Featured Case

Modern Diagnosis: Chronic Liver Disease- Decompensated liver disease

About the disease:

About 35 % of alcohol drinkers, are affected with advanced liver disease, while the rest handle the clinical condition with medical help. There are still no pharmacological or nutritional therapies that are FDA-approved to be used in the treatment of alcoholic liver disease. Excessive and chronic consumption of alcohol results in a range of hepatic lesions, like steatosis, hepatitis, and fibrosis/cirrhosis. This is a progressive disorder and requires medical intervention immediately. Cessation of drinking (i.e., abstinence) is an integral part of therapy. Liver transplantation remains the life-saving strategy for patients with end-stage alcoholic liver disease (Osna NA, Donohue TM Jr, Kharbanda KK. Alcoholic Liver Disease: Pathogenesis and Current Management. Alcohol Res. 2017;38(2):147-161. PMID: 28988570; PMCID: PMC5513682)

Prognosis: In the initial stages, like fatty changes the condition can be reversed. But when fibrosis and cirrhosis set in, it becomes irreversible. Alcohol abstinence is a mandatory rule as a part of therapy. The target of the treatment is to try and normalise the blood parameters and help maintain the quality of life. If the patient is nonresponsive to treatment and the condition worsens, then liver transplantation is suggested.

A 44-year-old male patient with complaints of distention of the abdomen, pitting oedema of both lower limbs and yellowish discolouration of eyes and urine for 2 weeks. At the onset of symptoms, he consulted a gastroenterologist who diagnosed him with Decompensated Chronic Liver disease on 29/5/21 (severe liver cirrhosis stage 3) based on the CECT abdomen. As his CHILD C CTP was 11/15 and MELD was 25, he was advised for a liver transplant.

Image 1. Diagnosis proof document dated 11.6.2021 added below

Image 2. CRP value dated 4.6.2021 and 9.06.2021 added below

Image 3. Serum sodium value and eGFR dated 8.6.2021 added below

Treatment options: Medical and surgical interventions are available depending on the extent of liver damage. Liver transplantation is the last option suggested if the patient is nonresponsive to the treatments, causing clinical deterioration.

Image 1. Diagnosis proof document dated 11.6.2021 added below

Image 2. CRP value dated 4.6.2021 and 9.06.2021

Image 3. Serum sodium value and eGFR dated 8.6.2021

AYURVEDA DIAGNOSIS: Yakritodara

About the Disease:

The term   ‘Yakrt     Vikara’   was first expounded by Bhavamishra in his treatise along with a detailed classification. ‘Ya’ stands for activity and ‘krt’ indicates disintegration or breaking down. So ‘Yakrt’  can be defined as an organ that breaks down various factors inside the body. The term ‘Vikara’ means disease. Yakrit is the mula of  raktavaha srotas. It is the ashaya of pitta and agni. When the yakrt is affected, the metabolism of rasa and rakta dhatu are affected, thus manifesting in kamala. This also matches with the modern concept of derangement of bile pigments thus causing the yellow discolouration. Udara is generally used to indicate abnormal enlargement of the organ due to accumulation of fluid. Yakrtodara can be correlated to Ascites. Madhava Nidana mentions 13 different types of udara, and yakrtodara is one among them.  Mala sancaya and Vata vrddhi can be considered as the main causative factors. Mala  sancaya is the main causative factor for all the udara rogas.

Samprapti- This is basically a tridoshaja vyadhi, but pitta is the main aggravated dosa, as yakrit is pittasthana. Rasa, Rakta and Medas are the dushyas involved. The srotas affected are rasavaha, raktavaha, medovaha, annavaha, and purishavaha. Vyaktasthana is udara and it is a krcchra sadhya vyadhi. 

