Case-presentation– AYURVEDIC MANAGEMENT OF CHRONIC PANCREATITIS– JIRNA-PITTODARA.

AYURVEDIC MANAGEMENT

OF CHRONIC PANCREATITIS

 (JEERNA-PITTODAR)

                             

*Dr. Nirali S. Thacker

**Prof. Surendra A. Soni

 

 

ABSTRACT

                        

The case of chronic pancreatitis with Malabsorption Syndrome with presentation of diabetes mellitus was treated successfully with classical line of treatment of Pittodara chikitsa. In ayurveda we can corelate it with Pittodara. Treatment given includes the use of Kshirbasti, Deepana, Pachana, Anulomana, Srotoshodhana, Brinhana, Ksheer abhyasa etc. targeting to the basic site of pathology along with main site of pitta Dosha (Aamashya).

Pancreatitis usually leads to Diabetes Mellitus and other consequences including malignancy if not checked appropriately, while timely ayurveda management not only cure the disease but also check the all its consequences that is mentioned in this case study.

 

KEYWORDS : 

Chronic pancreatitis, Malabsorption syndrome, Diabetes mellitus, Pittodara, Pancreatic cancer, Kshirbasti, Deepana, Pachana, Anulomana, Sroto-shodhana, Brinhana, Ksheer abhyasa, pitta dosha, Aamashya.

 

INTRODUCTION

The Pancreas is a large organ behind the stomach that produces digestive enzymes and a number of hormones. Pancreatitis is a condition characterized by inflammation of the pancreas. Pancreatitis is commonly described as autodigestion of the pancreas. There are two main types of clinical presentation: 

acute pancreatitis

chronic pancreatitis. 

Acute Pancreatitis is an acute inflammatory process of pancreas. The degree of inflammation varies from mild edema to severe hemorrhagic necrosis. Chronic pancreatitis is continuous, prolonged, inflammatory and fibrosing process of pancreas[i].

The annual incidence of chronic pancreatitis is 5-12 per 100000 persons, the prevalence is 50 per 1,00,000 persons[ii].The two most common causes of acute pancreatitis are; (1) A gallstone blocking the common bile duct after the pancreatic duct has joined and (2) heavy alcohol use. Chronic pancreatitis may develop as a result of acute pancreatitis. In chronic pancreatitis weight loss, steatorrhea, vomiting and diarrhea may occur[iii]. Complications may include infection, bleeding, diabetes mellitus, Jaundice, pancreatic cancer etc. As disease progresses defective autophagy, increased inflammation, pancreatic stellate cell activation and fibrosis occur[iv].

                                         According to Ayurveda Agnimandya is mentioned as basic etiological factor for development of Udararoga. Intake of excessive hot, saline, sour drinks, improper Samsarjana krama after Panchkarma therapy, Arsha, Grahani and Plihadosha, presence of Ama, ulcerations and perforations are the other causes described in our classics. Low and delayed digestion, burning sensation, inability to determine between digestion and indigestion, disappearance of folds with prominent network of veins over abdomen occurs initially are some of the prodromal features of Udara-roga. It has been described of eight types of Udar-rogas in Ayurveda[v].

We can correlate pancreatitis as Pittodara in ayurveda. Pittodara clinically presents with fever, burning sensation, thirst, diarrhea, fainting, yellowish discoloration of eyes, face, nails, skin, urine and stool, appearance of network of veins with blue, yellow, green, and coppery color. If not treated in time it gets easily suppurated. Virechana is advised but in weak patients, Anuvasana and Niruhbasti with Ksheera is advised. Eranda, panchatikta, Nishotha are given with different combinations of Virechana. Virechana or Virechana after Baladhana and constant Ksheera-abhyas are Chikitsa sutra of Pittodara[vi].

