Role of Ayurveda treatment in the management of hepatitis B (Ubhayapatha Ashrita Swatantra Kamala)- A case report

Abstract

Hepatitis B is one of the most common causes of liver disease, and due to unawareness of the safety measures, more prone to spread. As per the World Health Organization, for the South East Asia region, its prevalence is 2%. Yellowish discoloration of the eyes, body, and urine, abdominal discomfort, and vomiting is its cardinal symptoms. In Ayurveda, this set of symptoms is known as Kamala. This case report illustrates the effectiveness of the Ayurveda treatment modality in a patient with a viral load of 3705.71 IU/ml, and the values of AST (aspartate aminotransferase) and alanine transaminase (ALT) were 140 IU/ml and 173 IU/ml, respectively. A 40-year-old female patient with a complaint of yellowish discoloration of urine, eyes, and skin with fatigue and irritability was diagnosed with Ubhayapatha Ashrita Swatantra Kamala. The patient was treated with Ayurveda drugs and Virechana Karma (therapeutic purgation). After the treatment for 13 months, the disease was cured. Improvement was observed based on hepatitis B virus deoxyribonucleic acid (DNA) polymerase chain reaction (PCR) (hepatitis B DNA PCR) (decreased from 3705.71 IU/ml to <50.0 IU/ml) and the values of AST (decreased from 140 IU/ml to 19.0 IU/ml) and ALT (decreased from 173 IU/ml to 28 IU/ml). The patient was stable and asymptomatic during the follow-up period of 4 months.

Introduction

Hepatitis B virus (HBV) infection is one of the most common causes of liver diseases ranging from acute hepatitis to chronic hepatitis, liver cirrhosis, and hepatocellular carcinoma (HCC).[1] Over two billion people worldwide have been infected with HBV, and more than 350 million are chronically infected carriers.[2] The virology diagnosis and monitoring of the HBV infection are based on immunoassays detecting viral antigens and specific anti-HBV antibodies, as well as nucleic acid detection assays targeting the genomic material of the virus.[3] In comparison with immunoassays, HBV deoxyribonucleic acid (DNA) detection and quantification are more useful in the diagnosis of infection, therapeutic decision-making, and assessment of the response to therapy.[4] In addition, HBV DNA quantization can be used to monitor viral replication kinetics to understand better the mechanisms of infection and the virologic response to antiviral therapy. The ultimate goals of hepatitis B treatment are to decrease mortality by alleviating hepatic inflammation and preventing the development of fibrosis, which ultimately reduces the frequency of progression of hepatitis to liver cirrhosis or HCC,[5] as the main pathological factor behind these diseases is inflammation which turns in to fibrosis. Antiviral therapy is the primary treatment modality of current hepatitis management. Furthermore, the efficacy and side effects of these drugs may vary depending on the clinical situation.[6] Alanine transaminase (ALT) normalization, undetectable HBV DNA, hepatitis B surface antigen loss, or seroconversion can be treatment aims or endpoints.[7]

In Ayurveda, this disease condition bears symptomatic resemblance with Kamala, where cardinal symptoms are Haridra Netra (yellowish discoloration of eyes), Haridra Twak Nakha Aanana (yellowish discoloration of skin, nails, and face), Rakta Pita Shakrita Mutra (reddish yellow color of feces and urinals), Hatendriya (weakness of senses), Avipaka (indigestion), Daurbalya (generalized weakness), and Aruchi (anorexia).[8] Acharya Vagbhatta has mentioned it as a complication of other ailments[9] that can be compared with toxic jaundice. In Ayurvedic literature, the treatment of Kamala has been broadly discussed. As Kamala is Paittika Vyadhi (diseases due to disturbed Pitta Dosha) and Virechana Karma (therapeutic purgation) is mentioned in classics for the treatment principle, Hence, Here it was considered Shodhana Karma (bio cleansing therapy) followed by Shamana Chikitsa (palliative treatment).

