Ayurvedic Approach for Management of Liver Parenchymal Disease: A Case Study

Diseases of liver, biliary tract and pancreas are grouped under Grahani and Udar Roga. These triode has been narrated as places of Agni i.e., digestion, metabolism and assimilation. Agni refers to digestion and metabolism mechanism of human body and normal physiology of Agni is essential for maintenance of healthy status. Its vitiation leads to different ailments especially disorders of GIT. Liver parenchymal diseases were considered as Udar Roga. Alcohol has been identified as the major cause of liver parenchymal disease, but the ancient Ayurveda scholar Acharya Charaka identified different causes like drinking cold beverages/cold water after heavy food, eating unwholesome food in indigestion, diseases of other visceral organs, and piles, etc. Present management options for liver parenchymal disease is limited, liver transplant is costly management and has limitation of getting donor and bears risk. Ayurveda with its holistic approach of management offers management options with low risk, and better general wellbeing control of symptoms with oral medicaments or simple OPD based procedures. Author has treated liver parenchymal disease and remarkable improvement in symptoms and general wellbeing has been observed. Marked improvement was observed in cases chronic liver parenchymal disease, pancreatic calculus, hydatid cysts with only Ayurveda medicaments (mostly herbal treatment). The clinical success stories would be dealt in details in


Introduction
Ayurveda is the oldest medical science that has narrated disease and treatment in systemic and scientific methods. Ancient Ayurvedic scholar Acharya Charaka Scientifically classified disease, herbs, ODP of disease. According to ancient Ayurveda science liver and biliary tract disease has been classified as Udar Roga. Acharya Vagbhatta narrates that diseases of Udar Roga or ascites or alimentary tract occurs due to impairment of Agni (digestion-gastric fire). Agni in Ayurveda science refers to all form of digestion, metabolism and diseases of liver, biliary tract and pancreas are grouped under Grahani and Udar roga. These triode has been narrated as places of Agni i.e. digestion, metabolism and assimilation. Agni refers to digestion and metabolism mechanism, normal function of Agni maintains normal physiology and thus the health and its vitiation leads to diseases [1].
Udar Roga means generalised abdominal enlargement or ascites, liver parenchymal diseases is the most important cause of ascites. Alcohol has been the most important cause of disease; the other cause includes indulgence of cold beverages after heavy food [2]. Unwholesome food (Virudha Aahara), food that may alter digestion (produce indigestion), diseases of visceral organ, poisons, toxins, piles etc. may also eventually lead to liver disease [3].
Present management options for Liver parenchymal disease is limited, liver transplant is costly management and has limitation of getting donor and bears risk. Ayurveda with its holistic approach of management offers management options with low risk, and better general wellbeing control of symptoms with oral medicaments or simple OPD based procedures. Author has treated liver parenchymal disease and marked improvement in symptoms and general wellbeing has been observed.

Ayurveda Approach to Liver Parenchymal Disease
Ancient Indian scholars studied human in details how to remain healthy and regain health with the help of natural means of correcting altered physiology and restore normal physiology. The development of Ayurveda happens with eight specialties before 5000 years out of them extensive work has been preserved in form of two texts Charaka Samhita and Sushruta Samhita. Charaka Samhita is the book that describes the disease that can be managed by medicinal management including certain procedures also known as Panchakarma. The other text Sushruta Samhita describes surgical management of diseases. Ancient Ayurveda scholar were very strict in definition of prognosis of disease (a pathological change that has taken place in any clinical ailment that can't be restored to its original state-though patient is symptom free is narrated as Asadhya); Charaka Samhita in Chikitsa Sthana (treatment section) described this with the word Prakrutisthapana meaning restoration of original nature of body and tissue as a synonym of Chikitsa (treatment) [4]. This approach has importance whilst managing the disease. The disease has been identified as grave or severe disease (mahagada) but ancient ayurveda scholars described different management in details.
The older classification of disease was based on the chief complaints or chief presenting symptom, which was further classified into different cause i.e. pathological changes that were different from the present classification based on organ pathogenesis. Thus term liver diseases or liver parenchymal disease may not be found in ancient classic but it is described with Udar Roga.

