E-ISSN:2456-3110

Case Report

Viral Hepatitis

Journal of Ayurveda and Integrated Medical Sciences

2024 Volume 9 Number 12 DECEMBER
Publisherwww.maharshicharaka.in

Treating an Acute case of Koshtashrita Kamala (Viral Hepatitis) with Classical Virechana – A Case Report

Chandrika V1*, VenkataKrishna KV2
DOI:10.21760/jaims.9.12.37

1* Chandrika V, Post Graduate Scholar, Department of Swasthavritta and Yoga, Government Ayurveda Medical College and Hospital, Mysuru, Karnataka, India.

2 VenkataKrishna KV, 2Professor and HOD, Department of Swasthavritta and Yoga, Government Ayurveda Medical College and Hospital, Mysuru, Karnataka, India.

Kamala is a Raktapradoshaja[1] Vyadhi involving Rakta and Pitta. When a Pandurogi follows Pittavriddhikara Ahara[2] and Vihara, the vitiated Pitta along with Rakta hampers the functioning of Prakruta Pitta, leading to Peeta Twak, Mutra, and Netra, associated with other Lakshanas like Aruchi, Dourbalya, Avipaka, Balakshaya, Tandra, Bhekavarnata and Indriyadourbalya. It is classified into 2 types Koshtashrita (Bahu Pittakamala) and Shakashrita[3] (Alpa Pittakamala) Kamala based on the Lakshanas. Considering the Avastha of Pitta, Virechana[4] is said to be the treatment of choice to eliminate the vitiated Doshas. Viral hepatitis[5] is generally a self-limiting disease but when it turns chronic leads to complications. Often acute hepatitis is characterized with anorexia, fatigue, hyperbilirubinemia, nausea, and vomiting. Here is a case of 30-year-old women with complaints of reduced appetite, abdominal bloating, yellowish discoloration of sclera and urine since 4 days, with a history of fever and elevated bilirubin levels along with other components of the liver function test. She was initially treated with Shamanoushadhi followed by Udwartana, Snehapana and classical Virechana, for a period of 15days, followed by which the liver function tests were repeated. It showed marked changes in the Liver panel. Also, in addition to this it showed changes in certain blood parameters like lipid profile and HbA¬¬1C. Snehapana followed by Virechana aids in elimination of the aggravated Pitta Dosha in Kamala, which can be interpreted using the investigation reports. Also, the action of Virechana on other blood parameters can be understood in the present study.

Keywords: Ayurveda, Jaundice, Virechana, Viral hepatitis

Corresponding Author How to Cite this Article To Browse
Chandrika V, Post Graduate Scholar, Department of Swasthavritta and Yoga, Government Ayurveda Medical College and Hospital, Mysuru, Karnataka, India.
Email: 		Chandrika V, VenkataKrishna KV, Treating an Acute case of Koshtashrita Kamala (Viral Hepatitis) with Classical Virechana – A Case Report. J Ayu Int Med Sci. 2024;9(12):276-281.
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https://jaims.in/jaims/article/view/3916/

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2024-11-13 2024-11-23 2024-12-03 2024-12-13 2024-12-24
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© 2024by Chandrika V, VenkataKrishna KVand 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].

J Ayu Int Med Sci 2024;9(12)276
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Chandrika V et al. Treating an Acute case of Koshtashrita Kamala (Viral Hepatitis)