Patient histroy

A 40-year-old Hindu female visited our center, CBPACS, Delhi, in December 2018, having central I. D. no. 162146, with the complaint of yellowish discoloration of urine, eyes, and skin from 2 months. The patient had also complained of fatigue with irritability and experiencing upper abdominal pain on and off. Patient had complain of 1–2 episodes of vomiting per day from 2 months.

Initially, these symptoms were mild, but gradually severity increased. For 2 months, she was taking allopathic medication such as antibiotics, Vitamin E capsules, probiotics, and proton-pump Inhibitors, but did not get relief. Meanwhile, on November 27, 2018, doctors did her liver function test (LFT) and HBV DNA polymerase chain reaction (PCR). Through the test report, she was found to be hepatitis B positive. Hence, she visited our center, for better care and support for her ailment.

On further inquiry, we learned that she did not have any blood transfusions in her life. Neither her children nor her husband has this infection. No family history of this disease was there. She did not have any surgical history. She had not been vaccinated for hepatitis B.

Clinical findings

On physical examination, it was found that her conjunctiva, nail beds, and face were dark yellow. The patient was lethargic and restless. Her blood pressure was 100/70 mm Hg. The pulse rate was 70/min, which was feeble and regular. The patient was conscious and well-oriented to time, date, and place. On abdominal examination, there was no organomegaly, but the right hypochondriac region was tender. There were no signs of ascites. There was no puffiness of the face or edema on the body.

Dashavidha Pariksha (ten-fold examination of patient) was donewhich illustrated that patient was Pitta Kaphaj in Prakriti (physical constitution), Vikriti (morbidity) – Pitta, had moderate physical status with Avara Vyayam Shakti (lesser power to perform physical activity), and Avara Bala (low strength).

Astavidha Pariksha (eight-fold examination of the patient) was done, which reveals Nadi (pulse)-Kaphaja, Mootra (urine)-Rakta-Pita Varna (reddish yellow), Mala (feces)-Tila Pista Varna (grayish), Jihwa (tongue)-Sweta (whitish), Ruksha (dry), Shabdam (voice)-Aspasta (weak), Sparsham (touch)-Sheeta (cold), Ruksha, Druk (eyes and vision)-Haridra Varna (yellowish discoloration), Akriti (general body built)-Madhyam (moderate).

Timeline

The timeline of events is depicted in Figure 1.

Figure 1.

Timeline of events. HBV PCR: Hepatitis B Virus polymerase chain reaction, ALT: Alanine transaminase, AST: Aspartate transaminase

Diagnostic assessment

HBV DNA PCR test, which was done on November 27, 2018, showed viral load was 3705.71 IU/ml. LFT was done on November 21, 2018, and the value of AST (aspartate aminotransferase) and ALT was 140 IU/ml and 173 IU/ml, respectively [Figure 2]. To exclude HCC, alpha-fetoprotein test was done, which was negative.

Figure 2.

Hematological changes observed during the treatment

The patient was diagnosed with jaundice due to hepatitis B virus infection. Symptomatically, this situation resembles Kamala, and more precisely, this patient could be diagnosed as Ubhayapatha Ashrita Swatantra Kamala.

Therapeutic intervention

After assessing the patient and taking consent, the whole treatment was planned in two phases; in each phase, Virechana Karma is followed by 6 months of oral medications. [Details mentioned in [Table 1 and Figure 1]. In the first phase, before starting the oral medicine, Virechana karma was performed, 28 Vega (natural urges [for elimination]) were reported, and in the second phase, 25 Vega were reported. In both phases, there was Kaphanta Virechana (until mucus is seen as feces). No complications were observed during both phases. Seven days of Samasarjana Krama (posttherapy dietetic regimen for revival) were done in each phase, which included Peya (watery gruel prepared from Barley) for the first three diets, followed by Vilepi (thick gruel of rice), Yusha (soup prepared from green gram), and Mamsarasa (mutton soup) for succeeding three diets each.[10] After 1 week of Samsarjana Krama, oral medications were started. Oral medications were Bhumi Amalaki Churna (powder of whole dried plant of Phyllanthus niruri Linn.) (1 g) + Sharpunkha Churna (powder of whole dried plant of Tephrosia purpura Linn.) (1 g) + Katuki Churna (powder of dried rhizome of Pichrohiza kurroa Royle ex. Benth) (1 g) + Triphala Churna (2 g) BD (two times in a day) with lukewarm water after lunch and dinner and Aarogya Vardhini Vati 500 mg TDS (three times in a day) with lukewarm water after breakfast, lunch, and dinner. All the drugs for Panchakarma and oral administration were procured from the hospital pharmacy of CBPACS, New Delhi.