Journal of Gastrointestinal & Digestive System
Physiology of digestion and metabolism has been described by Acharya Charaka with action of Agni (all types of enzymes, hormones and catalysts) further the action of Agni is classified into three viz. Jathragni-responsible for digestion of ingested food, Bhootagni-chiefly associated with biotransformation to make the nutrient material assimilated and the third Dhatvagni-for nourishment of Dhatus i.e. body tissues. Impairment of all or/and any of them leads to morbid condition that eventually leads to clinical evident disease and subclinical disease also known as Lina Dosha. Thus a detailed analysis of ancient literature with present approach would be interpreted and presented.
Liver plays very important role in digestion and metabolism mechanism, thus primary biliary tract disease are described with Agni dysfunction or Grahani disease. Secondly disorder of liver has been dealt in Udar Roga and Kamala. Grahani Dosha is largely deals with liver dysfunctions. Kumbhakamala described by Acharya Charaka (1500BC) may also be correlated with chronic liver parenchymal disease and malignant disease as there is pathological change of sclerosing or hardening was described.
Udar Roga literally means disease of abdomen but ancient ayurvedic scholar Agnivesha (Charaka Samhita 1500 BC) opined that accumulation of fluid in abdominal is Udar Roga that is chiefly due to impairment of Agni functioning-liver parenchymal disease. Udar roga has been classified into 8 types viz. Vata, Pitta, Kapha, Tridoshaja, Badhagudodara, Chidrodara and Jalodara. Out of these Badhgudodara and Chidrodara occurs due to pathology of colon, intestine and alimentary canal, the rest describes different pathologies of liver including liver parenchymal disease. Jaladoara is the most important amongst them. The disease is caused due to derangement of Agni (digestion & metabolism) the factors may be classified into four group viz. Sannikruta (immediate and direct), Viprakrstha (delayed and indirect), Pradhanika (chief or principle) and Vyabhichari (additives). Ancient ayurvedic scholars identified these factors that cause disease were excessive indulgence Ushna (hot and spicy), Lavana (salts), Kshra (alkalies), Vidahi Anna (acidic food), Amla (sour materials), Gara (accumulative poison materials -like toxic chemicals and metals), Mithya Sansarjana (improperly performed purification process and follow up), Virudha Aahara (unwholesome food) and Ashuchi Bhojana (perished food), diseases of spleen (as well as liver), Arsha (pile in anus or ano-rectal disease), Grahani (mal absorption syndrome), accumulated morbid material, and lastly all the factors that hampers functions of Agni (digestion and metabolism) [5]. Acharya Charaka narrates some more factors that produce changes within the liver tissue viz. indulgence of unctuous material in condition of Mandagni and taking unctuous material with cold beverages alters function of Agni and produces liver parenchymal disease leading to ascites.
Kumbhakamala narrated by Acharya Charaka describes that chronic inflammation/ chronic infections leads to scleroses of hepatocytes (Kathinyad), these is clinically manifested as black, blackish yellow discolouration of urine, stool, nails, conjunctivae, Sarakta Chardi (hematemesis), malena, haematuria, and constitutional symptoms of burning, anorexia, thirst, flatulence, delirium, fainting, and unconscious. The person with complete derangement of gastric digestion & coma has grave prognosis and seldom survives [6]. The last line describes advanced case of hepatic coma that has poor prognosis even today.
The management of liver parenchymal disease has been planned with objective to complete resolution-remission of disease. The cases of liver parenchymal disease were further classified into liver parenchymal disease with ascites and without ascites. Patient suffering from liver parenchymal disease with ascites were treated as the line of management of Udar Roga i.e. reducing fluid in peritoneal cavity and interstitial fluid, regulate and improve water & electrolyte balance of plasma so that there is gradually reduction and proper reabsorption of fluids from organs of abdomen, improve digestion, metabolism and assimilation by purification procedure and medicinal management. In all cases of ascites digestion need to be improved. The other case of liver parenchymal disease that present without ascites treatment is done according to Kumbhakamala i.e. therapeutic purgation to pacify morbid Pitta followed by medicinal management.
General measure (SOP) for treatment of Udar Roga was laid down as correct fluid and electrolyte imbalance firstly by use of gaumutra, tikshna kshra (alkalies) {till it corrects electrolyte imbalance and reduction of abdomen girth}, followed by Dipana, Kaphaghna food and drugs [7]. Based on this principle the drugs like Katuki (picorriza), ginger, Chitraka, different types of kshra, digestives like trikatu, chaturjata, panchakola, arogyavardhani, etc. may be used. Cases of liver parenchymal disease have been treated effectively by the author on the basis of Ayurveda principle, a few cases has been presented here.

