A complete and successful management of ALD Induced Ascites fully by Ayurvedic line of management

A Komala; Siddesh Aradhyamath; T Mallinath I

A complete and successful management of ALD Induced Ascites fully by Ayurvedic line of management

Komala A.¹, Aradhyamath S.², Mallinath I T.^3*

DOI:

¹ A Komala, Assistant Professor, Department of Kayachikitsa, JSS Ayurveda Medical College & Hospital, Alanahalli, Mysuru, Karnataka, India.

² Siddesh Aradhyamath, Professor & Head, Department of PG & Ph.D studies in Shalya Tantra, JSS Ayurveda Medical College & Hospital, Alanahalli, Mysuru, Karnataka, India.

^3* T Mallinath I, Final Year PG Scholar, Department of PG & Ph.D studies in Shalya Tantra, JSS Ayurveda Medical College & Hospital, Alanahalli, Mysuru, Karnataka, India.

Ascites is pathological collection of fluid in the peritoneal cavity. When the causes, pathology, clinical symptomatology & the examination are taken under consideration, we can correlate Ascites to Dakodara or Jalodara mentioned by Acharya Sushruta. The procedure of paracentesis as followed in modern science is only a modified method of Acharya Sushruta mentioned under the treatment of Dakodara. We can proudly say that Ascites can be completely managed fully, only by the principles of ayurveda. Here we report a case of ALD induced Ascites in a 32-year-old male patient, got admitted for 30 days and underwent tapping for three episodes along with meticulous use of Nitya-Virechana, Deepaneeya-Pachaneeya & Hepato-protective drugs continued for 6 months. He was successfully managed only by treatment principles of Ayurveda. Detailed case history is presented as below.

Keywords: Udara, Jalodara, Dakodara, ALD induced Ascites, Kamala, Jaundice in Ayurveda, Nitya-Virechana, Paracentesis, Tapping

Corresponding Author	How to Cite this Article	To Browse
T Mallinath I, Final Year PG Scholar, Department of PG & Ph.D studies in Shalya Tantra, JSS Ayurveda Medical College & Hospital, Alanahalli, Mysuru, Karnataka, India. Email:	A Komala, Siddesh Aradhyamath, T Mallinath I, A complete and successful management of ALD Induced Ascites fully by Ayurvedic line of management. J Ayu Int Med Sci. 2022;7(1):427-433. Available From https://jaims.in/jaims/article/view/1695

Introduction

Ascites is a pathological collection of fluid in the peritoneal cavity. Ascites is the most common complication of cirrhosis. It is a poor prognostic factor. Portal hypertension, renin angiotensin aldosterone pathway causing renal sodium retention, increased hydrostatic pressure in hepatic sinusoids and splanchnic vessels cause ascites.^[1]

Ascites is of 3 types depending on the collection of ascitic fluid

1. Mild - Grade 1: Up to 150ml amount required to demonstrate sonologically, Puddle sign is positive.

2. Moderate - Grade 2: 1500-2000ml causes clinical dullness, shifting dullness is positive.

3. Severe (gross) - Grade 3: >2000ml, it causes marked abdominal distension, Fluid thrill is elicited.

As per modern science the cause is to be treated first along with therapeutic tap - It should be slow and gradual or staged tapping. Up to 5 liters can be tapped in 90 minutes. Salt restriction along with diuretics like spironolactone, frusemide can be prescribed. Ascitic shunt surgeries, TIPSS, Liver transplantation are the choices of next step.^[2]

Ayurveda gives a complete and elaborative description of Jalodara (Dakodara) & its management. In Sushruta Samhita Nidana Sthana 7^th chapter Udara Nidana mentions about the causes, classification, symptoms of 8 types of Udara, in which Dakodara or Jalodara can be correlated to Ascites of modern science.