Table 1.

Details of Virechana Karma

Procedure	Drug and dosage	Duration (days)
Deepana and Pachana (improvement of digestive fire and digestion)	Avipattikar Churna-2 g was administered twice a day with lukewarm water before lunch and dinner	3
Snehapana (therapeutic internal oleation)	On the 4th day, after assessing the patient’s status, Mahatikta Ghrita was started with 30 mL and increased by 30 mL on each consecutive day, early morning empty stomach, with lukewarm water The patient was observed for Sneha Jeerna Lakhshana (proper digestion of Ghrita) and accordingly, for the next 5 days, the dose of Ghrita was given in increasing pattern till the patient achieved proper Snehana (internal oleation) features	5
Abhyanga and Vashpa Swedana (oil massage and therapeutic fomentation)	After completing internal Snehana for the next 3 days, Abhyanga (whole body massage) was done with Bala Taila, twice a day for 20 min and Sarvanga Vashpa Sweda (steam fomentation) with Dashamoola Kwatha was performed for 10 min or until the patient feels comfortable	3
Virechana Karma (therapeutic purgation)	On the day of Virechana, after massage and fomentation in the morning, Virechana Yoga of Katuki Churna - 10 g, Triphala Kwatha - 100 mL, Draksha Kwatha - 100 mL was administered (9 am approximate). In the first phase, Virechana Karma was completed with 28 Vega and in the second phase, 25 Vega were reported. For both phases, Virechana Yoga and method were the same
Samsarjana Krama (posttherapy dietetic regimen for revival)	Regulatory diet regimen which including Peya (thin gruel of rice), Vilepi (thick gruel of rice), Akrita Yusha (nonprocessed soup of vegetables and/or pulses), and Krita Yusha (processed soup of vegetables and/or pulses) in a sequential manner	7

During the entire treatment course and follow-ups, the patient was advised not to take oily, junk food. She was advised to take freshly home-cooked food timely. She was advised to take seasonal green vegetables with minimal or no spices with rice and buttermilk. Minimal use of electronic gadgets during the night and proper and fixed night sleep timing (10 PM–5 AM) was advised. She was encouraged to get up early and do Pranayama (control of breath) such as Anuloma Viloma, Kapala Bhati, and Omkara chant. Pranayama was advised to do it in the morning for 15–20 min daily.

Follow-up and outcomes

Once the second phase of oral medications was done, an assessment of the patient was done based on subjective criteria [Table 2 and Figure 3], which revealed she was healthy. She was clinically stable also; therefore, medications were stopped, and ask her to do LFT, and HBV DNA PCR tests were performed. She came with these test reports in February 2020, which were negative for hepatitis B. During the follow-up period, i.e. for 2 months, the patient was advised to continue with Pathya.

Table 2.

Assessment criteria for subjective assessment

Criteria	Description	Score
Haridra Netra (yellowish discoloration of eyes)	Normal color of sclera	0
	Yellowish white color of sclera	1
	Yellow color of sclera	2
	Dark yellow color of sclera	3
	Greenish yellow color of sclera	4
Haridra Twaka Nakha Aanana (yellowish discoloration of skin, nails and face)	Normal complexion of skin, nails, and face	0
	Yellowish white color of skin, nails, and face	1
	Yellow color of skin, nails, and face	2
	Dark yellow color of skin, nails, and face	3
	Greenish yellow color of skin, nails, and face	4
Avipaka (indigestion)	Able to digest any kind of eatables	0
	Able to digest normal food	1
	Able to digest light food but difficulty in digestion of normal food	2
	Unable to digest light food as juice, Daliya, Khichadi, etc.	3
Daurbalya (generalized weakness)	No weakness	0
	weakness after doing some extra work other than daily routine work	1
	weakness after doing normal daily routine work	2
	weakness without doing anything	3
Aruchi (anorexia)	Take a full diet on a proper gap	0
	Take moderate diet on proper gap between meals	1
	Decreased amount of diet and the increased gap between meals	2
	Unable to consume a minimum amount of diet on at least 2 meal time	3
	Unable to consume a minimum amount of diet in a whole day	4

Figure 3.