Pancreas is referred as Agnyashay in ayurveda. There are eight types of Koshthanga (visceral organs) described in ayurveda. Agnyashay is one of them. PachakaPitta is assumed as the Dravya of Agni and Agnyashaya is the container of Agni. When more Pachaka pitta accumulate in duodenum then it induces reflex and activate zymogen to induce Shopha of Agnyashya due to Usna-tikshna Gunas of Pitta can manifest Shopha. Gall bladder slug and sphincter of oddi dysfunction/obstruction and inflammation of pancreatic duct can be correlated with Sroto-sanga mentioned in Ayurveda. So Pitta-shamana and Sroto-shodhana are the therapeutic target in treatment of pancreatitis.

 

PRELIMINARY DATA OF PATIENT

Age- 23 year

Sex- female

Date of admission – 01/12/2021

Date of discharge – 02/02/2022

 

CASE DESCRIPTION

On dated 1 December 2021, she came at our hospital, she had complain of vomiting (after ate any type of food except coconut water) and lower abdomen pain. Then she was admitted in our hospital.

History of present illness

•      Patient was healthy before 10 years. Then, she had complaint of epigastric region pain and vomiting. So, she went to gastroenterologist for her treatment. She had been admitted at hospital for iv treatment for 8 days.

•      After every 6-8 months, she was admitted in hospital for same complains.

•      She was diagnosed with acute pancreatitis in 2018.

•      She was diagnosed with antral gastritis and Malabsorption syndrome in July 2021.

•      She was diagnosed with chronic pancreatitis in October 2021.

ON EXAMINATION

•      B.P. – 118/76 mm hg

•      P.R.-88 /min

•      R.R.- 20/min

•      Weight- 40 kg

Table 1:

Personal history
Diet	Vegetarian
Appetite	Normal
Bowel	1 time/day
Sleep	Normal
Micturition	5-6 time/day

 

Table 2:

Dashvidha pariksha
Prakriti	Pitta-vata
Vikruti	Lakshna nimitta
Sara	Rasa sara (madhyama)
Samhanana	Hina
Pramana	Hina
Satmya	Madhyama
Aaharashakti	Abhyavarana shakti : Hina Jaran shakti : Hina
Vyayamshakti	Hina
Vaya	Madhyama

Samprapti

                                                             Nidana Sevana  

Aaharaj- Katu,Amla-Lavan-Ushna-Teekshan-Vidahi

Viharaj- Agni-Aatap Seven

Adhyashan & Ajeernashan

(she ate too much pickle and oily spicy food )

 Prakupitten Vat-Shleshma Margavarodh

 Unmarg(Vimarg-gaman)

Agni-nash

 Pittodara

 

Upadrav

 

Table 3:

Samprati Ghataka
Dosha	Pitta pradhana tridosha (kledaka kapha kshay, pachak pitta kshay, apana vayu pratiloma gati)
Dushya	Prana, Agni, Apana sandusyUdaka, Rasa, Rakta ,Mamsa,Meda,Asthi,Majjja,Sukra
Srotas	Annavaha, Udakavaha, Purishvaha, Rasavaha, Raktavaha, Swedavaha
Udbhavasthana	Aamashaya
Adhisthana	Sharira
Vyktisthana	Udara, Agnasaya
Agni	Dhatvagni evam Jatharagni Manda
Srotodusti	Sanga
Sadhya-asadhyatva	Kruchhsadhya
Sama/nirama	Nirama

 

Table 4:Treatment

1/12/2021 to 1/2/2022

1.Shanshamani vati- 2/2/2             2.Sudarshan ghanvati- 2/2/2 3.Hingvashtak churna-2 gm   dhatriloha- 500mg    muktasukti bhasma- 500mg      1 X  2 time 4.Tab.Sooktyn-   2/2/2 5.Tab.cytozen-   2/2/2 6.Tab. Suv. Sootshekhar rasa- ½, ½, ½, ½ 7.Panch-karma –  Kshirbasti (bindu prakshep) Water – 1 litre  Milk -250 ml Guduchi churna -20 gm Vasa churna -20 gm Khadir churna -10 gm Kalmegh churna -20 gm Haridra churna -10 gm Lodhra churna -10 gm Punarnva churna -20 gm After  1 week , added 10 ml gomutra.

