E-ISSN:2456-3110

Case Report

Crohn’s Disease

Journal of Ayurveda and Integrated Medical Sciences

2024 Volume 9 Number 2 February
Publisherwww.maharshicharaka.in

Ayurvedic Management of Crohn’s Disease - A Single Case Study

Soumyasree Vr1*, Aniruddha2
DOI:10.21760/jaims.9.2.50

1* Soumyasree Vr, Post Graduate Scholar, Department of Kayachikitsa, Sri Dharmasthala Manjunatheswara College of Ayurveda, Kuthpady Udupi, Karnataka, India.

2 Aniruddha, Associate Professor, Department of Kayachikitsa and Manasaroga, Sri Dharmasthala Manjunatheswara College of Ayurveda, Kuthpady Udupi, Karnataka, India.

Crohn’s disease is a chronic idiopathic inflammatory bowel disease condition characterized by skip lesions and transmural inflammation that can affect the entire gastrointestinal tract from the mouth to the anus. It is having variable presenting symptoms and may include diarrhoea, abdominal pain, weight loss, nausea, vomiting etc. The diagnosis is typically made with endoscopic and/or radiologic findings. A 16-year-old female patient diagnosed with Crohn’s disease having complaints of frequent loose stools, bleeding per rectum after evacuation of bowel, generalised weakness, reduced appetite and weight loss since more than 6 years approached the outpatient department of Kayachikitsa, SDM Ayurveda hospital, Kuthpady, Udupi, Karnataka, India. Patient was intervened with Vilwadi Gulika, Dadimashtaka Churna, Kutajarishta, Takra Kalpana, Parpati Kalpana, Picha Basti etc. strictly following Laja diet with Takra in 4 courses of admissions with a time gap of 2-3 months. There was marked improvement in the frequency of loose stools and rectal bleeding. Improvement in weight was noted by a gain of 12 kg and generalised weakness was completely relieved. The therapy gained confidence in the patient to stop all the steroid and immunosuppressant medications completely and continue with Ayurvedic medication. Thus, it can be concluded that Ayurvedic interventions are effective in the improvement of symptoms in Crohn’s disease.

Keywords: Ayurvedic management, Crohn’s disease, Grahani Dushti, Raktaja Atisara

Corresponding Author How to Cite this Article To Browse
Soumyasree Vr, Post Graduate Scholar, Department of Kayachikitsa, Sri Dharmasthala Manjunatheswara College of Ayurveda, Kuthpady Udupi, Karnataka, India.
Email: 		Soumyasree Vr, Aniruddha, Ayurvedic Management of Crohn’s Disease - A Single Case Study. J Ayu Int Med Sci. 2024;9(2):310-315.
Available From
https://jaims.in/jaims/article/view/2940

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2023-12-08 2023-12-18 2023-12-28 2024-01-08 2024-01-17
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
None declared Nil Yes 23.74

© 2024by Soumyasree Vr, Aniruddhaand 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].

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Soumyasree V.R. et al. Ayurvedic Management of Crohn’s Disease - A Single Case Study

Introduction

Crohn's disease is a chronic idiopathic inflammatory bowel disease condition characterized by skip lesions and transmural inflammation that can affect the entire gastrointestinal tract from the mouth to the anus.[1] Its incidence has a bimodal distribution with the onset occurring most frequently between ages 15 to 30 years and 40 to 60 years. In CD, the inflammation extends through the entire thickness of the bowel wall from the mucosa to the serosa. The disease runs a relapsing and remitting course and with multiple relapses, the CD can progress from initially mild to moderate inflammatory conditions to severe penetrating or stricturing disease. The pathophysiology is multifactorial and involves genetic predisposition, infectious, immunological, environmental, and dietary factors. Patients with flare-ups of Crohn disease typically present with abdominal pain (right lower quadrant), flatulence/bloating, diarrhoea (can include mucus and blood), fever, weight loss, anaemia. In severe cases, perianal abscess, perianal Crohn’s disease, and cutaneous fistulas can be seen.