Introduction

Kamala is one among the Raktapradoshaja Vikaras, it is either presided by Pandu Roga or can also occur as an independent disease. Excessive intake of Amla, Lavana, Kshara, Ushna, Teekshna Ahara[6] and following Viharas like Divaswapna, Vyayama improperly, causes Pittavriddhi in the Sharira, this vitiated Pitta, due to its similarities with Rakta in Gunas and Ashraya Ashrayi Bhava, vitiates the Rakta Dhatu, which in turn reaches the Mamsa Dhatu and produces Dagdhatva in it, further it also hampers the Utpatti Sthana of Rakta which is Yakrit and leads to Kamala. It manifests either as Koshtashrita Kamala where the Doshas are present in Mahasrotas and show symptoms of Agnisada, Aruchi, Haridra Netra, Twak, Mutra, Nakha and Anana, Rakta Peetashakrut, Mutra, Bhekavarnata and Hatendriya. Or as Shakhashrita Kamala, where in along with the above symptoms Tilapishtanibha Varcha, Hikka, Shwasa, Jwara, Atopa are also seen. Treatment protocol of Kamala states, “Samshodhyo Mrudubhistiktaihi Kaamalitu Virechane”[7], Virechana as the line of treatment for elimination of the vitiated Pitta. Hence, in the present study Snehapana was given with Panchagavya Ghrita which is also indicated in Pandu and Kamala, followed by Virechana with Katuki Kashaya and Gandharvahastadi Eranda Taila.

Hepatitis[8] refers to the inflammation of hepatocytes which is either of infectious (viral, bacterial, fungal, parasitic) origin or non-infectious (alcohol, drugs, metabolic diseases, autoimmune diseases) origin. It may be acute or chronic in nature. Acute illness is generally self-limiting but if it becomes chronic, it may lead to liver cirrhosis or liver failure. Hepatitis A, E are due to contamination of food and water, whereas B, C and D spread with contact of body fluids. As viral hepatitis is self-limiting, its treatment includes rehydration and antiviral therapies. Hepatitis generally shows changes in the LFT, with elevated bilirubin levels, SGOT, SGPT and Alkaline phosphatase levels. This case study also documents the changes observed in the blood parameters on following the treatment protocol.

Case Report

Personal data

Age: 30years

Gender: Female
Ethnicity: Indian
Occupation: Software engineer

Chief complaints: A 30years old female with complaints of reduced appetite, abdominal bloating, yellowish discoloration of urine and sclera since 4 days. With a history of fever and chills prior to this.

History of present illness: The patient was asymptomatic 4 days ago, later she had an episode of fever associated with chills, which subsided on intake of antipyretic medications. Since then, she has been having symptoms of reduced appetite, abdominal bloating. Later she started to notice yellowish discoloration of urine and sclera. For the same she consulted a physician and found mild relief, but later she started to notice itching in B/L upper and lower limbs which aggravated in the night hours. She again revisited the physician and found relief. For addressing the issue completely, she then approached GAMC.

History of past illness: N/K/C/O DM or HTN

Medication history: She is not on any regular medications.

Family history: Mother is K/C/O Viral Hepatitis B.

Personal history: Presently her appetite is reduced, Bowel is normal in consistency, yellowish in color, Micturition is dark yellowish, Sleep is disturbed, No history of addiction.

Vitals: Temperature - 98.6°F; BP - 130/80mm Hg; Pulse - 78bpm; Respiratory rate - 14cycles per minute.

Detailed history before treatment

Agni: Patient had reduced appetite for 4 days, preceded by fever episode. Her hunger was low, and appetite was also reduced.

Anthropometric measurements

Height - 171cms
Weight - 91kgs
Mid-arm circumference - 32.5cms (Rt), 33.5cms (Lft)
Mid-thigh circumference - 50cms (Rt), 52cms (Lft)
Waist circumference - 105cms
Waist-Hip ratio - 0.96

Dashavidha Pareeksha

Prakruti: Kapha Pittaja


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Chandrika V et al. Treating an Acute case of Koshtashrita Kamala (Viral Hepatitis)

Vikruti: Rasa, Rakta
Saara: Madhyama
Samhanana: Madhyama
Satva: Pravara
Satmya: Pravara
Pramana: Ht: 171cms Wt: 91kgs
Aharashakti: Abhyavaharana and Jarana: Avara
Vyayamashakti: Pravara
Vaya: Madhyama

Laboratory investigations: Patient was advised to undergo certain investigations including LFT, Lipid Profile, HbA1C, CBC, FBS and PPBS.

