E-ISSN:2456-3110

Case Report

Gallbladder Stones

Journal of Ayurveda and Integrated Medical Sciences

2024 Volume 9 Number 12 DECEMBER
Publisherwww.maharshicharaka.in

Holistic management of Gallbladder Stones (Pittashmari): A Case Study

Chaudhary G1*, Manish Ji A2, Richa3, Srivastava RK4
DOI:10.21760/jaims.9.12.46

1* Gitika Chaudhary, Senior Consultant, General Surgeon, Jeena Sikho Lifecare Limited, Zirakpur, Punjab, India.

2 Acharya Manish Ji, Director, Meditation Guru, Jeena Sikho Lifecare Limited, Zirakpur, Punjab, India.

3 Richa, Research Officer, Jeena Sikho Lifecare Limited, Zirakpur, Punjab, India.

4 Ritesh Kumar Srivastava, Consultant, Jeena Sikho Lifecare Limited Clinic, Allahabad, Uttar Pradesh, India.

Cholelithiasis, commonly known as gallstone disease, affects a significant portion of the global population, often leading to debilitating symptoms like biliary colic and digestive discomfort. This condition is caused by an imbalance in bile composition, stasis and infection within the biliary system. In Ayurveda, cholelithiasis is referred as "Pittashmari," with an imbalance of Pitta and Kapha Doshas leading to the formation of stones in the gallbladder. The aim of this case study was to explore the effectiveness of Ayurvedic treatment in managing cholelithiasis by addressing its root cause through Dosha - balancing therapies. A 23-year-old male patient with a solitary intraluminal gallstone, underwent two and a half-month Ayurvedic treatment protocol consisting of Ayurvedic formulations, including GBS Powder, Stoni Cap, Amla Pittanashak Powder and Yakrit Shothhar Vati. Pre and post-treatment evaluations using ultrasonography and subjective pain assessments revealed significant improvement. The gallstone size reduced, with no stones detected on follow-up ultrasound and the patient reported the complete relief from biliary colic and digestive symptoms. These findings suggests that Ayurvedic therapies targeting Pitta and Kapha imbalances, along with lifestyle modifications, offers an effective and holistic approach to manage gallstones. This integrated treatment strategy aligns with Ayurvedic principles of detoxification, digestion and systemic balance.

Keywords: Cholelithiasis, Pittashmari, Ayurvedic Medicines, Gall Bladder

Corresponding Author How to Cite this Article To Browse
Gitika Chaudhary, Senior Consultant, General Surgeon, Jeena Sikho Lifecare Limited, Zirakpur, Punjab, India.
Email: 		Chaudhary G, Manish Ji A, Richa, Srivastava RK, Holistic management of Gallbladder Stones (Pittashmari): A Case Study. J Ayu Int Med Sci. 2024;9(12):339-346.
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https://jaims.in/jaims/article/view/4130/

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 Chaudhary G, Manish Ji A, Richa, Srivastava RKand 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)339
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Gitika C et al. Holistic management of Gallbladder Stones (Pittashmari)

Introduction

Cholelithiasis, commonly known as gallstone disease, occurs when stone-like formations develop within the gallbladder. These gallstones primarily consist of cholesterol, bile pigments and calcium salts, stemming from imbalance in bile composition, bile stasis or infections within the biliary system.

Clinically, cholelithiasis presents a spectrum of manifestations, ranging from asymptomatic stage to severe symptoms such as biliary colic, acute cholecystitis, cholangitis and pancreatitis. It affects approximately 10-15% of the adult population globally, with higher incidence rates noted in females, individuals with obesity and those over the age of 40.[1],[2]

From a classical Ayurvedic viewpoint, this condition correlates with "Pittashmari", merging "Pitta" (bile) and "Ashmari" (stone), symbolizing the pathological formation of stones due to a disturbance in bodily energies. Key references in Ayurvedic literature like the Charaka Samhita and Sushruta Samhita discuss the nature of Ashmari extensively, covering its aetiology, pathogenesis and therapeutic methods.[3],[4]