Dakodara

Drinking of cold water immediately after the intake of Sneha, Anuvasana, Asthapana Basti, Virechana or Vamana leads to vitiation of the water carrying channels of the body. The same may be caused by drinking of oil, etc. in inordinate quantities. The water transuding through the walls of these channels causes extreme distension of abdomen, which becomes oily on surface & is full of water, distended, elongated umbilicus and the abdomen distended like a full bloated water drum. The abdomen fluctuates and makes a peculiar sound like water filled bag when percussed.^[3]

For the very first time we get the references of Ascitic tapping in our Sushruta Samhita. A patient of Jalodara (ascites) should be first

anointed with medicated oils possessing Vayu-subsiding virtues, and fomented with hot water. Then his relatives should be asked to hold him firmly by his armpits, when the surgeon would make a puncturing with a surgical instrument known as Vrihimukha, on the left side of the abdomen below the umbilicus, to the breadth of the thumb in depth and at a distance of four fingers to the left of the dividing line of hairs in the abdomen, simultaneously with that, a metal tube or a birds quill having opening at both ends, should be introduced through the opening to remove the Dakodara (vitiated fluid) accumulated in the abdomen.

After removing the tube opening should be lubricated with oil & Saindhava salt and bandaged. Continuing in the same verse Acharya Sushruta advises that, the entire quantity of vitiated fluid should not be removed in a single day, as thirst, fever, aching of limbs, dysentery, dyspnea and a burning of the feet may occur, as it might cause fresh accumulation of matter in the abdomen.^[4]

Case Report

A 32 years male patient (Reg no-141521, IP no-34873) came to Panchakarma OPD on 31^st Jan 2021 with complaints of Itching all over the body, Pain in the upper abdomen & distension of the abdomen associated with yellowish discoloration of the peripheries especially more on palms, nails & urine.

History of Illness

As per the history given by the patient & his attenders, He was chronic alcoholic for the past 9 years, he had consulted once allopathic physician for weakness and chronic alcoholism one & half year ago. After this again he started to drink alcohol increased in the last 5 months. He was normal without any complaints before 3 months, then gradually he developed yellowish discoloration of the sclera and other peripheries, then approached to allopathic doctor but he didn’t get complete relief and since last 15 days above symptoms get aggravated also associated with pain & distention of abdomen. So approached to our hospital for further management.

History of Past Illness

N/K/C/O T2DM/HTN/IHD/COPD/Thyroid dysfunction

No history of previous surgery.

Family History: Nothing significant.

Personal History

He was both vegetarian & non-vegetarian,

Vyasana: Chronic Alcoholism, Coffee, Smoking

Mutra: 4 -5 times /day

Mala: once in a day.

General Examination

Built - Moderate

Appearance - Depressed or dull

Temperature - 98° F

PR - 84 BPM

RR - 18 cycles/min

BP - 130/80 mmHg

Nourishment - Moderate

No evidence of cyanosis/koilonychia

E/O pallor over palms, tongue, palpebral conjunctiva / icterus on bulbar conjunctiva / oedema / clubbing / lymphadenopathy

Systemic Examination

CNS:

Higher mental function test: Conscious well oriented with time, place & person.

Memory: Recent and remote: Intact

Intelligence: Intact

Hallucination/delusion/speech disturbance: Absent

Cranial nerve/sensory nerve/motor system: Normal

Gait: Normal

CVS:

Inspection: No scar/pigmentation found

Auscultation: S1 and S2 heard

Percussion: Normal cardiac dullness

RS:

Inspection: B/L symmetrical,

Palpation: Trachea is centrally placed, non-tender

Auscultation: B/L NVBS heard

Percussion: Normal resonant sound

Abdomen/GIT:

Inspection

Umbilicus centrally placed, Everted, Distended,

Smiling horizontal umbilicus sign positive,

Tanyol sign is positive; Umbilicus is shifted downward

No E/o visible vein/scar/pigmentation

Palpation: Soft, Mild tenderness present in all quadrants more on right upper & mid-quadrant

Auscultation: Normal bowel sounds heard (4/m)

Percussion: Fluid thrill present, Shifting dullness present

Abdominal Girth: Ortho-static position – 104cm, supine position – 102cm.

Investigations done

Date	Bilirubin total (mg/dl)	Bilirubin direct (mg/dl)	Hb% (gm/dl)	Total count (Cells/Cumm)	ESR (mm 1st hour)	AST (U/L)	ALT (U/L)	ALP (U/L)	GGT (U/L)	A: G Ratio
01/02/21	13.3	10.3	11.5	13700	64	98	28	379	73	1.9:1
03/02/21	12.1	8.1
07/02/21	9.9	6.9	12.6	11200	58	91	44	435	69	1.9:1
13/02/21	7.3	4.6	12.3	8800	83	79	33	338	58	1.7:1
20/02/21	4.7	3.8	10.6	5000	64	56	20	401	50	2.3
28/02/21	4.7	2.9	11.5	5000	60	72	29	396	50	1.8:1

Lipid profile & Urine routine found normal, HIV & HBsAg negative, Electrolytes values monitored.

