E-ISSN:2456-3110

Case Report

Ruddhapatha Kamala

Journal of Ayurveda and Integrated Medical Sciences

2023 Volume 8 Number 7 July
Publisherwww.maharshicharaka.in

Ayurvedic management of Ruddhapatha Kamala (Obstructive Jaundice) - A Case Study

Bhargav H.1*, Diggavi M.2, Yadav P.3
DOI: http://dx.doi.org/10.21760/jaims.8.7.32

1* HM Bhargav, Final Year Post Graduate Scholar, Department of PG studies in Kayachikitsa, Taranath Govt Ayurveda Medical College, Bellary, Karnataka, India.

2 Madhava Diggavi, Professor & Head, Department of PG studies in Kayachikitsa, Taranath Govt Ayurveda Medical College, Bellary, Karnataka, India.

3 Puja Yadav, Assistant Professor, Department of PG studies in Kayachikitsa, Sri Krishna Ayurveda Medical College, Varanasi, Uttar Pradesh, India.

Biliary obstruction[1] refers to blockage of any duct that carries bile from the liver to the gallbladder or from the gallbladder to the small intestine. The clinical setting of the failure of biliary flow may be due to obstruction by mechanical means or by metabolic factors in the hepatic cells. The discussion of metabolic causes of biliary obstruction is very complex; the pathogenesis is not always clearly defined. While on the other hand, the condition Ruddha Patha Kamala in Ayurveda is the nearest possible clinical correlation to biliary obstruction wherein the flow of Pitta is obstructed by Kapha.[2] A structural / physical complete blockage of biliary flow needs a surgical intervention while if the cause is due to metabolic compromise or a partial block, the condition can be reversed effectively through Ayurvedic medications. Here is a case of obstructive jaundice, with a h/o cholecystectomy 20y back and H/O ERCP 5y back, treated successfully with Ayurvedic medications and some diet modifications for about 42 days. A combination of Avipatthikara Churna, Shweta Parpati, Yava Kshara and Katuki Churna was the intervention given. Mulaka Yusha twice a day along with bland diet was advised as Pathya. By the end of 42 days, the LFT report turned completely normal and the patient felt very healthy subjectively. There exists a need in the current times to critically understand the treatment techniques and principles of traditional medicine systems and to make use of them in treating certain conditions where the other conventional medicine systems fail.

Keywords: Shakhashrita Kamala, Ruddhapatha Kamala, Obstructive jaundice, Biliary obstruction, Cholestasis, Ayurveda treatment

Corresponding Author How to Cite this Article To Browse
HM Bhargav, Final Year Post Graduate Scholar, Department of PG studies in Kayachikitsa, Taranath Govt Ayurveda Medical College, Bellary, Karnataka, India.
Email: 		HM Bhargav, Madhava Diggavi, Puja Yadav, Ayurvedic management of Ruddhapatha Kamala (Obstructive Jaundice) - A Case Study. J Ayu Int Med Sci. 2023;8(7):169-173.
Available From
https://jaims.in/jaims/article/view/2617

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2023-05-27 2023-05-29 2023-06-05 2023-06-12 2023-06-18
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
Nil Nil Yes 18%

© 2023by HM Bhargav, Madhava Diggavi, Puja Yadavand Published by Maharshi Charaka Ayurveda Organization. This is an Open Access article licensed under a Creative Commons Attribution 4.0 International License https://creativecommons.org/licenses/by/4.0/ unported [CC BY 4.0].

Journal of Ayurveda and Integrated Medical Sciences 2023;8(7)169
Bhargav H et al: Ayurvedic management of Ruddhapatha Kamala (Obstructive Jaundice)

Introduction

Jaundice is usually detectable when the plasma bilirubin exceeds 2.5mg/dl. The causes of jaundice overlap with variations in LFTs. In a patient with jaundice, it is important to consider whether the pathology is pre hepatic, hepatic or post hepatic. The treatment principles differ based on the type of pathology presented. The pre hepatic jaundice is caused either by hemolysis or by congenital hyperbilirubinemia and is characterized by the isolated elevation of bilirubin levels. The hepatic jaundice results from an inability of the liver cells to transport bilirubin into the bile, occurring as a consequence of parenchymal disease. In hepatic jaundice, the concentration of both conjugated and unconjugated bilirubin levels in blood increase. Obstructive jaundice/ cholestatic/ biliary obstruction may be caused by failure of hepatocytes to initiate bile flow or obstruction of the bile ducts or obstruction of bile flow in extra hepatic bile ducts.