Case 1
A patient aged about 55 male from Nadiad, Gujarat non-alcoholic, non-smoker with occupation as religious priest (Hindu Dharma Guru) previously healthy and no history any major medical illness or surgery or jaundice or amoebiasis; but being a priest associated with religious activity he was taking too much of unctuous food (food made up of ghee-clarified butter) with cold water; he presented with marked ascites, perverted umbilicus, marked lethargy, loss of appetite, irregularity of bowel. Non-invasive investigations ultrasound diagnosed liver parenchymal disease, followed by CT scan that confirmed the diagnosis liver cirrhosis (liver parenchymal disease) and ascites. Patient was managed first with conventional medical management and was advised for liver transplant. Patient was not ready for transplant has ready for Ayurveda treatment. Patient was examined thoroughly as per ayurvedic diagnostic methods.
Treatment plan was designed with the primary objective to improve liver function and resolution of tissues and reduction in fluid in abdominal cavity (as there patient was not having any problem of breathlessness or impairment of cardiac function tapping was avoided as reducing water immediately by means of tapping may lead to reoccurrence in ascites as pathological impairment has not corrected and these process produce electrolyte and fluid imbalance that further favors accumulation of fluid in abdominal cavity-Acharya Sushruta (1500 BC) opined that tapping in small amount ought to be done and not completely at one go; there is high risk of recurrence of ascites). Patient was managed with conventional Ayurveda medicine mostly herbal, polyherbal and herbomineral combinations. Katuki (Picrorrhiza) was the drug of choice-a herbomineral compound Arogyavardhini (used for clinical practice since long back-centuries) was used as the primary drug to have mild purgative effects to remove the morbid material of metabolism and unwholesome electrolytes; Katuki also has hepatoprotective action that is an added benefit it improves hepatic secretion thus using mild dosage that reduced abdominal girth, improve digestion by removal of accumulated waste material.
The other drug used was Shankhavati and Sanjivani. Sanjivani was formulated in 7 th century AD by Sharnagdhara having miraculous properties to save life it has multiple roles and useful in many disease, it felicitates liver function, removal of morbid material, corrects fluid and electrolytes imbalance it has also anti toxic properties making it useful in toxic hepatitis. Patient was advised for fomentation and food restriction especially bakery items, food article prepared from white flood-refined floor, unctuous materials, oils, butter, cold beverages were strictly restricted. Restriction in aggregate quantity of food was advised and not to indulge water immediate after food if at all needed small bout was allowed. Patient was periodically examined for changes and follow up biochemical investigation and ultrasound were done.
Treatment was continued for approximately one year, there was marked improvement within a month with improved quality of life. Liver function returned to normal with SGPT, S. Bilirubin, S. Alkaline phosphate, S. Cholesterol were in physiological limits, follow up ultrasound scan opined the absence of ascites but noted no major changes in liver parenchyma. This implies that patient has recovered from the acute problem and patient can live normally without liver transplant.

Case 2
A diagnosed patient liver parenchymal disease presented with acute thrombocytopenia, diarrhoea, loss of appetite and mild ascites. Patient was diagnosed at Ahmedabad with biochemical and sonography. As the presenting feature was thrombocytopenia patient was managed with medicine that correct thrombocytopenia (by the use of treatment principle of Pandu). Patient was managed with the a combination of Shatavari (asparagus) 1 gm+Yastimadhu (G. glabara) 1 gm+dhatriloha 250 mg three times a day, along with Arogyavardhini 2 tab (500 mg) twice a day and shankhavati and sanjivani thrice a day with luke warm water thrice a day after meals. Patient was advised to take fresh juice of neem and galo (tinospora) twice a day. Treatment was continued for one year with regular follow up and all relevant examinations. The first improvement was observed in diarrhoeal symptom within a few days of treatment-bowel became regular and appetite improved (but patient was kept on strict diet control), improvement in thrombocytopenia was observed after three months therapy (BT-25000/cumm to AT 95000/cumm). General condition of patient improved. Post treatment sonography opined normal size of liver with normal hepatic veins, mild dilation of portal vein with changes of liver parenchymal disease. Parenchymal changes were not complete recovered to normalcy but clinical improvement was given to patient naturally.

Discussion/Conclusion
These two cases were only presented here that suggests that Ayurveda medicine has potential in treating liver parenchymal disease. The action of Ayurveda medicine is based on the diagnosis i.e. ODP that may differ from patient to patient and thus proper methodology ought to be used followed by treatment. Ancient Ayurveda scholar narrated fundamentals and objective of treatment based on pathological changes (Samanya-Vivesha Siddhanta) in organ and body humor or both. Thus medicinal herbs, poly herbal formulations, herbomineral formulations and therapeutic purification process have to be planned individually. In the above two cases different medicine were used based of difference in ODP.