Diagnosis: ALD Induced Ascites (Kamala a/w Jalodara or Dakodara)

Referral Consultation: Department of Shalya-Tantra, (JSS AMC&H)

Treatment: Paracentesis (Ascitic tapping) + Nitya-Virechana

Surgical Procedure

Pre-Operative

Consent for procedure & local anesthesia taken.
Patient advised for NBM for 6 hours before procedure.
Injection TT 0.5ml IM injection stat given
Injection Xylocaine 0.3ml S/C test dose given

Operative Procedure

Under all aseptic precaution, patient was placed in supine position.
Part prepared; painting & draping done.
Paracentesis was done under local anesthesia by using LP needle no 18.
Total 2.5 liters of ascitic fluid aspirated in a first sitting.
After spontaneous cessation of ascitic fluid flow, the LP needle was removed, Then the needle prick-point was closed by tight bandage.

Post-operative

Immobilization for 2 hours.
Patient was advised to be on liquids & soft foods on the day of procedure.

The same procedure repeated for 3 times during the period of hospitalization. The findings are as mentioned in below table.

Date	Orthostatic position	Supine position	Ascitic fluid aspirated	Orthostatic position	Supine position
31/01/21	104cm	102cm	-	-	-
02/02/21	105cm	103cm	2700ml	100cm	98cm
04/02/21	104cm	102cm	-	-	-
06/02/21	103cm	100cm	2200ml	96cm	94cm
10/02/21	96cm	93cm	-	-	-
13/02/21	96cm	94cm	1100ml	94cm	91cm
17/02/21	96cm	93cm
24/02/21	96cm	94cm

Treatment given: Oral medicines;

1. Gomutra Haritaki (2-0-2) after food for 8 days

2. NABB Swarasa (50ml-0-30ml) after food for 28 days

3. Bhrungharajasava (10ml-0-10ml) after food for 28 days

4. Haritaki Churna with warm water (1/2tsp-0-1/2tsp) after food for 15 days

5. Liv52 DS syrup (15ml-15ml-15ml) before food for 28 days

6. Agnitundi Vati (2-2-2) after food for 15 days

7. Chitrakadi Vati (2-2-2) before food 15 days

8. Anuloma DS (0-0-1) after food for 20days

9. Triphala Ghrita (20ml-0-20ml) before food 20 days

10. Gomutra Arka (10ml-0-10ml) after food 20 days

11. Jeerakarishta (20ml-20ml-20ml) after food 20 days

12. Narayana Churna (1/2tsp-0-1/2tsp) after food with water

13. Syr Madiphala Rasayana (20ml-20ml-20ml) before food with water

14. Suvarna Sutashekara Rasa (1-0-1) before food with water

15. Neeri KFT (20ml-0-20ml) after food with water

16. Sunthi Siddha Ksheera-Paka was given for 27 days

17. Trivrutt Lehya (10gm-0-0) with luke-warm water at 6am daily, kept NBM till 11am.

Advice on discharge

1. Tab Gomutra Haritkai (2-0-2) after food with water

2. Liv52 DS syrup (15ml-15ml-15ml) before food with water

3. Trivrutt Lehya (10gm-0-0) with warm water at 6am daily, kept NBM till 11am.

4. Puritin (1-0-1) after food with water

Pathya-Apathya (Diet regimes)

Pathya: Salt-free diet, Milk & Rice, Diet cooked with Yava, Wheat, Shali rice, Sunthi Siddha Ksheera-Paka when he feels thirst.

Apathya: Avoid salt, alcohol, non-veg foods & drinks, Tea-coffee, Tobacco and Abhishyandi, Vidahi, dry, oily substances.

Follow up

Patient advised for follow up, every 15 days continuously for 4 months.
Patient was feeling better.
No evidence of complications found.
His Agni improved.
Ascites reversed.
Liver function improved & normalized.

