreased
• Patient had started feeling healthy (swasthya)

Follow up

The patient reported for follow up on 12^th Feb 2018. The patient had almost recovered from the symptoms. He was feeling healthy and comparatively energetic. The biological values as evident from Liver Function tests at follow up too showed improvement.

Below mentioned medicines were prescribed for follow up period during the next 1 month.

• Syrup Kamilahar 3tsf twice daily after food i.e. after breakfast and dinner
• Tab Arogyavardhini Vati – 1-1-1 after food with warm water
• Katuki Churna + Triphala Churna – 1 tsf with hot water half hour before dinner

Summary

Summary of the treatment protocol, discussion and analysis
Looking at the signs and symptoms of the patient, the given condition was diagnosed and treated on the lines of Kamala Roga (Jaundice) since jaundice was present in this condition. Since the patient was alcoholic we could diagnose it as Jaundice associated with Alcoholic Liver disease, rather than just Jaundice. This is because, the Jaundice was present along with other signs and symptoms mentioned in the above mentioned context but the symptoms were neither resembling ‘obstructive jaundice’ nor ‘hemolytic jaundice’ which is the main types of jaundice. Therefore we had to tag it with ALD. Since we do not have a reference or treatment protocol for ALD directly mentioned in Ayurveda, and also since the given case had Jaundice and associated symptoms as important presentations, we planned to treat it on the lines of Kamala vis-à-vis Jaundice. The effect of treatment on the lines of Kamala was successful to a greater extent. Therefore with inference we can conclude that the line of treatment of Kamala can be readily applied on the ALD conditions and get good success.

The schedule of medication and treatment (virechana) was planned in a unique way, with yukti or situational understanding of the disease condition and the diseased.

Simple medications were prescribed and herbs with disease modifying properties were selected to prepare the formulations.

Since the patient was poor, the cost effective medicines were planned.

Sadhyo Virechana was planned in place of krama virechana (purgation administered after snehapana or oleation and swedana or sudation) because snehapana is contraindicated in KoshtaShakashrita Kamala.

The Kashayam which was formulated comprising of Guduchi, Katuki and Musta (given in the first schedule) was a wholesome recipe planned towards multidimensional approach towards curing jaundice and its symptoms. Guduchi is a Rasayana (Rejuvenator, anti-ageing medicine, disease modifying medicines, immunemodulator) which protects the liver and rejuvenates all the tissues. Katuki does the local liver cleansing and flushes excess pitta from the liver and gall bladder into the koshta or stomach, from where it could be expelled by administering Virechana. Virechana given after these medications would serve in systemic cleansing and flushing out the morbid pitta on larger scale, modifying the disease and helping in recovery. Musta is used as a Tikta Deepana (bitter medicines used to enhance the digestive fire). Musta was deliberately included instead of any other teekshna dravyas (intense acting medicines) because there was already pitta vriddhi (severe vitiation of pitta) in this patient and use of any other teekshna dravya would further vitiate the pitta and worsen the condition. Since Musta is Tikta Deepana, it would kindle the fire but not vitiate the pitta owing to its bitter taste which is antagonistic to pitta, thus modifying the disease.

The Paaneeya drava processed with Triphala, Katuki and Vidanga would cause mild cleansing of tissues, liver and also destroy the infections if any.

All the medicines which were used in the process of treatment were comprehensive package of disease modifying and disease specific (Kamilahar, Arogyavardhini, Liv 52, Vasaguluchyadi Kashayam), immune-modulators (Chandraprabha Vati), strengtheners (Drakshadi Ghritam), Liver detoxifying (Katuki, Liv 52, Arogyavardhini, Kamilahar, Vasaguluchyadi Kashayam), appetizer and carminative (Musta), Liver tonic (Bhumyamalaki) and systemic cleansing (Trivrit leham) medicines.

Enjoy comprehensive Liver Health through effective Ayurvedic remedies!!

For Details about the case and any related queries,
Contact:

1. Dr Keshava Rao, Associate Professor, PG Dept of Kaya Chikitsa, ALNRMAMC, Koppa –
keshavamdkc@gmail.com

2. Dr Divya.R, 2^nd PG Scholar, PG Dept of Kaya Chikitsa, ALNRMAMC, Koppa
Email – divyavilla@gmail.com

Ghritha Usage In Jaundice

Use Of Medicated Ghee In The Treatment Of Jaundice
Ghee is the most praised medication in the treatment of jaundice according to Ayurveda. The modern medicine contraindicates usage of ghee or any fats by a jaundice patient.
According to Ayurveda, Kamala i.e. jaundice manifests as an effect of neglected or improperly treated Panduroga i.e. anemia.

