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 TITLE OF CASE

Successful Ayurvedic intervention in improving the Quality of Life in Chronic case of Ulcerative Colitis non-responsive to conventional medicine- A Case report

Dr KG Raveendran

ABSTRACT

A 31-year-old female, suffered from chronic Irritable Bowel Disease and was provisionally diagnosed with Ulcerative colitis. She did not get relief even on taking conventional medicines for a period of 5 years. She now consulted Dr KG Raveendran, with the presenting complaints of frequent blood-stained watery stools, more than 6 times a day. This was diagnosed as Pittaja Grahani and treatment protocol was to address the atipravrtti of vayu, tikshnamsha of pitta and mandyatva of kapha. With Ayurvedic treatments as an out-patient, for 1 year and in-patient treatment for a period of 1 month, she got complete relief from her symptoms. Post Ayurvedic treatment, she passes stools only once or twice a day, and with no blood stains.

Irritable Bowel Disease- Quality of Life Questionnaire and MAYO Score was used to assess the treatment outcomes. The questionnaire at baseline was 163 and at endpoint it reduced to 133, indicating a significant improvement in the Quality of Life. The MAYO Score was 8 at baseline indicating a severe disease activity. At endpoint, it was 3, indicating a mild disease activity.

KEYWORDS

Ayurveda, Ulcerative colitis, Irritable Bowel Disease, Grahani, Pittaja Grahani

INTRODUCTION

Ulcerative colitis (UC) is a type of Irritable Bowel Disease. This is a long-term pathology, where the colon and/or rectum are inflicted with inflammation and ulcers. The main symptoms are abdominal pain and diarrhea mixed with blood. The condition can also be accompanied by episodes of fever, weight loss and anemia. The intensity of the symptoms may vary from mild to severe at different time intervals. Sometimes, there may be absolutely no symptoms in-between flare-ups.

Diagnostic criteria: Detailed history taking, and clinical evaluation are the basic diagnostic criteria. Imaging (colonoscopy, ileocolonoscopy, upper endoscopy) helps in confirming the diagnosis.

Treatments given:  The target of treatment in Ulcerative Colitis are threefold—improve quality of life, achieve steroid-free remission and minimize the risk of cancer. The choice of treatment depends on extent of being affected, severity and the course of the disease.

PATIENT INFORMATION

A 31-year-old female patient suffering from Ulcerative colitis since 6 and half years presented with frequent watery stools (more than 6 times a day) with blood. She did not get any relief despite taking conventional medicine for 5 years. She got good relief on taking Ayurvedic medicines on an Outpatient, but when an acute flare up happened, she had to get admitted.

Medical History: In the patient’s words, 6 and half years back, she ate a mango and developed acute diarrhoea. She was treated for food poisoning with antibiotics for a long period of time. Though that episode was completely cured, the symptoms persisted on & off. In 2014, a Distal Colonoscopy done diagnosed evidence of mild inflammation commencing from rectum till sigmoid. Further mucosa is free from inflammation/ulceration/stricture/growth (IBD in query). Patient refused to undergo further colonoscopy or biopsy, so a provisional diagnosis was made as Ulcerative Colitis. And she was prescribed Coolgut 800mg. She took it for 5 years (2014-2019). She did not get significant relief. In 2014 weight was 39 kg, in May 2015- 37kg, June 2015- was 39 kg (last recorded), but she became very weak and exhausted. She stopped the allopathic medicine and consulted Dr Raveendran in his OP in 2019. In 2019 her weight was 31kg. After starting Ayurvedic medicines, she had regular bowel movement with only occasional rectal bleeding. This continued until April 2021. But suddenly there was a flare-up in her symptoms with 6-7 episodes of watery stools in a day. Now she mentioned about frequent mouth ulcers and boils in the eye on & off. She noticed that anxiety and stress was aggravating her symptoms. So, she was admitted in the Ayurvedic hospital on 30-4-21 and took In patient treatment until 14/6/21. Past illness- H/o chicken pox, Measles, Herpes in childhood. Marital Status- Married, no kids. Planning for conception. Menstrual History- Regular cycles in 35 days, 5-6 days bleeding. Patient has no comorbidities.

Family History: Father  has Diabetes mellitus & Hypertension. Mother has Hypertension. Mother’s Sister is diagnosed with Ulcerative colitis & Rheumatoid arthritis

Psychosocial History: Since the severe relapse occurred, she is very anxious and stressed and this aggravates her symptoms simultaneously.

