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TITLE OF CASE

Standalone Ayurvedic management of cholelithiasis- a case report

Dr Jyoti Joshi

ABSTRACT

A 30-year-old female patient presented with recurrent episodes of regurgitation and abdominal pain for 2 years. The pain is unbearable and associated with vomiting for 1 year for which she took analgesics and would get temporary relief. The USG done revealed a gall bladder calculi of size 24 mm. Based on the USG report, the biomedical diagnosis was made as Cholelithiasis. She opted for Ayurvedic management and approached Dr Jyoti Joshi. The ayurvedic diagnosis was made as Pittashmari. The line of treatment followed was Virecana to induce pitta shamana and to dissolve the ashmari. With 3 weeks of Ayurvedic treatments, the patient could get significant relief from the abdominal pain and regurgitation. With 4 months of treatment, the patient was relieved from all the symptoms and the repeat USG revealed normal gall bladder with no calculi. This case report demonstrates the successful standalone ayurvedic management of a chronic case of Cholelithiasis in a patient who was not getting relief from symptoms despite taking conventional medicines. 

KEYWORDS

Cholelithiasis, Pittashmari, Ayurveda, Case report, Standalone

INTRODUCTION

Gallstones are hardened deposits of digestive fluid that can form in your gallbladder. Your gallbladder is a small, pear-shaped organ on the right side of your abdomen, just beneath your liver. The gallbladder holds a digestive fluid called bile that's released into your small intestine. Gallstones are hardened deposits of bile that can form in the gallbladder. Bile is a digestive fluid produced in the liver and stored in gallbladder. When we eat, the gallbladder contracts and empties bile into the small intestine (duodenum). Gallstones range in size from as small as a grain of sand to as large as a golf ball. Some people develop just one gallstone, while others develop many gallstones at the same time.

Symptoms- Gallstones may cause no signs or symptoms. If a gallstone lodges in a duct and causes a blockage, the resulting signs and symptoms may include: 

Sudden and rapidly intensifying pain in the upper right portion of your abdomen 

Sudden and rapidly intensifying pain in the centre of your abdomen, just below your breastbone 

Back pain between your shoulder blades 

Pain in your right shoulder 

Nausea or vomiting 

Gallstone pain may last several minutes to a few hours.

Causes: An exact cause is not being defined. But, some factors identified are when the bile contains too much cholesterol or bilirubin, or when the bladder does not empty the contents correctly.

Types of gallstones: There are different type of gall stones depending on the depending on the appearance and the composition. 

Cholesterol gallstones. The most common type of gallstone, called a cholesterol gallstone, often appears yellow in colour. These gallstones are composed mainly of undissolved cholesterol, but may contain other components. 

Pigment gallstones. These dark brown or black stones form when your bile contains too much bilirubin.

Complications: Complications may include 

• Inflammation of the gallbladder.
• Blockage of the common bile duct.
• Blockage of the pancreatic duct.
• Gallbladder cancer. 

Diagnostic criteria- Medical history taking and clinical evaluation are the basic diagnostic criteria, followed. Apart from this the general technique followed are Abdominal and Endoscopic Ultrasound, Imaging like HIDA, CT, MRCP, ERCP, are used two understand the intensity of the problem. Blood tests are done to identify or rule out any infections.

Prognosis & Treatment available: Most people with gallstones that don't cause symptoms will never need treatment. Your doctor will determine if treatment for gallstones is indicated based on your symptoms and the results of diagnostic testing. The doctor may recommend that you be alert for symptoms of gallstone complications, such as intensifying pain in your upper right abdomen. If gallstone signs and symptoms occur in the future, you can have treatment. 

Treatment options for gallstones include: 

• Surgery to remove the gallbladder (cholecystectomy). 
• Medications to dissolve gallstones. 
• Laparoscopic cholecystectomy

PATIENT INFORMATION

In this case report, a 30-year-old female patient presented with recurrent episodes of regurgitation and abdominal pain for 2 years. The pain is unbearable and associated with vomiting for 1 year for which she took analgesics and would get temporary relief. The USG done revealed a gall bladder calculi of size 24 mm. Based on the USG report, the biomedical diagnosis was made as Cholelithiasis. She opted for Ayurvedic management and approached Dr Jyoti Joshi.