The classical texts mention the symptoms of Yakrtodara as folllows;

लक्षण- 

क्रमेण कुक्षिं जठरमग्न्यधिष्ठानं च परिक्षिपन्नुदरमभिनिर्वर्तयति॥३७॥

तस्यरूपाणि-दौर्बल्यारोचकाविपाकवर्चोमूत्रग्रहतमःप्रवेशापिपासाग़्गमर्दच्छर्दिमूर्च्छाग़्गसाद- कासश्वासमृदुज्वरानाहाग्निनाशकार्श्यास्यवैरस्यपर्वभेदकोष्ठवातशूलानि, अपि चोदरमरुणवर्णं विवर्णं वा नीलहरितहारिद्रराजिमद्भवति; एवमेवयकृदपि दक्षिणपार्श्वस्थं कुर्यात्, तुल्यहेतुलिग़्गौषधत्वात्तस्य प्लीहजठर एवावरोध इति; एतत् प्लीहोदरमिति विद्यात्। ||38|| (CS.Ci.13). 

Acarya mentions that the symptoms of plihodara and yakrtodara are identical in features and can be managed in a similar way. Daurbalya, arocaka, avipaka, mutraghatam, pipasa, angamarda, chardi, murccha, angasada, kasa, shvasa etc are the symptoms. All or some of the symptoms may manifest in a patient suffering from this condition.  In this patient, the symptoms were icterus, yellow discolouration of the skin, pedal oedema, and abdominal distention.

In this case report, a 44-year-old male patient presented with complaints of distention of the abdomen, pitting oedema of both lower limbs and yellowish discolouration of eyes and urine for 2 weeks. At the onset of symptoms, he consulted a gastroenterologist who diagnosed him with Decompensated Chronic Liver disease on 29/5/21 (severe liver cirrhosis stage 3) based on the CECT abdomen. As his CHILD C CTP was 11/15 and MELD was 25, he was advised for a liver transplant. As the patient was not willing to undergo surgery, he consulted Dr G G Gangadharan. The ayurvedic diagnosis was made as yakritodara.

Prognosis- Kricchrasadhya vyadhi

Treatment- Vatanulomana is the main target in udara rogas. In pittadhishthana rogas, like yakrit, virecana is the best treatment option to pacify the aggravated pitta. Virecana is also indicated in bahudoshavastha and srotorodha. As pitta gets pacified, there is also a direct pacifying effect on rakta. (CS. Si.6.9).

 In this patient, the rationale of treatment is yet to be recieved from the treating physician. 

Ayurvedic Assessment and Diagnosis: This patient is a confirmed case of Acute Liver Disease. Based on the lakshanas, clinical evaluation and the confirmed biomedical diagnosis, the Ayurvedic diagnosis was made.

OUTCOME MEASURES

A 44-year-old male patient with complaints of distention of the abdomen, pitting oedema of both lower limbs and yellowish discolouration of eyes and urine for 2 weeks. At the onset of symptoms, he consulted a gastroenterologist who diagnosed him with Decompensated Chronic Liver disease on 29/5/21 (severe liver cirrhosis stage 3) based on the CECT abdomen. As his CHILD C CTP was 11/15 and MELD was 25, he was advised for a liver transplant. As the patient was not willing to have surgery, he consulted Dr G G Gangadharan. The ayurvedic diagnosis was made as yakritodara.

Assessment criteria: Both subjective and objective parameters were taken into consideration for assessing the outcomes.

Subjective parameters: At the time of discharge, after 2 weeks, yellowish discolouration of eyes and urine resolved, and abdominal distention and pitting oedema in lower limbs reduced.

Objective parameters: The blood parameters were constantly monitored before, during and after the treatment.

Table 1. The blood values documented throughout  the treatment are added below

Table 2. The abdominal girth continuously monitored before, during and after treatment added below.

Image 1. The ascetic fluid analysis done before, during and after treatment is added below.

Image 2. USG abdomen dated 19.8.2021 added below

Disease-modifying effect: The patient is free from symptoms and requested to come for regular follow ups.

Table 1. The blood values documented throughout the treatment

Table 2. The abdominal girth monitored before, during and after treatment

Image 1. The ascetic fluid analysis done before, during and after treatment

Image 2. USG abdomen dated 19.8.2021