This suggest that an aggravation of Pitta and Kapha Doshas plays a critical role in cholelithiasis. Ayurvedic management of Pittashmari involves dietary and lifestyle modifications, Ayurvedic formulations such as Pashanabheda (Bergenia ligulata) and Gokshura (Tribulus terrestris) and detoxification therapies like Panchakarma, aiming to restore Doshic balance and prevent future stone formation.[5],[6]

Modern medical perspectives on cholelithiasis, align with Ayurveda in recognizing the importance of metabolic imbalances and lifestyle factors, in the pathology of the disease. Advanced diagnostic tools and imaging technologies now plays a crucial role in the accurate detection and assessment of gallstones, enhancing treatment precision and efficacy.

Integrating these contemporary diagnostic techniques with traditional Ayurvedic treatment strategies holds promise for a holistic approach to manage cholelithiasis, addressing both symptomatic relief and the root causes to reduce recurrence rates.[7]

Case Report

A 23-year-old male presented with a six-month history of intermittent colicky pain localized to the upper right abdomen and epigastric region, which exacerbated particularly after meal consumption. Accompanying symptoms included occasional nausea, bloating and discomfort following the intake of fatty or spicy foods. Over the previous three months, the patient noticed a decreased appetite and had experienced recurrent episodes of indigestion. He also reported disturbances in his sleep pattern during the same period.

Upon diagnostic evaluation using ultrasound imaging, gallbladder stones were identified, confirming the condition of cholelithiasis. The patient disclosed that, he did not have any significant previous medical, surgical or familial history of related conditions. However, he admitted to a dietary pattern irregular in nature, predominantly consisting of high-fat and spicy foods, which likely contributed to the present condition. In terms of treatment history, the patient had not taken any specific allopathic or Ayurvedic medicines for gallstones before this consultation. Until his diagnosis, there was no therapeutic intervention for his gastrointestinal symptoms. The patient's lifestyle was noted to include sporadic physical activity and significant periods of sedentary behaviour, which, combined with his dietary habits, might have contributed to the onset and progression of the gallstone formation.

The onset of his symptoms was gradual, commencing subtly with digestive discomfort and progressively leading to more pronounced abdominal pain and other digestive issues over several months. This progression suggests a gradual increase in either the size or number of gallstones, exacerbating the obstruction of bile flow and the associated symptoms.

Investigation Assessment:

The patient was diagnosed with Cholelithiasis based on clinical symptoms and imaging. Ultrasonography revealed solitary intraluminal calculi of ~5.0mm in the neck region of the gallbladder. His Ayurvedic diagnosis was based on the principles of Samprapti (pathogenesis), which reflects a disturbance in the balance of the doshas and their effects on the bodily systems.


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Ayurvedic Disease Assessment:

Dominant Doshas: Pitta and Kapha

Doshic imbalance: Aggravated Pitta (heat) & Kapha (congestion) leading to obstruction of gallbladder (Pitta Ashrita Kapha), resulting in formation of Pitta Ashrita Shleshma (bile-dominant mucus).

Samprapti (Pathogenesis):

In Ayurveda, the pathogenesis of gallstones is understood through the following process:

1. Imbalance of Doshas: An aggravated Pitta causes increased bile secretion and a tendency to form cholesterol stones. The Kaphadosha, when disturbed, contributes to stagnation and improper elimination of bile.

2. Utklesha (Movement of Doshas): The disturbed Pitta circulates through the liver and gallbladder, thickens bile, while Kapha stagnates bile flow. This results in the formation of solidified deposits, leading to stone formation.

3. Srotorodha (Obstruction of Channels): The disturbed Doshas obstruct the bile ducts, leading to symptoms such as nausea, vomiting, and upper abdominal pain.