When the small bowel is involved, it may present with diarrhoea, malabsorption, weight loss, abdominal pain, and anorexia.[2]

According to Ayurveda, this case is diagnosed as Rakta Atisara with Grahani Dushti. Here the patient presents with Ati Drava Pureesha Pravrithi, Rakta srava, Agnimandhya, Dourbalya, Pandu etc. Atisara (diarrhoea) is defined as the Atinisarana of Drava Dhatus through Guda. Agnimandhya is the primary cause, which results in expulsion of Ap Dhatus. Ap Dhatu here is referred to as Rasa, Jala, Sweda, Kapha, Pitta, Rakta etc.[3] The Agni Vikriti results in Pitta Dushti and vitiation of Dhatu like Shonita etc.[4] Chronic Atisara results in Grahani dushti which results in impaired Dhatu Poshana (Nourishment of tissues).

Case Report

A female patient aged 16 years having complaints of loose stools 7-8 times per day, abdominal pain, bleeding per rectum after evacuation of stools, mucous discharge, lethargy, weight loss since 6 years.

Her history of presenting illness revealed that 6 years back patient had

the complaints of constipation and took laxatives and other contemporary medications for the same for a duration of 6 months. Since the complaint persisted, she underwent colonoscopy and endoscopic biopsy which revealed inflammatory bowel disease and impressions of Crohn’s disease. She was treated for the same with milk powder diet etc. After 2 months of starting that she developed loose stools along with mucous, abdominal pain and mild rectal bleeding after evacuation of bowel. These complaints persisted with remissions and exacerbations even after taking various allopathic medications. By the end of 2021, she was having loose stools 7-8 times per day with profuse bleeding after every evacuation of bowel. She also experienced generalised weakness and lost around 10 kgs in a span of 10 months. In 2022, colonoscopy was repeated and it showed pseudo polyps in distal colon and showed impression of severe distal Crohn’s disease. She was on steroids and immuno suppressants and her condition persisted with remissions and exacerbations.

She was admitted in our hospital and took 4 courses of treatments with a gap of 2-3 months.

On examination the patient was pale, lean and under nourished. Vitals were within normal limits. Body weight was 37 kg.

Personal history

Patient was following mixed diet pattern, regular meals, Appetite was reduced, Micturition was 4-5 times/day, Sleep was sound and no addictions were present.

Family history

Patient’s sister is having similar complaints of less severity.

Recent treatment history included medicines Adalimumab, Modulen IBD powder, Azathioprine, Ciprofloxacin, Cholecalciferol, Gabapentin, Mesalazine prolonged release tablet, Metronidazole tablet, Multivitamin syrup, Omeprazole capsule, Trimebutine maleate tablet etc.

Menstrual history pointed out absence of monthly menstruation for the past 2 year.

Gastrointestinal system examination revealed mild ulcerations inside oral cavity. On per abdomen examination abdominal distension was absent,


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tenderness was present over left lower quadrant of abdomen. Bowel sounds were 6-7/min. Impressions of Oesophageo-gastro Duodenoscopy and Colonoscopy on October 26, 2022 implies severe distal Crohn’s disease.

Grahani Roga, Raktaja Atisara and Raktaja Pravahika were considered for differential diagnosis. Pravahika was excluded from the absence of Pravahana (straining) and Kritepyakrita Sajnatha (tenesmus).

Table 1: Timeline of events

2016Onset of complaint as constipation persisted for 6 months, Took medications for constipation. Wt.-30 kg
2016 AugustColonoscopy findings - Likely Crohn’s disease - stomach and colon involvement
From 2016 AugustTreatment started with milk powder diet.
Developed complaints of abdominal pain, loose stools associated with mucous and blood in lesser amount. Later symptoms got reduced
2017MR Enterography findings - Chronic inflammatory findings involving left colon worse in the sigmoid.
2020Treatments including infliximab injection -
Symptoms got reduced, loose stools 2-3 times/day, Wt.-44 kg
2021-2022Same treatments continued, Exacerbation of symptoms, Loose stools 7-8 times/day, severe abdominal pain, bleeding ~5 ml during every evacuation. Wt-34 kg
2022 DecStarted Ayurvedic treatment in SDM Ayurveda hospital, Udupi. Wt- 37 kg