Subjective assessment of the patient

Discussion

Hepatitis B can be correlated with Ubhayapatha Ashrita Swantantra Kamala. There is no direct reference to hepatitis B in any Ayurvedic literature. This is an attempt of the author to correlate this. Swatantra Kamala in Ayurvedic literature is coined for Kamala, which is not originated as a complication of Pandu Roga.[10] Ubhayapatha Ashrita Kamala means that Dosha is present in Koshtha as well as Shakha. Hepatitis B bears symptomatic similarity with Kamala and in this situation, Kamala is not a consequence of Pandu. In addition, hepatocellular malfunctions along with icterus and gastrointestinal tract disturbances are also there in hepatitis B. Swatantra Kamala is purely Paittika Vyadhi (diseases due to disturbed Pitta Dosha). When perturbed Pitta increases in excess amount, it will contaminate Rakta Dhatu (blood tissue); after this step only, features of Kamala become evident.[11] One of the roots of Raktavaha Srotas (channels carrying blood tissue) is Yakrita (liver).[12] Kamala is categorized under Pittaj Nanatmaja Vyadhi (diseases due only to vitiated Pitta Dosha) and Rakta Pradoshaja Vyadhi (diseases due to Rakta Dosha) also.[13,14] Virechana and administration of Pittahara drugs (drugs which alleviate Pitta dosha) are considered as a treatment of choice for Kamala.[15] Virechana drugs not only remove the Dosha present in the stomach and large gut but also of the entire body. Virechana Dravya has Tikshna (sharpness), Ushna (hotness), Sukshma (penetrating), Vyavayi (substances with quick spread even without digestion), Vikasi (property of substance resulting in quick spread and action) properties.[16] After the Shodhana (bio purification) process, remaining Dosha (regulatory functional factors of the body) is pacified by the administration of drugs which alleviates Pitta dosha, having Madhura (sweet), Tikta (bitter), and Kashaya (astringent) Rasa (taste). Drugs used in this study have a predominance of these properties.

Moreover, Triphala treatment suppresses the production of inflammatory mediators, intracellular free radicals, inflammatory enzymes, and lysosomal enzyme release.[17] Katuki Churna has been shown to reduce mortality due to hepatitis B (virus) hepatotoxicity. Its hepatoprotective effect appears to result from a combination of membrane stabilizing, hypolipidemic, and antioxidant properties.[18] The administration of this Sharpunkha extract decreases the necrosed area and the infiltration of the inflammatory cells in the liver lobules.[19] It also showed a significant increase in liver glutathione levels and a significant decrease in lipid peroxidation in the liver. Bhumi Amalaki has been observed to possess anti-viral and anti-bacterial properties,[20] protective effect on the liver,[21] anti-oxidant and anti-inflammatory properties,[22] and as an immunomodulator.[23]

Aarogya Vardhini Vati has a maximum proportion of Kutaki as its ingredient. Apart from this, it also has Triphala in it.[24] It has also effects on the enhancement of antioxidant enzymes, superoxide dismutase, glutathione, and catalase amylase activity in the body.[25,26]

Conclusion

Despite the advancement of modern medical facilities and various awareness programs, hepatitis B is fatal till date. This is the need of the era to develop Ayurvedic protocols for various viral diseases. This study provides a lead where a patient who took ayurvedic medications along with Panchakarma therapy get cured with hepatitis B. By intensive practical studies with more subjects and with a definite protocol will help to validate this combination more scientifically.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.