Ayurveda pathogenesis of jaundice – when anemia has not yet been completely cured, if the patient takes pitta aggravating foods and activities jaundice is caused. This happens when the pitta further aggravates and damages the blood and muscles of the patient.
Read – Anemia: Ayurvedic Treatment, Medicines, Remedies

Jaundice can also manifest individually.

Therefore, Ayurveda has mentioned common treatment principles for both anemia and jaundice. The principles include –

• Snehana – oleation / saturating the body of the patient with medicated fats given for oral consumption
• Shodhana – therapeutic emesis in anemia and therapeutic purgation in both anemia and jaundice
• Pathya bhojana – conducive diet
  Read – Importance Of Diet (Pathya) For Specific Diseases

For oleation the one of the below mentioned medicated ghee should be used –

• Panchagavya ghrita
• Mahatiktaka ghrita
• Kalyanaka ghrita

Many other ghee too have been mentioned as ideal options –

• Dadima ghrita
• Katukadhya ghrita
• Pathya ghritam
• Danti ghritam
• Draksha ghrita
• Haridradi ghrita etc

Sanskrit Verse

What is the logic of using ghee in the treatment of jaundice?

In anemia there is excessive damage of the tissues and indriyas i.e. sense organs. There is also severe morbidity of doshas. Jaundice develops on this backdrop. Therefore the damages caused in anemia would not only carry into jaundice but will also be more severe and progressive. Jaundice has predominant presence of vitiated pitta and increased heat in its pathogenesis. In this condition it is logical to use medicated ghee as an effective remedy due to the below mentioned reasons –

• Medicated ghee controls excessive tissue damage which is caused by vitiated pitta in anemia and is progressive in jaundice.
• It balances pitta. It combats inflammation, corrosion and excessive heat caused by pitta.
• It is a dosha specific and disease specific remedy in jaundice.
• It causes micro-cleansing of the channels and enables flow of nutrients.
• It provides unctuousness and lubrication of tissues and related channels. By doing so, it removes the excessive dryness caused due to depletion of tissues in these diseases.
• It helps in balancing the belly and tissue fires.
• It provides strength.
• Since appetite is sluggish and variable in anemia and jaundice, medicated ghee also serves as ideal diet. Thus ghee has nutritive value. The medicated ghee will be processed with herbs which kindle the digestive and tissue fire, enhance appetite and cause digestion. Therefore it balances the digestive capacity, corrects metabolism and balances doshas, without causing indigestion.
  Read – Diet And Lifestyle Advice For Pitta Dosha Body Type

Thus, use of medicated ghee has multidimensional benefits in the treatment of jaundice and anemia.

Use of medicated ghee in jaundice or anemia is from the point of view of administering the purifying treatments. Therefore we do not stop the treatment after saturating the patient with oleation therapy. Therefore the use of ghee is for preparing the patient for cleansing therapy.
Read – Principles Of Making Herbal Ghee – Ghritham

The intention of using medicated ghee in the treatment protocol of jaundice may include –

• treating cases where there is bahudosha i.e. abundance of morbidity and hence needing purifying therapies
• treating jaundice developing on the backdrop of anemia, as one shot remedy to address the pathology of both diseases
• to skillfully administer the ghee in mild to moderate conditions of the mentioned diseases as a part of medicine, diet or both
• to use it as a strength promoting medicine
• to use it as a nutritive tonic
• to cure and to prevent recurrence of these diseases
• to use it as an immune-modulator in the post-treatment care
• to use it as dosha-specific and disease-specific remedy
• to use it as a supportive medicine, as a buffer, to repair damages caused in the tissues

Click to Consult Dr Raghuram Y.S. MD (Ayu) – Skype

Yogas for Kamala from Sahasra Yoga Text Book

Vatapitta Jvarahara Kashaya
Panduhara Kashaya
Kamalahara Kashaya
Tiktaka Ghrita
Mahatiktaka Ghrita
Vrisha Ghrita
Mahakusmada Ghrita
Chandanadi Taila
Sudarsana Choorna
Khandasama Choorna
Hapushadi Choorna
Patoladi Choorna
Nimbadi Choorna
Vyoshadi Choorna
Varahyadi Choorna
Dasamoolarishta
Parpatadyarishta
Satavari Guda
Chinchadi Lehyam
Danti Haritakyavaleha
Gandira Rasayana
Pushparaga Lehyam
Trivrit Kulambu
Mandoora Vatakam
Lavangadyam Modakam
Yashtivasadi Kashaya
Tartavaladi Mukkudi
Trayantyadi Kashaya
Arukaladi Tailam
Dasa Swarasa Ghrita
Ardraka Ghrita