Ayurvedic Interventions

4 courses of IP treatment of 7-10 days duration were taken with a gap of 2-3 months. During the first course of admission Vilwadi Vati, Kutajarishta, Panchamrita Parpati Kalpana dose starting from 60 mg, increases by 60 mg daily up to 240 mg and reducing back to 60 mg. During 3rd course dose of 60 mg was followed. Dadimashtaka Churna was administered 5gm with Takra in empty stomach. Takra Kalpana along with Laja diet was strictly followed. During second course Tab.Styplon was added. During 4th course of treatment Picha Basti was given, along Matra Basti with Sukumara Ghrita.

Takra Kalpana and Laja diet: Diet schedule including only Buttermilk and Parched rice. i.e., Morning 300 ml of Buttermilk, 300 ml buttermilk and boiled Laja in the afternoon and night was given. Apart from this whenever the patient gets hungry buttermilk and boiled Laja was advised.

Table 2: Interventions

InterventionDischarge medicines
1st course
16/12/22 - 31/12/22		1) Tab.Vilwadi Vati 1-1-1
2) Kutajarishta 3 teaspoon thrice daily after food
3) Koshta Abhaya 1-1-1
4) Yashtimadhu Churna 2gm + Amalaki Churna 2gm + Honey q.s + Ghrita q.s on empty stomach
5) Syrup. Amlotone 2 teaspoon thrice daily before food
6) Takra Kalpana + Laja diet		1) Kutajarishta 3 teaspoon thrice daily
2) Vilwadi Vati 1-1-1
3) Koshtabhaya 1-1-1 before food
2nd course
02/02/23-07/02/23		1) Tab.Vilwadi Vati 1-1-1
2) Dadimashtaka Churna 5gm + Panchamrita Parpati Kalpana with Takra Anupana
3) Kutajarishta 15ml Thrice daily after food
4) Tab Koshta Abhaya 1-1-1
5) Takra kalpana + Laja diet		1) Kutajarishta sos
2) Tab.Vilwadi Vati 1-1-1
3) Tab. Koshta Abhaya 1-1-1 before food
4) Panchamrita Parpati Kalpana
3rd course
05/04/23-08/04/23		1) Vilwadi vati 1-1-1
2) Dadimashtaka Churna 5gm + Panchamrita Parpati 60 gm + Takra
3) Normal diet
4) Picha Basti
Matrabasti with Sukumara Ghrita		1) Vilwadi Vati 1-1-1
2) Kutaja Ghana vati 1-0-1 A/f
3) T.Styplon 1-0-1
4th course
07/07/23-12/07/23		1) Tab.Styplon 1-1-1
2) Tab.Kutaja Ghana Vati 1-1-1
3) Kutaja Avaleha 1 tsp-1 tsp-1tsp
4) Shankha Vati 1-1-1
5) Normal diet		1) Tab. Vilwadi Vati 1-1-1
2) Tab Styplon 1-0-1
3) T.Kutaja Ghana vati 0-0-1
4) Dhatri loha 1-0-0

The medicines were from SDM Ayurveda pharmacy, Tab. Styplon was from Himalaya drug company, Panchamrita Parpati was of Dhootpapeswar pharmacy,

Result

Before treatment, patient had loose stools 7-8 times/day, after 4th course of treatment it reduced to formed stools 2-3 times /day. Bleeding per rectum got reduced from ~5 ml/evacuation to 1-2 drops/day occasionally; Mild abdominal pain was present before, it got completely subsided. Weight was 37 kg which got increased by 12 kg in 1 year.

The disease activity was assessed before and after


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treatment using Harvey Bradshaw index for Crohn’s disease. A score of 8-16 signifies moderate disease and less than 5 indicates remission. The after-treatment score indicates remission stage of the disease.

