|Year : 2020 | Volume
| Issue : 4 | Page : 143-147
Ayurveda management of alcoholic liver disease with acute hepatitis B: A case report
Kshirod Kumar Ratha1, Suchanda Sahu2, Krishna Rao Sathya1, Indu Sabu1, Meda Mruthyumjaya Rao1
1 Clinical Research, Central Ayurveda Research Institute for Hepatobiliary Disorders, Bhubaneswar, Odisha, India
2 Department of Biochemistry, AIIMS, Bhubaneswar, Odisha, India
|Date of Submission||18-Aug-2020|
|Date of Acceptance||30-Jan-2021|
|Date of Web Publication||18-Mar-2021|
Dr. Kshirod Kumar Ratha
Central Ayurveda Research Institute for Hepatobiliary Disorders, Bhubaneswar - 751 029, Odisha
Source of Support: None, Conflict of Interest: None
Hepatitis B is a viral infection affecting millions of people across the globe. It is one of the common causes of liver cirrhosis and hepatocellular carcinoma and there is no specific treatment available. In Ayurveda, such conditions can be managed in line of Kamala (~jaundice). A 44 year old male patient with jaundice and abnormal liver functions (high transaminases and hyper bilirubinemia) positive hepatitis B marker and fatty liver. The patient was elsewhere diagnosed to be suffering from viral hepatitis and visited to the outpatient department with reports suggesting of acute viral hepatitis B and Alcoholic Liver Disease (ALD). He was administered Ayurvedic medications along with dietary advices for 72 days. There was a significant improvement in clinical findings, reduction in liver transaminases, and fatty infiltration during the treatment. The patient became hepatitis B surface antigen negative, though no studies on reduction in viral load of Hepatitis B Virus (HBV) and anti-HBc (Hepatitis B core antibody) was done, but the clinical improvements and reduction in transaminase and fatty liver indicate a possible role of Ayurvedic therapy in hepatic injury due to HBV and ALD. This case report also warrants further study of Ayurvedic therapy in other liver conditions.
Keywords: Acute hepatitis, alcoholic liver diseases, Ayurveda, hepatitis B virus, Kamala
|How to cite this article:|
Ratha KK, Sahu S, Sathya KR, Sabu I, Rao MM. Ayurveda management of alcoholic liver disease with acute hepatitis B: A case report. J Ayurveda Case Rep 2020;3:143-7
|How to cite this URL:|
Ratha KK, Sahu S, Sathya KR, Sabu I, Rao MM. Ayurveda management of alcoholic liver disease with acute hepatitis B: A case report. J Ayurveda Case Rep [serial online] 2020 [cited 2021 Apr 15];3:143-7. Available from: http://www.ayucare.org/text.asp?2020/3/4/143/311504
| Introduction|| |
Hepatitis B Virus (HBV) infection is a global health problem and nearly two billion people in the world have been acutely infected and nearly 350 million people are infected chronically. In India, nearly 3%–4% population are infected by the virus with chronic hepatitis B constituting more than 50% of the chronic hepatitis in the country. It is the most common cause of chronic liver disease, including cirrhosis of the liver and hepatocellular carcinoma. There is no specific treatment available for acute hepatitis B. In most cases, its treatment is symptomatic and supportive. Oral antiviral agents are helpful in chronic hepatitis B infection to slow down the progression of the disease and to reduce the incidences of complications. In most cases, the drugs do not cure the disease but only suppress the replication of the virus. Alcoholic Liver Disease (ALD) involves the liver manifestation of alcohol overconsumption, including fatty liver, alcoholic hepatitis, chronic hepatitis, and liver cirrhosis. It is the most common cause which accounts for 20%–50% of the prevalence of liver cirrhosis. A combination of HBV infection and ALD accelerates the progression of liver disease and causes cirrhosis later.