PHYSICAL EXAMINATION/CLINICAL FINDINGS

CVS- S1, S2 Heard. GI system- P/A – On examination Bloated, On percussion – Resonance heard over the quadrants of abdomen, Tenderness: + Lower quadrant of abdomen, Warmth: +: Pulse – 62/min: Weight – 31.4 kgs. Blood pressure – 106/70 mm hg: Temperature – Normal. Appetite – Increased. Bowel – Loose with blood. Micturition – Normal. Tongue – Mildly coated.

Patient is very lean built and appears weak and febrile. IBD QOL SCORE – 163. MAYO SCORE - 8 (baseline on 30.4.21) (data attached) indicating the severity of the disease.

TIMELINE

Image 1. Timeline of events attached below

DIAGNOSTIC ASSESSMENT

Modern Diagnostic parameter: The records available from the modern hospital confirm the diagnosis as Irritable Bowel Disease. A colonoscopy would help confirm the diagnosis, but the patient refused to do it. So she was provisionally diagnosed as Ulcerative Colitis.                 

Image 2. Blood Parameters done at baseline attached below

Image 3. Images available to confirm the diagnosis attached below

Image 4. PARTIAL MAYO SCORING INDEX (at baseline) attached below

Ayurvedic Assessment was done based on the clinical evaluation by the ayurvedic physician.

Differential Diagnosis- This does not apply as the patient came in with a definite diagnosis.

Prognosis: Though the disease is not life-threatening, getting medical help is the most important aspect in the management of this condition. If left untreated, there is always a risk of getting colon cancer. The episodes may or may not be severe, but the right diet and lifestyle is very important. There is no cure for the condition, it must be managed with medical intervention. There can be complications like bleeding, dehydration, nutritional loss, inflammation of the inner organs and even a perforated bowel. Addressing the clinical condition is very important.

In this patient, the onset is chronic. Despite the long history of the complaints, and being non-responsive to conventional medicines, she could get relief with Ayurvedic interventions.

THERAPEUTIC INTERVENTION

See the tab ' Treatment Details' 

FOLLOW-UP AND OUTCOMES

The patient is asked to come for a follow up after 6 months.

Clinician-based assessment:

Subjective parameters:

A physical examination was done before and after treatment and this revealed significant improvement.

Table 1. Vitals documented before and after treatment

During admission	During discharge
Appetite -- Increased	Appetite -- Normal
Bowel – Loose with blood	Bowel – Semisolid consistency, Once with no bleeding
Micturition – Normal	Micturition – Normal
Temperature – Normal	Temperature – Normal
Tongue – Mild coated	Tongue – Mild coated
Sleep – Disturbed	Sleep – Improved
Pulse – 62/min	Pulse – 66/min
Weight – 31.4 kgs	Weight – 31.8 kgs
Blood pressure – 106/70 mmhg	Blood pressure – 108/70 mmhg

 

Table 2. Physical examination/Clinical Findings documented before and after treatment

During admission	During discharge
P/A – On examination Bloated	P/A – On examination Mild Bloatedness present
On percussion – Resonance heard over the quadrants of abdomen	On percussion – Mild Resonance heard over the quadrants of abdomen
Tenderness - + Lower quadrant of abdomen	Tenderness - Nil
Warmth - +	Warmth – Localised

 

Objective Parameters: Blood parameters were assessed after the Ayurvedic treatment

Table 3. Blood parameters before and after Ayurvedic Treatment 

On 04/05/2021 (After admission)	On 11/06/2021 (Before discharge)
Hb – 9.6	Hb – 10.8
Platelets count – 2.1 Lakhs/cumm	Platelets count – 2.6 Lakhs/cumm
ESR – 65	Esr – 48 mm/hr
C R P – 1.41 mg/L	C R P – 0.50 mg/L

 

Image 5. Endpoint Blood report attached below

Patient-assessed: MAYO Scoring and IBD QOL Questionnaire were done pre and post treatment.

At the baseline, the score was 8 indicating ‘severe’ disease activity. At the endpoint, the score was 3 indicating a ‘mild’ disease activity.

Image 6. MAYO Scoring Index at endpoint attached below

IBD - Quality of life assessment questionnaire was also filled up at the endpoint to assess the severity of the disease. At baseline, the score was 163. At the endpoint, it was 133 indicating the disease activity has reduced.