No relevant family/surgical/psychosocial/genetic history.

Addictions- Nil

CLINICAL FINDINGS

Per abdominal examination and general examination were done. 

Vitals- Normal
Tenderness - +++ in  epigastric region and around the navel region 

TIMELINE

Image 1. Timeline of events added below

DIAGNOSTIC ASSESSMENT

Modern Diagnostic parameter; The condition was pre diagnosed as Cholelithiasis based on the presenting complaints and the USG report. 

Image 2. USG done at Baseline dated 2.11.2022

Ayurvedic Assessment was done based on the presenting complaints, and the clinical evaluation. 

Differential Diagnosis- 

Acute Pancreatitis

Appendicitis

Bile Duct Strictures
Peptic Ulcer Disease
Gallbladder Cancer
Irritable bowel syndrome
Based on the USG report and clinical evaluation, the the diagnosis was confirmed as Cholelithiasis. 

Prognosis & Treatment available: Treatment of gallstones usually depends on the size and type of stone and symptoms of the patient. However, it may take months or years of medication to completely dissolve the stone. This option is not generally recommended and is only suggested to people who cannot undergo surgery for some reason. In this patient, initially symptomatic management was done with analgesics and injections, but the pain was becoming unbearable and associated with vomiting. So she opted for Ayurvedic management. With 4 months of treatment, the patient was relieved from all the symptoms and the repeat USG study revealed a normal gall bladder with no calculi.

THERAPEUTIC INTERVENTION

Please refer the tab ‘Treatment’ in the Portal. 

FOLLOW-UP AND OUTCOMES

Both objective and subjective parameters were assessed to analyse the outcome of the ayurvedic treatment. 

Subjective parameters: With 3 weeks of Ayurvedic treatments, the patient could get significant relief from the abdominal pain and regurgitation. After 4 months of treatment, the patient was relieved from all the symptoms and the repeated USG study revealed a normal gall bladder with no calculi.

Objective parameters:  Repeat USG was done at endpoint, detected no cholelithiasis. 

Clinician-based assessment; Symptoms during the treatment were assessed to analyse the outcome of the treatment. 

Table 1. Date-wise documentation of symptoms

DATE	SYMPTOMS
3.3.23	Epigastric pain reduced.
20.3.23	Significant relief from the abdominal pain and regurgitation.
10.6.23	Patient completely relieved from all symptoms

Patient-assessed; Not relevant

Endpoint Evaluation:

Image 3. USG at endpoint dated 10.6.2023

Intervention adherence and tolerability – The patient adhered to the prescribed treatments and tolerated the treatments well. 

Method of assessment- By monitoring the patient.

Adverse and unanticipated events; None reported

DISCUSSION: 

Management of gallstones depends on the symptoms and the age of the patient. This patient had tried analgesics for 2 years, when the symptoms persisted and got temporary relief. But since  1 year, the pain is unbearable and associated with vomiting. The ayurvedic diagnosis was Pittashmari and the main treatment given was Virecana to pacify the vitiated pitta, and also to dissolve the ashmari. 

PATIENT’S PERSPECTIVE

Not available. 

LEARNING POINTS/TAKE HOME MESSAGES 

This case report showcases the effectiveness of Ayurveda in treating chronic cholelithiasis, underscores its potential in achieving remarkable results within a short timeframe, emphasising the value of Ayurveda in successfully managing such conditions.

INFORMED CONSENT

Written consent obtained from patient for publishing of the case report in the Portal

ACKNOWLEDGEMENTS

None specified

CONFLICT OF INTEREST

None declared.

FUNDING

None

REFERENCE

1. https://www.mayoclinic.org/diseases-conditions/gallstones/diagnosis-treatment/drc-20354220