Ayurveda is an Indian traditional system of medicine which describes voluminous medicinal plants, classical formulations for many chronic, and lifestyle disorders. Numerous Indian medicinal plants were explored for activities on liver disorders. Even in rural areas, traditional medicine is the initial choice for the patient in various pathologies including jaundice. However, the efficacy of many of these formulations is neither scientifically documented nor reported. Herein, a case of acute hepatitis B with ALD treated successfully through Ayurvedic principles and practice is reported.
| Case Report|| |
A 44-year-old male patient with average body built presented on January 28, 2020, at Ayurvedic Hospital with complaints of yellow-colored urine and eyes, loss of appetite, and generalized weakness for 25 days, followed by mild itching all over the body and cough for eight days. The onset was gradual without any history of fever, vomiting, myalgia, or diarrhea. The patient was a chronic alcoholic for the past 25 years and had quit alcohol a year back. He had no history of diabetes or hypertension but had a history of sedentary lifestyle. Neither history of blood transfusion nor vaccination against hepatitis B was given by the patient. On examination, his respiratory, cardiovascular, and central nervous systems were found normal. Abdomen appeared normal in shape, umbilicus centrally placed, no visible venous prominence, mild local tenderness (Grade I) on the right hypochondrium and epigastric region with mild hepatomegaly, and bowel sounds were audible. There were pulse rate of 82 beats/min, regular rhythm, resting blood pressure of 124/78 mmHg, body weight of 65 kg, body mass index of 24.5 kg/m2, afebrile, icterus-present, absence of pallor, cyanosis, clubbing, lymphadenopathy, edema, tongue coating, and visible thyroid swelling. There was no history of epidemic outbreak of jaundice in the patient's residential area. He consulted a physician and was diagnosed to be suffering from viral hepatitis and advised bed rest along with conservative treatment. However, his symptoms aggravated with the treatment and he discontinued them. He was conscious, oriented, and co-operative. He had Kapha dominant Pitta Prakriti; Madhyama koshta; Rakta sara; and Satva and Samhanana were Madhyama.
The baseline laboratory investigations revealed normal hemogram (differential white blood cell count [neutrophil: 76%, eosinophil: 4%, lymphocyte: 19%, and monocyte: 1%], total leukocyte count: 7100/mm3, total platelet count 260,000/mm3, and random blood sugar: 135 mg/dl,), hyperbilirubinemia (7.6 mg/dl), high transaminases level (serum glutamic pyruvic transaminase: 1073 IU/L and serum glutamic oxaloacetic transaminase: 945 IU/L), elevated alkaline phosphatase (388 IU/L), positive hepatitis B surface antigen (HBsAg), hepatitis B envelope antigen (HBeAG) and immunoglobulin G (IgG) anti-HBc, increased HVB viral load, negative for HCV, elevated alpha-fetoprotein, and increased prothrombin time. His baseline abdominal ultrasonography showed mild hepatomegaly with Grade I fatty liver.
| Timeline|| |
Patient was prescribed with formulation after thorough examination for a period of two months in the outpatient department (OPD) setting and followed up for another one month. Apart from the drugs, the patient was advised to adhere to the prescribed dietary regime. Initially, the patient was given with Patola katurohinyadi kashaya and a decoction was prepared from equal quantities of Guduchi (Tinospora cordifolia [Willd.] Miers), Nimba (Azadirachta indica A. Juss.), Bhumyamalaki (Phyllanthus fraternus G. L. Webster), Bhringaraja (Eclipta alba [L.] Hassk.), Haridra (Curcuma longa L.), and Triphala (Terminalia chebula Retz., Terminalia bellirica [Gaertn.] Roxb., and Phyllanthus emblica L.) for one month to counter aggravated Kapha and Pitta and also to check alkaline phosphatase levels. 500 mg of Arogyavardhini vati twice daily was also given after food during this period. Then, the patient was advised to continue the decoction made from Guduchi and Vasaguduchyadi kashaya till the liver transaminases and bilirubin levels decreased to 0.8 mg/dl. During the follow-up period of one month, the patient was advised to continue only the decoction made from Guduchi [Table 1].