In the absence of treatment, cholestatic jaundice tends to become progressively more severe because conjugated bilirubin, due to obstruction, passes back into the blood. The clinical symptoms of obstructive pathology are characteristically associated with pale stools and dark urine. Pruritis may be a dominant associated complaint.[3]

In Ayurveda, the concept of Kamala has been told under Pandu Roga. Pandu in Ayurveda is an umbrella term that includes all the blood related diseases and also the hepato - biliary tract related diseases. Pitta Pradhana Tridoshas when elevated, end up in Dhatu Shaithilya, Gourava, Alpa Raktha, Alpa Meda, Nissarata and Shithilendriyata completing the Samprapthi of Pandu.[4] The patient with Pandu Roga when indulges in furthermore Pitta Kara Ahara Viharas, the result is Koshtashritha Kamala. The same elevated Pitta if obstructed by Kapha, the movement of Pitta from the Shakhas towards Koshta is blocked leading to Ruddhapatha Kamala / Shakhashrita Kamala. In a broader sense, the pre hepatic / anemic type of jaundice can be seen as Pandu, the hepatic jaundice as Koshtashrita Kamala and the post hepatic / obstructive type as Ruddhapatha Kamala.

Investigations play an important role in understanding and managing liver diseases. Understanding the variations in LFT is the key to arrive at the correct diagnosis.


Bilirubin: The degree of elevation of bilirubin can reflect the degree of liver damage. A raised bilirubin often occurs earlier in the natural history of biliary disease than in the disease of liver parenchyma. Swelling of the liver within its capsule can impair bile flow and cause an elevation of bilirubin level that is disproportionate to the degree of liver injury.[5]

ALT and AST: Although both the transaminases are widely distributed, expression of ALT outside the liver is relatively low and this enzyme is therefore considered more specific for hepatocellular damage.

ALP and GGT: The pattern of modest increase in aminotransferase (ALT & AST) activity and large increases in ALP and GGT activity favors biliary obstruction and is commonly described as ‘cholestatic’ or ‘obstructive’.[6]

Materials and Methods

A female patient aged 50y came with complaints of fatigue, myalgia, fever with chills on and off, loss of appetite, nausea, pain abdomen, dark yellow colored urine, mild bloating, oily stools, constipation, occasional body itching and weight gain since 1 month. Not a known case of DM2 and HTN, h/o cholecystectomy 20y back, h/o ERCP 5y back. On investigation, her LFT pointed towards obstructive pathology (AST, ALT and ALP raised. See Table 1, Image 1). And USG abdomen came with an impression of: obstructive biliary pathology secondary to CBD calculi, suggested ERCP, mild splenomegaly, bilateral renal cyst Rt > Lt with well-defined margins and with no echogenic effect (Image 2 and 3).

Table 1: LFT reports before and after treatment.

Parameter Before treatment 23/11/2023 After treatment 04/01/2023 Reference range Unit
Bilirubin total 3.0 0.74 0 to 1.1 mg/dL
Bilirubin direct 2.2 0.23 0 to 0.2 mg/dL
Bilirubin indirect 0.8 0.51 < 0.90 mg/dL
AST or SGOT 300 35 0 to 31 U/L
ALT or SGPT 316 24.9 0 to 33 U/L
AST/ALT ratio 0.95 1.41 < 1  
ALP 437 172 0 to 105 U/L
Total protein 7.6 7.41 6.4 to 8.3 g/dL
Albumin 4.4 4.34 4 to 4.9 g/dL
Globulin 3.2 0.74 1.9 to 3.7 g/dL

Intervention given: Dry powders of Avipatthikara Churna 200g, Shweta Parpati 10g, Yava Kshara 50g,


Journal of Ayurveda and Integrated Medical Sciences 2023;8(7)170
Bhargav H et al: Ayurvedic management of Ruddhapatha Kamala (Obstructive Jaundice)

Katuki Churna 100g were made into a homogenous mixture and filled into size-2 capsules (approx. – 500mg). 2 capsules TID before food was the dosage given and Mulaka Yusha 50ml thrice a day before food for 42 days.

jaims_2617_01.JPGImage 1

jaims_2617_02.JPGImage 2

jaims_2617_03.JPGImage 3

Results

The complaints - fatigue, myalgia, fever with chills on and off, loss of appetite, nausea, pain abdomen, dark yellow colored urine, mild bloating, oily stools and constipation, occasional body itching got completely reversed. And there was a remarkable improvement in LFT reports too (table 1 and image 4). However, USG abdomen was not repeated in spite of doctors’ advice.