Table 3: Result

ParameterBTAfter 1st courseAfter 4th course
Loose stools7-8 times /day4-5 time /day2-3 times /day formed stools
Bleeding per rectum~5ml/evacuation~5-6 drops/each bowel evacuation1-2 drops /day occasionally
Abdominal painMild pain presentAbsentAbsent
Weight37 kg38 kg49 kg
MenstruationAbsence of cycles for 1 yearMonthly cycles restartedMonthly cycles maintained
Investigation27/10/227/2/2311/7/23
Hb %7.9 gm%10.8 gm%10.3 gm%
ESR87 mm/hr28
CRP61.9 Positive5.2 negative

Table 4: Harvey-Bradshaw index for Crohn’s disease[5]

SNSymptomBefore treatmentScoreAfter 5th course of treatmentScore
1.General wellbeingPoor2Very well0
2.Abdominal painMild1None0
3.No. of liquid/soft stools88None0
4.Abdominal massNone0None0
Total110
CommentsModerate diseaseRemission

Discussion

Considering the Dosha-Dushya and Lakshana, the case was diagnosed as Raktaja Atisara with Grahani Dushti. As it’s mentioned in classics that Chirakala Atisara can contribute to Grahani Mardavatha or reduced strength of Grahani Sthana. The same pathology is visible in this case with symptoms of loose stools, bleeding per rectum etc., gradually led to weight loss and weakness. Pandu is mentioned as an Upadrava of Grahani Roga, here the patient presented with pallor and Anaemia which was evident through the haematology profile. An underlying inflammation in the gut resulted in Atisara. In due course of time, it manifested as Raktaja Atisara and Grahani Dushti.

Agnimandhya and Grahani Dushti resulted in evacuation of Ama Drava Pureesha. Jataragni Mandhya led to Rasa Dhatwagni Mandhya which resulted in reduced Poshya Rasa Dhatu and further Dhatu Poshana was impaired. Rakta Dhatu Poshya Bhava from Rasa became deranged and is evident from Anaemia and absence of menstrual cycles. All other Dhatu were in Kshaya Avastha which resulted in Dourbalya (weakness) and Karshya (weight loss) in the patient. Involvement of all the Doshas were visible in different stages of the disease, initially predominating Vata and Kapha with severe abdominal pain and loose stool with mucous secretions, consequently Pitta and Rakta got involved with symptoms of Daha, Mukha Paka and Rakta Nisarana. Presently moderate involvement of Tridosha is visible with predominance of Rakta.

Based on the above pathogenesis, the principles of Ama Pachana, Agni Deepana, Grahi, Rakta Sthambana and Grahani Bala Vardhana was applied.

Vilwadi Gulika explained in Visha Prakarana has an effect on the inflammatory immune response in the gut. It has actions as Vishahara, Garavishahara, Jwarahara. Visha is an acute condition explained in our classics and formulations explained in Vishaprakarana can be inferred to have Ashukari action (Rapid action). It helps against the autoimmune pathology of the disease.

Yashtimadhu and Amalaki helps in pacifying Koshtagatha Pitta Dosha.

Kutajarishta have ingredients like Kutajamoola, Mridwika, Madhukapushpa, Kashmari, Dhataki, Guda. It has actions like Jwarahara, Grahaninashana, Raktathisara Nasana, Agnimandhyahara.Most of the ingredients are Raktapittahara and helps in reducing bleeding per rectum. Kutajarishta helps in reducing intestinal motility due to its Stambhana Guna. It is also proved that Kutaja is having potent immune stimulatory and anti-secretory activities.

Tannin is a constituent of Kutaja which is an astringent. The astringents have ability to precipitate superficial proteins forming a protective layer on mucous membranes, which helps in reducing secretions. Anti-motility activity helps in slowing down intestinal transit permitting more time for absorption.

Dadimashtaka Churna having ingredients like


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Tugakshiri, Chaturjatha, Yavani, Dhanyaka, Ajaji, Granthi, Vyosha, Dadima and Sita have properties of Deepana, Pachana, Grahi which helps in correcting the Grahani Dushti.