| Follow Up and Outcome|| |
The patient was assessed through changes in signs and symptoms, liver functions, and ultrasound (USG) reports. Occurrences of any adverse events were also noted on each visit. The renal function tests were also performed at the end of two months of therapy. The patient was subsequently followed up at weekly intervals for seven consecutive visits [Table 2]. At the end of treatment, a significant improvement in his clinical features and biochemical parameters was noticed. Progressively decrease in bilirubin level, transaminases, and normal gamma-glutamyl transferase shows the efficacy of the Ayurveda intervention in managing liver injury and improvement in general well-being. Normal USG study reports with normal echo-texture demonstrate the effectiveness of Ayurveda treatment in ALD. No adverse reactions were noticed during the treatment. No significant abnormalities were found in liver or renal function tests inferring safety of Ayurveda drugs.
|Table 2: Changes in the laboratory parameters during the course of assessment|
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| Discussion|| |
The patient was diagnosed to be suffering from viral hepatitis and visited to the OPD with reports of suggesting acute viral hepatitis B and ALD. These pathologies, if left untreated, it leads to Vata prakopa and Sushkata (~steatosis/fibrosis/cirrhosis) of the liver and can cause Udara roga (~ascites) eventually due to dryness that develop as the disease progresses.
The treatment principles of Kamala (~jaundice) include Mridu virechana (~mild laxative) using Tikta rasa (~bitter taste) drugs. Based on Doshas (Pitta and Kapha) and Dhatus (~body tissues) involved, Kapha pitta hara treatment and subsequently Pitta haram (~drugs that alleviate Pitta), Visha haram (~antitoxins), and Rakta shodhakam (~blood purifying) treatment was planned. Drugs bitter in taste owing to Pitta and Kapha alleviating property, Ruksha (~dry), Mridu vireka drugs, and formulations were selected for the conservative management.
As per the Ayurvedic perspective and characteristic features, the patient was diagnosed as Kosthashrita kamala, in which vitiation of Kostha gata pitta, Pitta rakta dushti, and Yakrit ashrita pitta dusti occurs. The presenting complaints such as Kshudha alpata (~loss of appetite), Peeta netrata (~icterus), and Peeta mutrata (~yellowish urine) demonstrates the signs of Pitta dosha and Rakta dhatu vitiation due to Ashraya-ashrayi bhava. However, the presence of Kandu (~mild pruritus) signifies the involvement of Kapha dushti and Margavarodha (~obstructive pathology). Evident of hepatomegaly and fatty infiltration of the liver indicates an association of Mala sanchaya (~accumulation of waste) due to defective metabolism of Madya (~alcohol), which is a form of Kapha dushti usually occurs from excessive calorie intake, sedentary lifestyle, obesity, type 2 diabetes, and alcohol consumption.
The case reported here was diagnosed as Kamala (~jaundice), which manifests with increased intake of Pitta aggravating factors. The consumption of alcohol for a long period of time vitiates Pitta dosha and causes Rakta dusti causing Kamala. Viral hepatitis due to virus A and E origin causes acute viral hepatitis whereas due to hepatitis B and C viruses causes chronic viral hepatitis. Hepatitis B is diagnosed by HBsAg (Australian antigen) testing and its presence implies current hepatitis B infection. Hepatitis B is of paramount importance as it may lead to hepatic malignancy and liver cirrhosis. In the acute form of HBsAG, HBeAG (envelope antigen) and IgM anti-HBc are found positive.
However, chronic hepatitis B is said when the duration of infection is over six months. The presence of IgG anti-HBc implies acute infection and development of core antibodies (IgM anti-HBc) connotes improvement in body defense mechanism and antibody formation against HBV. HBV-DNA estimation is useful in the detection of the viral load or replication of HBV. Alcohol increases the replication of HBV and promotes liver damage and cirrhosis later.