2/2/2022 to till now

1.Aarogyavardhini vati- 2/0/2 ( for 1 month ) 2.Sanshamani vati- 2/0/2 3.Poonarnava mandur- 2/0/2 4.Pathyadi kwath-10 gm 1 X 2 time      + kalmegh 5 gm         punarnava 5 gm Tab.Sooktyn-   2/2/2 Tab.cytozen-   2/2/2 Tab. Suv. Sootshekhar rasa- ½, ½, ½, ½

 

 

RESULT

Patient did not take any contemporary medicine and she got completely relief through ayurvedic treatment. After 3^rd day of treatment, improvement was seen in abdominal pain, nausea and vomiting. After 7 days of sansarjan krama, she could able to eat normal food. Kshirbasti holding time increase day by day. 26^th kshirbasti holding time was 24 hour. After 2 month  treatment patient had not any complaints.

 

 

Table 5:

 

No.	Symptoms of chronic pancreatitis		Duration	After treatment
1	Upper abdominal pain	Present	10 years(on & off )	Absent
2	Abdominal pain radiates to back	Absent	-	-
3	Abdominal pain that feels worse after eating	Present	10 years	Absent
4	Nausea	Present	10 years	Absent
5	Vomiting	Present	10 years	Absent
6	Weight loss	Present	Gradually	Absent
7	Diarrhea	Absent

DISCUSSIONS

As we understand that “Pittodara” is mainly caused by dominant localised Pittadosha. Sequence of localised pitta dosha must be reviewed as per the concept of Dhatugtatva of the disease mentioned in Jwara and Vatavyadhi chikitsa. As per the general consideration each and every disease penetrates/progresses into deeper tissue viz. Rasa, Rakta etc onward. Malignancy is considered as Sukragatatva of the disease where regeneration process of the body is completely disrupted. Fibrosis in the tissue is also a type of Sukragtatva of the disease where body loose active specific cells of group of cells or tissues. The present case is also considered the Sukragata pathology of the pittodara because of chronicity of the disease as well as severe imbalance in Agni at Dhatu level leading to excessive Dhatukshaya condition in presence of pratiloma Vayu. The management of pittodara instructed by Acharya Charaka is completely sufficient to check such condition of Sukragata level of Pittodara.

                           When patient first visited our hospital, she was not able to drink even normal water or take any kind of food article since last 6 months except coconut water. She was too much anxious and in grief when modern doctors advised her for surgery (partial pancreatomy).

                            She was given Suvrna Sootshekar Rasa initially, in small dose to boost immunity and regulate the function of vitiated Pittadosha. Along with this Deepana, Pachana, Tikta and other Pittashamaka drugs given as mentioned above. As per the instruction by acharya Charaka for weak pittodari, Tiktakshir vasti was planned to give strength to the body and to revert the Pratiloma Vayu that was responsible for Agnimandya, Aruchi, Hrillas & Chchhardi etc. On 3^rd day of the treatment, patient tried to take Mudagayusha etc. as per instruction but it resulted nausea and vomiting on/off, Then classical Sansarjana krama started and it responded very well because of Anulomana Karma shown by Kshirabasti being given simountaneously.

                             After seven days of sansarjana krama, she could take regular food. Day by day her appetite was improved and her kshira basti holding time gradually increased.

Dhatugatatva of Pittodara

Dhatugatatva concept well mentioned by Acharya Charaka in Jwara and vatavyadhi chikitsa. It can be observed in each and every chronic disease. So as per this principle of the pittodara progressed up to the level of sukradhatu where active pancreatic cells became fibrosed and pancreas/body was unable to regenerate to fibrosed cells. Hence consideration of pittodara can be justified very easily and the result obtained with the use of kshir-basti, gold preparation and ubhay- prtyanik chikitsa confirms this.