4. Shoshana (Dehydration of Tissues): The chronic imbalance of Doshas can lead to the dehydration of the gallbladder wall, further contributing to the solidification of bile.

Systemic Examination:

1. General Appearance: No visible abnormalities

2. Cardiovascular System (CVS): No Abnormality detected.

3. Respiratory System (RS): Normal breath sounds.

4. Gastrointestinal System (GIT): Hyperacidity, Heart Burn

a) Inspection: No visible abnormalities.
b) Palpation: Tenderness in right hypochondrium, particularly over gallbladder region (Murphy's sign), indicates gallbladder inflammation.
c) Percussion: Normal
d) Auscultation: Bowel sounds reduced.

5. Central Nervous System (CNS): Normal findings

6. Skin: No Abnormality detected.

Ayurvedic Examination

Table 1: Dashavidha Pariksha (Tenfold Examination)

SNExaminationFindings
1. Nadi (PulsePitta-Kaphaja
2. Mutra (Urine)Peeta Varna
3. Mala (Stool)Avikrita
4. Jihva (Tongue)Saam
5. Shabda (Voice)Spashta
6. Sparsha (Touch)Anushna Sheeta, tenderness in the right hypochondrium on palpation.
7. Drik (Eyes)Shweta
8. Akriti (Appearance)Sthoola; signs of abdominal distension.

Table 2: Timeline

EventDetails
09/09/2024Consultation for Ayurveda treatment and medicines started
16/11/2024Significant results achieved

Diagnostic Assessment

Ayurvedic Diagnosis: Pittashmari (cholelithiasis)

Objective Parameters:

1. Ultrasonographic evaluation of gallbladder for size, number and composition of stones.
2. To reduce in gallstone size or complete resolution post-treatment.

Subjective Parameters:

1. Assessment of pain severity using a Visual Analogue Scale (VAS) (0–10, where 0 = no pain and 10 = worst possible pain).[8]
2. Frequency and intensity of biliary colic episodes, categorized as

  • Mild (1–3 episodes/month)
  • Moderate (4–6 episodes/month)
  • Severe (≥7 episodes/month).[9]

3. Improvement in digestive symptoms such as bloating, nausea and indigestion, rated on a Likert scale (0 = no symptoms, 5 = severe symptoms).[10]


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4. Quality of life assessment using standardized questionnaires such as SF-36 or WHOQOL-BREF, with higher scores indicating better quality of life.[11]
5. Patient-reported satisfaction with treatment outcomes, rated on a 5-point scale (1 = very dissatisfied, 5 = very satisfied).[12]

Treatment Plan

1. Diet Plan:[19] The dietary guidelines provided by Jeena Sikho Lifecare Limited Clinic Allahabad were included the following key commendations:

a. Foods to be avoided:

  • Do not consume wheat, refined food, milk and milk products, coffee and tea and packed food.
  • Avoid eating after 8 PM.
  • During solid consume as small bite and chew 32 times.

b. Hydration:

  • During water intake, take sip by sip and drink slowly to ensure the amount of water intake each time.
  • Drink about 1 liter of alkaline water 3 to 4 times throughout the day.
  • Include Herbal tea, living water and turmeric-infused water part of daily routine.
  • Boil 2 liters water & reduce up to 1 liter and consume.

c. Millet Intake:

  • Incorporate five types of millet in to diet:
    Foxtail (Setariaitalica), Barnyard (Echinochloaesculenta), Little (Panicumsumatrense), Kodo (Paspalumscrobiculatum) and Browntop (Urochloa ramose).
  • Use only steel cookwares for preparing millets
  • Cook the millets only using mustard oil.

d. Meal Timing and Meal Structure:

  • Early Morning (5:45 AM): Herbal tea, curry leaves (1 leaf-1 min/5 leaves-5 min) along with raw ginger and turmeric.
  • Breakfast (9:00-10:00 AM): The patient had given steamed fruits (Seasonal), steamed sprouts (according to the season) and fermented millet shake (4-5 types).
  • Morning Snacks (11:00AM): The patient had given carrot juice (150 ml) and soaked almonds.
  • Lunch (12:30 PM - 2:00 PM): The patient had received Plate 1 and Plate 2. Plate 1 included a steamed salad, while Plate 2 with cooked millet-based dish along with raw ginger and turmeric.
  • Evening Snacks (4:00 – 4:20 PM): Green juice (100-150 ml) along with 4-5 almonds.
  • Dinner (6:15-7:30 PM): The patient had served a steamed salad, chutney and soup, as Plate 1, along with millet khichdi as Plate 2 along with raw ginger and turmeric.

e. Fasting:

  • It is advised to observe one-day fasting.

f. Special Instructions:

  • Express gratitude to the divine before consuming foods or drinks.
  • Sit in Vajrasana (a yoga posture) after each meal.
  • 10 minutes slow walk after every meal.

g. Diet Types:

  • The diet comprises salt-less solid, semi-solid and smoothie options.
  • Suggested foods include Herbal tea, red juice, green juice, a variety of steamed fruits, fermented millet shakes, soaked almonds and steamed salads.

2. Lifestyle Recommendations:
a) Includes meditation for relaxation.
b) Practice barefoot brisk walk for 30 minutes.
c) Ensure 6-8 hours of quality sleep each night.
d) Adhere to a structured daily routine.

Medicines Given

Table 1: First month – 09/09/2024

MedicationsDoseAnupanaDuration
GBS Powder1/2 Tsf BDLukewarm Water (Koshna Jala)Adhobhakta (After Meal)
Stoni Cap1 Capsule BDLukewarm Water (Koshna Jala)Adhobhakta (After Meal)
Amla Pittanashak Powder1/2 Tsf BDLukewarm Water (Koshna Jala)Pragbhakta (Before Meal)
YakritShothHarVati1 Tab BDLukewarm Water (Koshna Jala)Adhobhakta (After Meal)

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Table 2: Second Month - 16/11/2024

MedicationsDoseAnupanaDuration
Stoni Cap1 Capsule BDLukewarm Water (Koshna Jala)Adhobhakta (After Meal)
Avipattikar Powder1/2 TsfBDLukewarm Water (Koshna Jala)Pragbhakta (Before Meal)
Yakrit Shothhar Vati1 Tab BDLukewarm Water (Koshna Jala)Adhobhakta (After Meal)

Results and Outcome

After 2 months of Ayurvedic treatment, the results that were seen are-

Table 3: Outcomes – Objective Parameters

ParametersPre-TreatmentPost-Treatment
Ultrasonographic EvaluationSolitary intraluminal gallstone of ~5 mm observedNo Significant Abnormality detected.
Reduction in Gallstone SizeAverage stone size was 5 mmNo gall stones

The changes in the subjective parameters that were observed are-

Table 4: Outcomes – Subjective Parameters

ParametersPre-TreatmentPost-Treatment
Pain Severity (VAS)Average score of 8 (severe pain).Average score reduced to 0 (No pain).
Frequency of Biliary Colic EpisodesSevere frequency (7-8 episodes/monthNo frequency of colicky pain.
Digestive Symptoms (Likert Scale)Average score of 4 (moderate-to-severe symptoms).Average score reduced to 1 (mild-to-no symptoms).
Quality of Life (SF-36 or WHOQOL-BREFAverage score of 40 (poor quality of life).Average score increased to 75 (good quality of life).
Patient’s SatisfactionAverage satisfaction score of 1 (very dissatisfied).Average satisfaction score of 4 (satisfied).

Discussion

Cholelithiasis represents a complex interplay of pathophysiological factors from both modern and Ayurvedic perspectives. Modern medicine identifies key factors such as supersaturation of bile, impaired gallbladder motility and chronic inflammation leading to stone formation.