The definite cure for cirrhosis is unavailable till date and the drug available for HBV is costly and needs a longer duration of treatment, hence sometimes shows poor drug compliance. Seroconversion of hepatitis B and a decrease in viral load always require a longer duration of treatment in any system of medicine. The use of Ayurvedic intervention can be utilized in such cases as they are safer and low priced. Patola katurohinyadi kashaya was selected at the initial stage for removal of Mala sanchaya and Margavarodha due to Kledarupa kapha, as it is Pitta kapha shamana. This will be useful to detoxify liver. Owing to the presence of Katuka (Picrorhiza kurrooa Royle), it is mild laxative and good for Madhyama koshta persons for the elimination of Dosha. The formulation also removes Visha (~toxins/virus) and is effective in Kamala. Vasaguduchyadi kashaya is Pitta samana and contains Tikta rasa predominant drugs, which reduces elevated bilirubin and elevated transaminases level, hence useful in hepatocellular jaundice particularly of infective origin. Arogyavardhini vati is Yakrit prasadana and it is helpful in Pachanam (~correcting the metabolism) of Amavisha (~virus and postdigestive toxin-like substances) and corrects the formation of vitiated Dosha. Tikta saka (~vegetables with bitter taste) is Pitta samaka, liver protective, and Jwaraghna (~antipyretic) and useful in the long run.
Guduchi has shown to have immunomodulator and modulates Kupffer cell activity and antioxidant,, Nimba exhibits antioxidant and antiviral activities,, Bhumyamalaki is antioxidant, effective against HBV, Bhringaraja reverses the toxic effects on the liver, Haridra is an antioxidant and modulates pro-inflammatory and profibrotic cytokines, and Triphala possess Rasayana, hepatoprotective, anti-inflammatory, and antiviral properties. The combination of these drugs is intended for a synergistic effect and comprehensive hepatoprotection by virtue of antioxidant, anti-inflammatory, antiviral, antifibrotic, and immunomodulation effect. Since the drugs such as Guduchi, Triphala, and Bhringaraj are Rasayana in nature, they can be safely used for a longer duration.
| Conclusion|| |
The case report infers the usefulness of Ayurveda treatment approaches in decreasing elevated transaminase level or delay the hepatocyte damage in hepatitis B virus and other liver diseases. This report is a lead from a single-case study and to arrive at a certain conclusion, clinical trials with an adequate sample size are recommended.
Declaration of patient consent
Authors certify that they have obtained patient consent form, where the patient/caregiver has given his/her consent for reporting the case along with the images and other clinical information in the journal. The patient/caregiver understands that his/her name and initials will not be published and due efforts will be made to conceal his/her identity, but anonymity cannot be guaranteed.
The authors are grateful to Dr. Manas Kumar Panigrahi, Associate professor, Gastroenterology Department, AIIMS, Bhubaneswar, for helping in diagnosis of the case.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Lee WM. Hepatitis B virus infection. N Engl J Med 1997;337:1733-45.
Chowdhury A, Santra A, Chakravorty R, Banerji A, Pal S, Dhali GK, et al
. Community-based epidemiology of hepatitis B virus infection in West Bengal, India: Prevalence of hepatitis B e antigen-negative infection and associated viral variants. J Gastroenterol Hepatol 2005;20:1712-20.
Lavanchy D. Public health measures in the control of viral hepatitis: A World Health Organization perspective for the next millennium. J Gastroenterol Hepatol 2002;17 Suppl:S452-9.
Asrani SK, Devarbhavi H, Eaton J, Kamath PS. Burden of liver diseases in the world. J Hepatol 2019;70:151-71.
Singh SP, Panigrahi S, Mishra D, Khatua CR. Alcohol-associated liver disease, not hepatitis B, is the major cause of cirrhosis in Asia. J Hepatol 2019;70:1019-38.
Mukherjee PK, Harwansh RK, Bahadur S, Banerjee S, Kar A, Chanda J, et al
. Development of ayurveda – Tradition to trend. J Ethnopharmacol 2017;197:10-24.
Janghel V, Patel P, Chandel SS. Plants used for the treatment of icterus (jaundice) in Central India: A review. Ann Hepatol 2019;18:658-72.
Murthy SK, editor. Astagahridaya of Vagbhatta, Chikitsa Sthana. 5th
ed., Vol. 2., Ch. 16., Ver. 1. Varanasi: Chaukhamba Surbharati Prakasan; 2003. p. 449.
Anonymous. The Ayurvedic Pharmacopoeia of India Part - II (formulations) Volume - II, Appendix 6. 1st
ed. Delhi: The Controller of Publications; 2008. p. 43.