Panchamrita Parpati has ingredients like Sudha Gandhaka, Sudha Parada, Lauha Bhasma, Abhraka Bhasma, Tamra Bhasma. It has Deepana, Pachana, Sukshma properties and it acts on Agnisthana. It helps to correct Agnimandhya and has Deepana, Pachana, Grahani Balya and Drava Shoshana properties. It exerts its action on the intestinal mucosa and regenerates the absorption mechanism, thereby improves the absorption of iron and other nutrients. It also helps in pacifying the irritation and inflammation of mucosa of colon.

Kutaja Ghana Vati has ingredients like Kutaja Twak and Ativisha. It’s having Deepana, Pachan, Grahi properties. It helps in reducing the intestinal motility and secretions thereby correcting the absorption from mucosa and assists in controlling the watery stools.

Styplon tablet is having haemostatic properties and helps in protecting irritated and inflamed mucosa. It has ingredients like Amalaki, Sariva, Lodhra, Pravala Pishti.

Importance of Takra is explained in Grahani Adhyaya. Takra has Madhura, Amla and Kashaya Anurasa, Laghu Ruksha Guna and Ushna Virya. Buttermilk helps in iron absorption from the gut. In diseases like Arsas, Atisara, Grahani etc. iron metabolism is deranged and Pandu is mentioned as an Upadrava of Grahani. So, the medicaments including Takra explained in Grahani Prakarana can be inferred to have the properties to correct the deranged Dhatu Poshana Krama. Buttermilk also contributes to healthy gut microbiome. Maintaining the balance between the good and the bad bacteria in gut has been associated with enhancing the immune system and regulating metabolism.

Picha Basti is considered best for the treatment of Raktatisara and Grahani. Ingredients include Salmali Niryasa, Ghrita, Taila, Madhu and Dugdha. It acts as Shothahara and Vrana Ropaka which helps in healing the inflammation and ulcerations in the colon mucosa. It’s also act as Raktasthambaka, Sangrahi, Pitta Shamaka and Agnideepaka. It helps in expelling the circulating inflammatory markers in the gut.

After the treatment, symptoms have reduced significantly. Weight has increased significantly and menstrual cycle has restarted which substantiates the normalization of Dhatu Poshana and improvement in Agni.

After these improvements allopathic medications were tapered. The patient is still on follow up and no episodes of exacerbations in symptoms were witnessed and patient is continuing the treatment.

Conclusion

Crohn’s disease is a multisystemic gastrointestinal disorder with an autoimmune pathology. The present case of Crohn’s disease was diagnosed as Raktaja Atisara with Grahani Dushti. In the contemporary science treatments include corticosteroids, amino salicylates, immunosuppressants, biologics, antibiotics etc. which are having some undesired effects and limitations. The promising results of Ayurveda medications boosts the confidence of the patients to adopt and explore Ayurveda treatments. Treatment principles aimed at correcting Agnimandhya, Atisara, Raktasrava, Dhatu Poshana and Grahani Balavardhana helps in the effective management of Crohn’s disease.

References

1. Feuerstein JD, Cheifetz AS. Crohn Disease: Epidemiology, Diagnosis, and Management. Mayo Clin Proc. 2017 Jul;92(7):1088-1103. Available from: Crohn Disease: Epidemiology, Diagnosis, and Management - PubMed (nih.gov) doi: 10.1016/j.mayocp.2017.04.010.

2. Crohn Disease - StatPearls - NCBI Bookshelf (nih.gov)

3. Madhava Nidana with Madhukosha commentary. Bramhmanand Tripathi, editor. (reprint ed.) Vol 1, Atisaranidanam verse 4 Varanasi: Chaukhamba SurBharati Prakashan;2007,pg 193

4. Acharya YT, editor, (reprint ed.) Commentary Ayurveda-Dipika of Chakrapanidatta on Charaka Samhitha of Agnivesha, Chikitsasthana Verse 19/9. Varanasi: Chaukhamba Orientalia,2015; pg 549.

5. Harvey-Bradshaw Index (HBI) for Crohn's Disease (mdcalc.com)


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