Table 4. The IBD QOL Questionnaire documented before and after treatment 

 

	IBD QOL Questionnaire
S No	QUESTIONNARE	SCORE (DURING ADMISSION) 30.4.21	SCORE (DURING DISCHARGE) 14.6.21
1	I feel helpless because of my bowel problems	5	3
2	I am embarrassed by the smell caused by my bowel problems	5	2
3	I am bothered by how much time I spend on the toilet.	5	3
4	I feel vulnerable to other illnesses because of my bowel problems	5	5
5	I feel fat because of my bowel problems.	1	1
6	I feel like I'm losing control of my life because of my bowel problems	5	3
7	I feel my life is less enjoyable because of my bowel problems	5	3
8	I feel uncomfortable when I talk about my bowel problems	3	3
9	I feel depressed about my bowel problems	5	5
10	I feel isolated from others because of my bowel problems	5	5
11	I have to watch the amount of food I eat because of my bowel problems	5	5
12	Because of my bowel problems, sexual activity is difficult for me	5	5
13	I feel angry that I have bowel problems	5	5
14	I feel like I irritate others because of my bowel problems	5	5
15	I worry that my bowel problems will get worse	5	5
16	I feel irritable because of my bowel problems	5	5
17	I worry that people think I exaggerate my bowel problems	5	3
18	I feel I get less done because of my bowel problems	5	5
19	I have to avoid stressful situations because of my bowel problems	5	5
20	My bowel problems reduce my sexual desire	5	4
21	My bowel problems limit what I can wear	5	5
22	I have to avoid strenuous activity because of my bowel problems	5	5
23	I have to watch the kind of food I eat because of my bowel problems	5	5
24	Because of my bowel problems, I have difficulty being around people I do not know well	4	2
25	I feel sluggish because of my bowel problems	5	2
26	I feel unclean because of my bowel problems	5	2
27	Long trips are difficult for me because of my bowel problems	5	3
28	I feel frustrated that I cannot eat when I want because of my bowel problems	5	5
29	It is important to be near a toilet because of my bowel problems	5	2
30	My life revolves around my bowel problems	5	5
31	I worry about losing control of my bowels	5	5
32	I fear that I won't be able to have a bowel movement	5	2
33	My bowel problems are affecting my closest relationships	5	5
34	I feel that no one understands my bowel problems	5	5
	Total Score	163	133

 

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:

The treating physician diagnosed this condition as Pittaja Grahani and the line of treatment adopted was to reduce the atipravritti of vayu and simultaneously reduce the tikshnamsha of pitta and kapha mandyatva. The treatment targets were as follows.  

a. Reduce the atipravritti of vayu and reduce the amatva of purisha

b. Purisha soshana cikitsa

c. Agni vardhaka cikitsa

d. Vatapittahara line

e. Purisha sthapana

Over all amahara, doshavarana hara, agnivardhaka and purisha sthapana cikitsa were adopted.

PATIENT’S PERSPECTIVE

Not available.

LEARNING POINTS/TAKE-HOME MESSAGES

Even in patients of Chronic conditions like Ulcerative colitis, where satisfactory outcomes were not obtained despite taking conventional medicines can keep Ayurvedic treatments as an alternative for an effective management.  

INFORMED CONSENT

Written consent obtained from patient.

ACKNOWLEDGEMENTS

None

CONFLICT OF INTEREST

None declared.

FUNDING

None

REFERENCE

1. Fabián O, Kamaradová K. Morphology of inflammatory bowel diseases (IBD). Cesk Patol. 2022 Spring;58(1):27-37. English. PMID: 35387455.
2. Ordás I, Eckmann L, Talamini M, Baumgart DC, Sandborn WJ. Ulcerative colitis. Lancet. 2012 Nov 3;380(9853):1606-19. doi: 10.1016/S0140-6736(12)60150-0. Epub 2012 Aug 20. PMID: 22914296.
3. Shakyawal et al. World Journal of Pharmaceutical Research. Grahani Roga and their management. Vol 10, Issue 3, 2021

      Image 1. Timeline of events 

Image 2. Blood Parameters done at baseline May 2021

Image 3. Images available to confirm the diagnosis (Distal Colonoscopy 2014 and Ileocolonoscopy 2015)

Image 4. PARTIAL MAYO SCORING INDEX (at baseline)

 

 

Image 5. Endpoint Blood report  dated June 2021

Image 6. Endpoint MAYO Score dated June 2021