Diagnostic advancements like ultrasonography and biochemical markers aids in early detection and monitoring. In contrast, Ayurveda correlates this condition with "Pittashmari" emphasizing the role of aggravated Pitta and Kaphadoshas and the subsequent formation of calculi due to systemic and local imbalances.

The treatment strategy employed in this case aimed to address the root cause of gallstone formation by breaking the Samprapti (pathogenesis) through a combination of oral medications and dietary modifications. During the first month, GBS Powder, Stoni Cap, Amla Pittanashak Powder and Yakrit Shoth Har Vati were administered to reduce Pitta-Kapha imbalance and to promote the dissolution of gallstones. These formulations, rich in lithotriptic, anti-inflammatory and hepatoprotective properties, facilitated the breakdown of stones and alleviated associated symptoms.[13],[14]

In the second month, Avipattikar Powder was introduced to enhance digestion and reduce acidity, alongside continued use of Stoni Cap and Yakrit Shoth Har Vati to sustain the anti-lithogenic effect. The gradual improvement observed in ultrasonographic parameters and subjective outcomes, such as pain reduction and enhanced quality of life, underscores the efficacy of this integrated approach. The therapeutic protocol aligns with Ayurvedic principles emphasizing detoxification and systemic balance.15

The probable mechanism of action of the formulations in this study are GBS Powder, such as Varsabhu, Patherchat, and HajrulyahoodBhasam, targets the imbalance of Pitta and Kaphadoshas, which are the key contributors to Pittashmari (gallstone disease). Their lithotriptic properties helps to disintegrate calculi, while anti-inflammatory actions reduce associated symptoms. Additionally, herbs like Gokshura and Sfatika Bhasam promotes bile flow and prevents recurrence.

Stoni Cap, comprising Pashan Bhed, Gokhru Chota, Kulthi, Pather Bar, Elaichi Badi, Jawakhar, Akshar, Shudh Shilajeet, and Hajrulyahood Bhasam, offers a comprehensive approach to manage gallstones through its lithotriptic, diuretic and anti-inflammatory properties. Pashan Bhed and Gokhru Chota aids in breaking and expelling gallstones, while Kulthi and Pather Bar enhance bile flow and digestion, addressing bile stasis.


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Elaichi Badi alleviates associated symptoms like bloating and nausea. Jawakhar and Akshar, with their alkalizing and litholytic effects, contribute to stone dissolution. Shudh Shilajeet acts as a hepatoprotective and adaptogen, improving liver function and bile metabolism. Hajrulyahood Bhasam specifically targets the disintegration of calculi, preventing recurrence by maintaining the balance of bile composition. These combined actions align with Ayurvedic principles of detoxification and dosha equilibrium, effectively breaking the pathogenesis of Pittashmari.

Amla Pittanashak Powder includes ingredients like Shunti, Maricha, Pippali, Amalaki, Bibhitaka, and Haritaki, which balances aggravated Pitta and Kaphadoshas while enhancing digestive fire (Agni). Shunti, Maricha, and Pippali (Trikatu) improves digestion and alleviates bloating by promoting bile secretion. Amalaki, Bibhitaka and Haritaki (Triphala) possess antioxidant and anti-inflammatory properties, aiding in detoxification and digestion. Musta and Sukshmaila regulates acid production and prevent gastritis, while Tvak Patra, Vidanga, Lavanga, and Bid Lavana exhibit carminative and antimicrobial properties. Trivrita and Sharkara acts as mild laxatives, supporting gut health and clearing Ama (toxic metabolites). Together, these ingredients promote bile flow, reduce inflammation, and support resolution of gallstones. Yakrit Shoth Har Vati is composed of herbs like Punarnava, Kalimirch, Pippali and Kutki, which exhibit anti-inflammatory, hepatoprotective and detoxifying properties. Punarnava reduces hepatic inflammation and acts as a diuretic, while Kutki supports liver function by enhancing bile secretion and detoxification. Kalimirch, Pippali, and Vayavidanga stimulate digestion and metabolism, preventing bile stasis. Other ingredients like Chitrak, Devdaru and Amla Danti helps in breaking down Ama (toxic metabolites) and reduce congestion in biliary tract. Mandur Bhasam aids in correcting anaemia and improving liver health. Together, this formulation helps to alleviate symptoms of gallstones by addressing underlying Pitta-Kapha imbalance and improving liver function. A study by Pandya et al. (2022) examined effects of a combination of Ayurvedic formulations in management of cholelithiasis. The research indicated that Ayurvedic treatments, particularly those targeting Pitta and Kaphadosha imbalance, helped in reducing gallstone size and improving gallbladder motility.