Intervention: The patient was initially treated with Shamanoushadhi consisting of Katuki Kashaya 50ml HS and Syp.

Livotrim for 2 days, followed by which Krishnajeeraka Taila 50ml was also added along with Katuki Kashaya for 3 days.

Post this patient got admitted in Hitech Panchakarma Hospital and was given Udwartana with Triphala Churna + Sarshapa Churna + Kulattha Churna and Koshta Shodhana with 50ml each of Katuki Churna and Gandharvahastadi Eranda Taila HS for 3 days. Snehapana was planned with Panchagavya Ghrita and Gandharvahastadi Eranda Taila for 7 days. Vishrama Kala of 3days was given with Sarvanga Abhyanga with Ksheerabala Taila followed by Bashpa Sweda. Virechana was given with 50ml Katuki Kashaya and 50ml Gandharvahastadi Eranda Taila. She had 18 Vegas and was then advised Samsarjana Krama for 5days.

Table 1: Gives a detailed description of the Chikitsa given.

DateLakshanasTreatmentKshudaMalaMutraJihva
29/09/23Aruchi, Glani, Peeta Netra and MutraKatuki Kashaya 50ml HS
Gangadhara Yoga 1 BD
Syp. Livotrim 15ml BD		Reduced1 episode of well formed stool2-3 Vegas
Yellowish		-
01/10/23Previous symptoms reduced but she developed urticarial rashes over B/L forearms.Along with the above, 50ml Krishnajeeraka Taila was added HSReducedWell formed stools3- 4 Vegas
Yellowish		-
10/10/23Mild yellowish discoloration of sclera, itching all over the body, more on B/L upper and lower limbs associated with blackish discoloration.Sarvanga Udwartana with Triphala + Sarshapa + Kulattha Churna
50ml Katuki Kashaya with 10ml GH Eranda Taila HS		Reduced1 episode of well-formed stool3-4 Vegas straw coloredLipta
11/10/23Blackish discoloration persisted.
No fresh complaints		Udwartana - Day 2
Katuki Kashaya HS		Reduced2 Vegas
Semi liquid consistency		3-4 Vegas straw coloredLipta
12/10/23No fresh complaints
Blackish discoloration persisted.		Udwartana - Day 3
Katuki Kashaya HS		Improved3 Vegas
Semi liquid consistency		3-4 Vegas
Straw colored		Alpa Lipta

DateLakshanasTreatment Snehapana PG Ghrita + GH Eranda TailaUdgara ShuddhiKshut PravrittiAppetiteVega
13/10/23Complained of mild abdominal discomfort30ml10ml12:20pm12:30pmGood4
14/10/23Loose watery stools60ml20ml12:15pm12:30pmGood7
15/10/23Loose watery stools110ml10ml12:20pm12:30pmGood2
16/10/23Mild dryness of skin and itching
Abdominal discomfort reduced		150ml10ml2:15pm2:30pmGood1
17/10/23Generalized weakness170ml10ml4:10pm4:45pmGood2
18/10/23Malaise reduced190ml20ml4:15pm4:30pmGood3
19/10/23No fresh complaints230ml20ml1:50pm2:30pmGood3

DateLakshanasTreatmentKshudMalaMutraJihva
20/10/23Abdominal discomfort reducedSarvanga Abhyanga with Ksheerabala Taila
Bashpa Sweda D1		Good1 episode of semisolid stool4-5 Vegas
Straw colored		Alipta
21/10/23Abdominal discomfort reduced.
Itching mildly persists		Sarvanga Abhyanga
D2		Good2 episodes of semisolid stools3-4 VegasAlipta
22/10/23Itching reducedSarvanga Abhyanga
D3		Good2 episodes of semisolid stools4-5 VegasAlipta
23/10/23Abdominal discomfort presentVirechana with 50ml Katuki Kashaya + 50ml Gandharvahastadi Eranda Tailam-Total
18 Vegas

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Results

Post treatment patient found marked improvement in the appetite, itching in bilateral upper limbs (forearm) reduced and she also felt reduction in abdominal discomfort.