Before Treatment

During Tapping

2^nd Sitting Tapping

3rd Sitting Tapping

Follow-up after 1 month

Follow-up after 2 month

Follow-up after 3 month

Discussion

Ascites is pathological collection of fluid in the peritoneal cavity. When the causes, pathology, clinical symptomatology & the examination are taken under consideration, we can correlate Ascites to Dakodara or Jalodara mentioned by Acharya Sushruta. The procedure of paracentesis as followed in modern science is only a modified method of Acharya Sushruta mentioned under the treatment of Dakodara. So, it’s clear that principal seeds of Paracentesis were mentioned by Acharya Sushruta several years ago. Neeri KFT is having nephroprotective & diuretic action. Agnitundi Vati, Chitrakadi Vati, Jeerakarishta, Narayana Churna, Triphala Ghrita, Anuloma DS are digestive, anti-flatulent, carminative in action. Gomutra Haritaki, NABB Swarasa, Liv52 DS syrup are hepatoprotective in action. Madiphala Rasayana, Suvarna Suta Shekara Rasa are antacids, antiemetic

& gastrofriendly in action. Trivrutt Lehya is Nitya-Virechaka in action. So, this all-in combine reduced the further collection ascitic fluid, improved Agni, liver function improved, Reinstated the metabolism, ultimately the pathology of ascites reversed.

According to Sushruta “Snehadishvanabhidno Ye Chedhyadisu Cha Karmasu I Te Nihanti Janam Lobhat Kuvaidhya Nrupadosht II”^[5] (Su.Su.3/52) means one should be expert enough in therapeutic skills like administration of Snehadi Karmas and/or Chedana etc. will destroy the people by his greediness & by the fault of king. And continuing that “Yastubhayajno Matimann Sa Samartho-Arthasadhane I Ahave Karma Nirvodhum Dvichakra: Syandano Yatha II”^[5] (Su.Su.3/53) means One who is expert in both knowledge of text and also in therapeutic skills will be able to attain the purpose just like a chariot which is well oleated becomes capable in doing its work in warfield. These two quotes indicates that, one should be capable enough to implement medicine and surgery efficiently, with his own discretion.

Conclusion

We can proudly say that Ascites can be completely managed fully, only by the principles of Ayurveda. Merely there is no importance in ascitic fluid tapping without indication like respiratory embarrassment etc. One has to reduce the hydrostatic pressure increased in the hepatic sinusoids & splanchnic vessels which is only primary cause of developing ascites. Then ultimately Portal hypertension will be under control. As we knew well that Ayurveda is having a holistic approach with drugs of having multidimensional activity. Ascitic shunt surgeries, TIPSS, Liver transplantation are the very invasive techniques. It’s so costly that poor people cannot afford. Nidana, Samprapti & Chikitsa of Udara as advised by Sushruta is very relevant now-a-days & can be correlated directly and broadly to the Ascites. By this we can conclude that Nitya-Virechana helps in reversing the pathology of Ascites. A Multi-centric & large sample size study is required to prove the efficacy of Nitya-Virechana procedure.

Reference

Sriram Bhat M, SRB’s Manual of Surgery, 6th Edition, Published by Jaypee Brothers Medical Publishers, p617

Sriram Bhat M, SRB’s Manual of Surgery, 6th Edition, Published by Jaypee Brothers Medical Publishers, p618
Prof Dr. Vasant C. Patil, Dr. Rajeshwari N. M, Sushruta Samhita of Maharsi Sushruta with English Translation of Text and Dalhana’s Commentary with Critical Notes, 1st edition 2018, Vol 2, Published by Chaukhambha Publications, p55-56
Prof Dr. Vasant C. Patil, Dr. Rajeshwari N. M, Sushruta Samhita of Maharsi Sushruta with English Translation of Text and Dalhana’s Commentary with Critical Notes, 1st edition 2018, Vol 2, Published by Chaukhambha Publications, p409-410
Prof Dr. Vasant C. Patil, Dr. Rajeshwari N. M, Sushruta Samhita of Maharsi Sushruta with English Translation of Text and Dalhana’s Commentary with Critical Notes, 1st edition 2018, Vol 1, Published by Chaukhambha Publications, p54

Manuscript Received	Review Round 1	Review Round 2	Review Round 3	Accepted
2022-01-15	2022-01-17	2022-01-24	2022-01-31	2022-02-07
Conflict of Interest	Funding	Ethical Approval	Plagiarism X-checker	Note
Nil	Nil	Yes	19%

Case Report

Ascites

Journal of Ayurveda and Integrated Medical Sciences