Image 4

Discussion

The subject had a h/o cholecystectomy 20y back and h/o ERCP 5y back. She was not a known case of DM2 and HTN. The complaints like nausea, oily stools, bloating, constipation, mild generalized body itching etc., were suggestive of an obstructive hepatic pathology. And on investigations, the obstructive biliary pathology secondary to CBD calculi was confirmed. The treatment was started based on the lines of Shakhashrita Kamala i.e., ‘Shleshmana Ruddhamargam Tam Pitttham Kapha Haraih Jayet’.[7] Even though the Kamala is Pitta Pradhana Vyadhi, the Shakhashritha variety of Kamala has to be treated under the lines of anti Kapha drugs. So, the combination chosen was Avipatthikara Churna, Shweta Parpati, Yava Kshara and Katuki Churna. And Mulaka Yusha was advised as Pathya.


Journal of Ayurveda and Integrated Medical Sciences 2023;8(7)171
Bhargav H et al: Ayurvedic management of Ruddhapatha Kamala (Obstructive Jaundice)

The Avipatthikara Churna[8], a Ruksha Virechana Yoga with Trivruth as main ingredient is from Bhaishajya Ratnavali, Amlapittha Adhikara. Gunakarma - Katu Kashaya Tikta Rasa, Ushna Veerya, Pitthakapha Shamana, Anulomana, Deepana and Koshta Shodhana. The Shweta Parpati[9], an Ashmari Hara Yoga with Surya Kshara as major ingredient is from Siddha Yoga Sangraha, Ashmari-Mutrakricchra Adhyaya. Gunakarma - Katu Rasa, Ushna Veerya, Chedaka, Ashmari Hara, Kapha Hara. The Yava Kshara[10], a Shula Hara drug with general Kshara properties is from Rasatarangini, Kshara Trika Vijnaneeya Adhyaya. Gunakarma - Katu Rasa, Ushna Veerya, Kapha Vata Hara, Ama Shula Ashmari Dosha Hara. The Katuki Churna[11] is a potent Tiktha Rechaka, Kapha Pitta Hara and Yakruth Rasayana. And the Mulaka[12,13] Yusha is Katu Rasa, Ushna Veerya and is Kshara in nature.

The logic behind the combination given was- Avipatthikara Churna as a Sukha Ruksha Rechana. Shweta Parpati and Yava Kshara as Ashmari Hara, Shula Hara and Avruta Kapha Hara. And Katuki Churna as a potent Yakrith Rasayana. Since the condition is Ruddhapatha Kamala, the usage of any Sneha and Asavarishta is not the appropriate choice. The drug or the combination of drugs chosen should be a Ruksha Rechaka, Kapha Hara, Pitthavirodhi, Ashmari Hara, Shula Hara and Yakrit Rasayana. And hence the combination was selected and administered.

For a Pandu Rogi, Teekshna Shodhana has been told as treatment. Whereas for a Kamala Rogi, only Mrudu Ruksha Virechana is advised.[14] The rationality behind avoiding Teekshna Virechana in Kamala may be due to the chronicity of the disease (if presented as the continuation of Pandu - Paratantra) as more chronicity leads to Vata Vriddhi leading to Dourbalya making the patient unfit for Teekshna Shodhana. And for a Kamala without the previous manifestation of Pandu (Swatantra Kamala), the logic of giving Mrudu Virechana may be - Pitta Vriddhi by itself causes Balakshaya unlike Kaphavriddhi (as increased Kapha will not hamper Bala of the patient usually). In that way, in a case of Swatantra Kamala also Teekshna Virechana has to be avoided. However, in Balavan patient, Teekshna Shodhanas can be carried out to achieve quicker results. The presented subject was a 50y old female with Dourbalya as one of the associated complaints.