AnthropometryBefore TreatmentAfter Treatment
Weight91kgs84kgs
Mid-arm circumference32.5cms (Rt), 33.5cms (Lft)30cms (Rt), 31.5cms (Lft)
Mid-thigh circumference50cms (Rt), 52cms (Lft)48cms (Rt), 50.5cms (Lft)
Waist circumference105cms99cms
Hip circumference109cms104cms
Waist-Hip ratio0.960.95

Blood parameterBefore Treatment (28/09/2023)After Treatment (29/10/2023)
LPT Total cholesterol223mg/dl150.0mg/dl
Triglycerides413mg/dl90.0mg/dl
LDL95.8mg/dl86.0mg/dl
HDL44.6mg/dl36.0mg/dl
LFT Total bilirubin6.4mg/dl0.9mg/dl
Direct bilirubin3.1mg/dl0.2mg/dl
Indirect bilirubin3.30mg/dl0.7mg/dl
SGOT201U/L51.2U/L
SGPT444U/L56.2U/L
ALP344U/L190.0 IU/L
FBS115mg/dl96mg/dl
PPBS162mg/dl127.2mg/dl
HbA1C8.8%5.9%

Discussion

Kamala involves both Pitta and Rakta in its manifestation, in this case there was involvement of both Pitta, Kapha and Rakta in the Samprapti, hence Virechana Karma was opted as the treatment protocol. Virechana Karma helps to eliminate the vitiated Pitta and Kapha Dosha from the Shareera. As the Poorvakarma for Virechana, Snehapana was planned with Panchagavya Ghrita.

Panchagavya Ghrita[9] has Go Shakrit, Go Ksheera, Go Ghrita, Go Mutra and Go Ghrita in its preparation. It is indicated in Apasmara, Jwara, Unmada and Kamala. Go Ghrita[10] has Madhura Rasa, Sheeta Virya, Snigdha Guna, and Vatapittahara Karma, Go Mutra[11] has Katu, Tikta, Kashaya Rasa, Ushna Virya, Laghu Guna, Katu Vipaka, Agni Deepana, Pitta Kara, Vatakaphahara Karma, Go Dadhi has Madhura, Amla Rasa,

Ushna Virya, Snighdha, Guru Guna, Amla Vipaka, Vatagna, Kaphakara, Brumhana, Graahi, Shukrala Karma, Go Ksheera[12] has Sheeta, Snigdha Guna, Madhura Arsa, Sheeta Virya, Madhura Vipaka, Brumhana, Hrudya, Medhya, Chakshushya, Rasayana and Ojovardhaka Karmas. Go Shakrit[13] has Kshara Guna. This Ghrita acts as Pitta and Kaphahara, it was here used for Snehapana, due to presence of Gomutra and Goshakrit in it which have Tikshna, Ushna, Kshara Gunas it acts as Vyavayi and helps to reach the minute Srotas and does Vilayana of the Mala in the Dhatus, and easily brings it to the Koshta.

Ksheerabala Taila[14] was used for Abhyanga during the Vishrama Kala, it contains Bala Kalka, Kashaya and Go Ksheera prepared into Paka in Tila Taila, it further helps in Vilayana of the Doshas. Patient was also advised to take Amla Bhojana during Vishrama Kala. It included addition of juice of half lemon in every meal for 3 days. Nimbuka[15] is said to be Teekshna, Amla, Pittakaraka. With these Gunas it helps to cause Utklesha of Pitta which helps in easy elimination of the Doshas during Virechana. Katuki Churna[16] which has Tikta Rasa, Katu Vipaka, Ruksha, Laghu Guna, Sheeta Virya, Kaphapittahara Karma, was selected as the Virechana Dravya due to its Bhedana and Rechana action. Along with this Gandharvahastadi Eranda Taila[17] was also used for Virechana, it has Gandharvahasta Moola, Yava, Nagara, Jala, Ksheera, Eranda Taila and Shunti. It helps in Ama Pachana and acts as Vatahara by its Ushna, Snigdha, Guru Guna and has Anulomana properties. It also acts as Malashodaka and has Sookshma Srotogamana Karma.