Their findings suggested that the lithotripsic properties of certain herbs like Chitrak, Kutki and Bhumyamalaki contributed to the dissolution of stones and reduction of symptoms.[16]. Similarly, a study by Mishra and Tiwari (2021) investigated the use of Kanchanar Guggulu, an Ayurvedic formulation known for its anti-inflammatory and anti-lithogenic properties. The research found significant improvements in gallstone size and the reduction of pain and discomfort associated with the condition.[17]

Furthermore, research by Kumar et al. (2020) highlighted the role of Amla Pittanashak Powder and Yakrit Shoth Har Vati in managing cholelithiasis by restoring the balance of digestive fire (Agni) and reducing systemic inflammation. The study concluded that these formulations were effective in treating the root causes of gallstone formation, as they targeted the aggravated Pitta and Kaphadoshas that contribute to the disease process.[18]

These studies align with the Ayurvedic view of cholelithiasis as a disease resulting from internal imbalance, with an emphasis on addressing the pathogenesis rather than merely the symptoms. The promising results from Ayurvedic treatments in managing cholelithiasis, as observed in these studies, underscores the importance of combining traditional knowledge with modern diagnostic methods for holistic treatment approaches.

Need for Further Research

Although promising results have been observed with the integration of Ayurvedic and modern approaches in managing cholelithiasis, there remain significant gaps in the literature. Most studies exploring Ayurvedic formulations, such as Pashanabheda and Gokshura, are limited to small sample sizes and lack standardization in methodology. Large-scale randomized controlled trials are necessary to validate their litholytic efficacy, safety and reproducibility.

Additionally, the pharmacodynamics and pharmacokinetics of Ayurvedic formulations in the context of gallstone dissolution requires further investigation. Advances in biochemical and molecular analyses could shed light on the mechanisms by which these herbs interact with bile metabolism and inflammation pathways.


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Comparative studies assessing Ayurvedic therapies alongside conventional bile salt’s treatments, such as ursodeoxycholic acid, would help to establish evidence-based integrative protocols.

jaims_4130_01.JPG
Image 1: Before Treatment Ultrasonography reports

jaims_4130_02.JPG
Image 2: Post Treatment Ultrasonography reports

Conclusion

This case study highlights the efficacy of Ayurvedic treatment in managing cholelithiasis, focusing on rectifying imbalance of Pitta & Kaphadoshas, which are vital factors in onset & progression of disease.

The patient presented with symptoms including abdominal pain, nausea and indigestion, which are characteristic of gallstone disease. Through the use of Ayurvedic formulations designed to enhance bile flow, alleviate inflammation and dissolve gallstones, there was a significant improvement in both the physical symptoms and the underlying condition. Diagnostic investigations like ultrasound imaging confirmed a reduction in gallstone size. By integrating these traditional Ayurvedic treatments with modern diagnostic techniques, the approach not only addressed the immediate symptoms but also contributed to the long-term management and prevention of gallstones. This holistic strategy underscores the therapeutic potential of Ayurveda in treating complex conditions such as cholelithiasis.

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