Hence, Mrudu Ruskha Virechana and Kapha Hara treatment was chosen and carried out. After a period of 42 days, good results were seen and the case was documented.

Conclusion

Today, in spite of researches, development of technology and newer drugs in modern medicine, treating the cases with hepatic compromise is still not up to the mark. A keen observation on the presenting complaints and correlating with investigations, a Vaidya can arrive at the nearest Ayurvedic diagnosis in a Tridoshic perspective and can plan the treatment accordingly. To conclude, whatever may be the condition, either Ekadoshaja or Sannipataja, when it comes to Yakrith Roga, Ayurveda has the potential to reverse or at least to manage even the last stage complications of hepatic compromise.

Reference

1. Jennifer Lynn Bonheur, Medscape, Biliary Obstruction https://emedicine.medscape.com/article/187001-overview?src=mbl_msp_android&ref=share

2. Acharya Dridhabala, Acharya Agnivesha, Charaka Samhita with Ayurveda Dipika commentary of Chakrapanidatta edited by Acharya Yadavji Trikamji, Varanasi: Chaukhamba Orientalia; 2015. Chikitsa sthana, chapter 15/124, p532.

3. Q M Anstee and D E J Jones, Davidsons principles and practice of medicine edited by Brian R Walker Et al., 22nd edition 2014, Elsivier publications, Liver and Biliary tract disease, p929.

4. Acharya Dridhabala, Acharya Agnivesha, Charaka Samhita with Ayurveda dipika commentary of Chakrapanidatta edited by Acharya Yadavji Trikamji, Varanasi: Chaukhamba Orientalia; 2015. Chikitsa sthana, chapter 15/4, p526.

5. Q M Anstee and D E J Jones, Davidsons principles and practice of medicine edited by Brian R Walker Et al., 22nd edition 2014, Elsivier publications, Liver and Biliary tract disease, p928.

6. Q M Anstee and D E J Jones, Davidsons principles and practice of medicine edited by Brian R Walker Et al., 22nd edition 2014, Elsivier publications, Liver and Biliary tract disease, p928.


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7. Acharya Dridhabala, Acharya Agnivesha, Charaka Samhita with Ayurveda dipika commentary of Chakrapanidatta edited by Acharya Yadavji Trikamji, Varanasi: Chaukhamba Orientalia; 2015. Chikitsa sthana, chapter 15/125, p532.

8. Kaviraj Govind Das Sen, Bhaishajya rathnavali, edited by Prof. Siddhinandan Mishra with Siddhiprada commentary, Choukambha Surbharti Prakashan, chapter 56/24, p903.

9. Pharmacopoeia committee, The Ayurveda Pharmacopoeia of India - part 2, published by The Controller of Publications Civil lines - Delhi 54, 12th chapter, 2nd formulation.

10. Shri Sadananda sharma, Rasa tarangini with hindi translation by Pt. Dharmananda shastry, edited by Pt. Kashinath shastry, Motilal Banarasidas publications, Varanasi 2000, 13th chapter, verse 6, p308.

11. Bhavamishra, Bhava prakasha with commentary by Dr Bukusu Sitaram, Chaukambha Orientalia 2020, Haritakyadi varga, verse 152, p161.

12. Acharya Vagbhata, Ashtanga Hridaya with Sarvangasundara teeka by Aruna datta, edited by Pt. Hariprasad shastri paradakara, Chaukambha Surbharathi Prakashan Publication, Varanasi 2017, Chikitsa sthana, 16th chapter, verse 49, p504.

13. Acharya Vagbhata, Ashtanga Hridaya with Sarvangasundara teeka by Aruna datta, edited by Pt. Hariprasad shastri paradakara, Chaukambha Surbharathi Prakashan Publication, Varanasi 2017, Sutra sthana, 6th chapter, verse 103, p107.

14. Acharya Dridhabala, Acharya Agnivesha, Charaka Samhita with Ayurveda dipika commentary of Chakrapanidatta edited by Acharya Yadavji Trikamji, Varanasi: Chaukhamba Orientalia; 2015. Chikitsa sthana, chapter 15/40, p532.


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