Virechana Karma acts on the Pitta Dosha primarily, but in this case the Aushadha selection was made in such a way that it acted on Kapha Samsrushta Pitta Dosha. Post Virechana it was also observed that there were significant changes in the blood parameters like Lipid profile, HbA1C and Liver function test indicating the action of Shodana Karma on the Dhatus.

Conclusion

Virechana Karma has a key role in eliminating the Pitta Samsrushta Doshas. It eliminates the Prakupita Pitta which is accumulated in the body and manifests Kamala.


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Snehapana helps to reach the Dhatus and does Vilayana of the Doshas that are accumulate in each of them, it also carries all the Doshas to the Koshta for the evacuation of the same.

References

1. Agnivesa, Charaka Samhita, Ayurveda Dipika Commentary of Chakrapanidatta, edited by; Vaidya Jadavaji Trikamji Acharya, Chaukhambha publications, Varanasi, reprint-2014, page no 179

2. Agnivesa, Charaka Samhita, Ayurveda Dipika Commentary of Chakrapanidatta, edited by; Vaidya Jadavaji Trikamji Acharya, Chaukhambha publications, Varanasi, reprint-2014, page no 528

3. Agnivesa, Charaka Samhita, Ayurveda Dipika Commentary of Chakrapanidatta, edited by; Vaidya Jadavaji Trikamji Acharya, Chaukhambha publications, Varanasi, reprint-2014, page no 529

4. Agnivesa, Charaka Samhita, Ayurveda Dipika Commentary of Chakrapanidatta, edited by; Vaidya Jadavaji Trikamji Acharya, Chaukhambha publications, Varanasi, reprint-2014, page no 125

5. https://www.niddk.nih.gov/health-information/liver-disease/viral-hepatitis/what-is-viral-hepatitis

6. Agnivesa, Charaka Samhita, Ayurveda Dipika Commentary of Chakrapanidatta, edited by; Vaidya Jadavaji Trikamji Acharya, Chaukhambha publications, Varanasi, reprint-2014, page no 536

7. Agnivesa, Charaka Samhita, Ayurveda Dipika Commentary of Chakrapanidatta, edited by; Vaidya Jadavaji Trikamji Acharya, Chaukhambha publications, Varanasi, reprint-2014, page no 529

8. https://www.who.int/health-topics/hepatitis#:~:text=Hepatitis%20is%20an%20inflammation%20of,%2C%20C%2C%20D%20and%20E.

9. Vagbhata, Ashtanga Hrudayam, Sarvangasundara Commentary of Arunadatta and Ayurvedarasayana of Hemadri, edited by; Pt. Hari Sadasiva Sastri Paradakara, Chaukhamba Orientalia Prakashan, Varanasi, reprint-2022.

10. https://www.easyayurveda.com/2009/08/12/ayurvedic-description-of-ghee-ghritam/

11. https://www.easyayurveda.com/2011/05/10/cow-urine-therapy-benefits-indication-and-contra-indications/

12. https://www.easyayurveda.com/2011/06/23/cow-milk-benefits-according-to-ayurveda/

13. https://www.researchgate.net/publication/362215158_Sariga_JDRAS_Gomaya_swarasa

14. https://www.ayurmedinfo.com/2019/01/28/ksheerabala-thailam-kshirabala-oil/

15. https://www.easyayurveda.com/2012/11/14/health-benefits-of-lemon-ayurveda-details/

16. https://www.easyayurveda.com/2014/07/17/kutki-picrorhiza-kurroa-benefits-dose-side-effects-research/

17. https://www.ayurmedinfo.com/2012/06/03/gandharvahasthadi-thailam-benefits-how-to-use-ingredients-side-effects

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