Sharma RK, Dash B, editors. Charaka Samhita of Agnivesha, Chikitsa Sthana. Vol. 4., Ch. 16., Ver. 39-43. Varanasi: Chowkhambha Sanskrit Series; 2015. p. 94.
Murthy SK, editor. Astagahridaya of Vagbhatta, Sutra Sthana. 5th
ed., Vol. 1., Ch. 15., Ver. 18. Varanasi: Chaukhamba Surbharati Prakasan; 2004. p. 202.
Rathore S, Kumar Vk C, Sharashchandra R. A critical review on neonatal hyperbilirubinemia – An Ayurvedic perspective. J Ayurveda Integr Med 2020;11:190-6.
Singhal P, Nesari T, Gupta GS. Efficacy of herbomineral compounds and pathya (Ayurvedic dietary regime and physical exercise) in the management of Yakṛt Roga (Non-alcoholic fatty liver disease). Anc Sci Life 2015;34:216-22.
Satsangi S, Chawla YK. Viral hepatitis: Indian scenario. Med J Armed Forces India 2016;72:204-10.
Krajden M, McNabb G, Petric M. The laboratory diagnosis of hepatitis B virus. Can J Infect Dis Med Microbiol 2005;16:65-72.
Sarin SK, Kumar M, Lau GK, Abbas Z, Chan HL, Chen CJ. Asian-Pacific clinical practice guidelines on the management of hepatitis B: A 2015 update. Hepatol Int 2016;10:1-98.
Ganesan M, Eikenberry A, Poluektova LY, Kharbanda KK, Osna NA. Role of alcohol in pathogenesis of hepatitis B virus infection. World J Gastroenterol 2020;26:883-903.
Wang L, Chen P, Zheng C. Poor adherence is a contributor to viral breakthrough in patients with chronic hepatitis B. Infect Drug Resist 2018;11:2179-85.
Sharma BP. Kamala (jaundice) and its Ayurvedic management. In: Kumar AV, editor. Book Ayurvedic Clinical Medicine. Vol. 2. New Delhi, India: Satguru Publication; 2007. p. 498-511.
Shastri HS, editor. Ashtanga Hridayam of Vagbhata. Sutra Sthana. Ch. 15., Ver. 15. Varanasi: Chaukhambha Surbharati Prakashan; 2002. p. 235.
Kotecha KN, Kotecha BK, Shukla VJ, Prajapati P, Ravishankar B. Acute toxicity study of Vasaguduchyadi Kwatha: A compound Ayurvedic formulation. Ayu 2013;34:327-30.
] [Full text]
Ratha KK, Barik L, Panda AK, Hazra J. A single case study of treating hypertrophic lichen planus with Ayurvedic medicine. Ayu 2016;37:56-61.
] [Full text]
Saha S, Ghosh S. Tinospora cordifolia: One plant, many roles. Anc Sci Life 2012;31:151-9.
Nagarkatti DS, Rege NN, Desai NK, Dahanukar SA. Modulation of Kupffer cell activity by Tinospora cordifolia
in liver damage. J Postgrad Med 1994;40:65-7.
] [Full text]
Alzohairy MA. Therapeutics role of Azadirachta indica
(Neem) and their active constituents in diseases prevention and treatment. Evid Based Complement Alternat Med 2016;2016:7382506.
Subapriya R, Nagini S. Medicinal properties of neem leaves: A review. Curr Med Chem Anticancer Agents 2005;5:149-6.
Thyagarajan SP, Subramanian S, Thirunalasundari T, Venkateswaran PS, Blumberg BS. Effect of Phyllanthus amarus
on chronic carriers of hepatitis B virus. Lancet 1988;2:764-6.
Jahan R, Al-Nahain A, Majumder S, Rahmatullah M. Ethnopharmacological Significance of Eclipta alba
(L.) Hassk. (Asteraceae). Int Sch Res Notices 2014;2014:385969.
Rivera-Espinoza Y, Muriel P. Pharmacological actions of curcumin in liver diseases or damage. Liver Int 2009;29:1457-66.
Peterson CT, Denniston K, Chopra D. Therapeutic uses of triphala in ayurvedic medicine. J Altern Complement Med 2017;23:607-14.
[Table 1], [Table 2]