Table 6:

	Rasa	Rakta	Mamsa	Meda	Asthi	Majja	Sukra
symptoms	Aruchi	Pittashay-shotha	Weight loss	Weight loss (Kaarshya)	Calcification in pancreas	Generalized weakness	Anartva
	Ashrdhha	Daah	Pittashay-shotha	plihavrudhhi		bhram	Fibrosis of pancreas
			Lymphnode enlargement

CONCLUSION

Chronic pancreatitis originated diabetes mellitus with precancerous and malabsorption stage /jirna dhatugat pittodara can be managed effectively with the principle of jirna pittodara in dhatugatatva from Suvarna sootshekhar rasa with other vyadhi prtyanik chikitsa and tikta-kshir basti along with appropriate dietary restriction are capable to treat this disease.

                        This patient had been advised to go for partial pancreatomy because of high cancer marker CA 19/9, while ayurvedic management not only reverted the CA 19/9 within the limit but also CT-scan of Abdomen, USG of Abdomen, HbA1C and CBC proved the mark improvement. That is perfect evidence to show the efficacy of management.

 

Table-7:

Investigation Summary

	BEFORE TT  6/10/21	On 01/01/2022	On 3/2/22	28/04/2022
MSCT SCAN	Chronic pancretitis Largest calculus 12.8 mm MPD size 8.3 CBD size 10 mm Fibrotic changes of duodenum wall Changes of para duodenal pancreatitis & reactive Lymphnodes	-	Chronic pancretitis Largest calculus 9.5 mm MPD size 6.5 CBD size 6.5 mm No evidence of Fibrotic changes of duodenum wall No evidence of paraduodenal pancreatitis & reactive Lymphnodes	-
CA 19/9	58.52 U/mL  (0-37)	24.66 U/mL  (0-37)	-	17.26 U/mL  (0-37)
HBA1C	7.7  % (174 mg/dL)	6.7  % (146 mg/dL)	6.3 % (134 mg/dL)	6.2 % (131.24 mg/dL)
WBC count	10250/ cmm	8000 /cmm	7100 /cmm	6390 /cmm

 

 Investigations :

 Before treatment :

 After Treatment: 

 

REFERANCES

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[i]Kleeff J, Whitcomb DC, Shimosegawa T, Esposito I, Lerch MM, Gress T, et al. Chronic pancreatitis. Nat Rev Dis Primers 2017;3:17060.  

 

[ii]The National Pancreas Foundation. Chronic Pancreatitis; 2019. Available from: https://pancreasfoundation.org/patient-information/chronic-pancreatitis/. [Last accessed on 2020 Jul 07].

  

[iii]Banks PA, Conwell DL, Toskes PP. The management of acute and chronic pancreatitis. Gastroenterol Hepatol 2016;6:1-16.  

 

[iv]Barry K. Chronic pancreatitis: Diagnosis and treatment. Am Fam Physician 2018;97:385-93.  

 

[v]Jitesh M & Uma Venugopal. Ayurvedic approach to chronic Pancreatitis: A case report, Int J Sci Res 2016;5(9):564-66.

 

[vi]Sharma RK, Dash B: Agnivesha’s Caraka Samhita. Text with English Translation.  Volume 3. 4^th edition. Varanasi: Chowkhamba Sanskrit Series Office; 2000:13(38):521. 

 

(This article has already been published on WJPR research journal  in 11th publication on august 2022.)

link: https://wjpr.net/abstract_file/19745

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Presented by:-

*Vd. NIRALI  S. THACKER, 

Final year P.G. 

Upgraded P.G. Dept. of Kayachikitsa, Govt. Akhndanand Ayurveda College, Ahmedabad, Gujarat, India. 

 

**Vd. SURENDRA A. SONI, 

M.D., PhD (KC), 

Professor & Head, 

Upgraded P.G. Dept. of Kayachikitsa, 

Govt. Akhndanand Ayurveda College, Ahmedabad, Gujarat, India.