Ayurvedic Management of Yakrit Vidradhi (Liver Abscess) – A Case Report

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[Find the meaning and references behind the names: Jitendra, Low, Prakash, Kumari, Jeet, April, Ritu]

Case Report This work is licensed under a CC BY 4.0 License International Research Journal of Ayurveda & Yoga Vol. 6 (4),38-48, April,2023 ISSN: 2581-785 X : https://irjay.com/ DOI: 10.47223/IRJAY.2023.6406 Ayurvedic Management of Yakrit Vidradhi (Liver Abscess) – A Case Report Jitendra Varsakiya, Divyarani Kathad, 2 Ritu Kumari 3 , Sourava Nayak 4 1-Assistant Professor, PG Department of Kayachikitsa Chaudhri Brahma Prakash Ayurved Charak Samsthan Khera Dabar,Najafgarh, New Delhi 2-Director and Chief Consultant, Punarvasu Ayurveda Health Care & Panchkarma Center, New Delhi. 3- SRF, ITRA, Jamnagar Gujarat. 4-PG Scholar, PG Department of Kayachikitsa Chaudhri Brahma Prakash Ayurved Charak Samsthan Khera Dabar,Najafgarh, New Delhi INTRODUCTION A liver abscess is a pus-filled mass in the liver that can occur due to hepatic injury or an intra-abdominal infection disseminated by the portal vein 1 Liver abscess can be broadly divided into categories such as amoebic and pyogenic 2 A pyogenic abscess is a collection of pus having numerous inflammatory cells, primarily neutrophils and tissue debris 3 Because the liver receives blood circulation from both the systemic and portal circulations, it is more vulnerable to infections and abscesses 4 Another risk factor for the liver is proximity to the gallbladder. Abscesses could also be caused by parasites, malignancies, foreign material, or complications from liver transplantation 5,6 Article Info Article history: Received on: 15-03-2023 Accepted on: 22-04-2023 Available online: 30-04-2023 Corresponding author- Jitendra Varsakiya, Assistant Professor, PG Department of Kayachikitsa Chaudhri Brahma Prakash Ayurved Charak Samsthan Khera Dabar,Najafgarh, New Delhi. Email: jeet 12989@gmail.com ABSTRACT: The liver abscess is the most frequent visceral abscess caused by a parasite or bacterial infection in low and middle-income countries. A liver abscess can cause fever, chills, night sweats, malaise, nausea or vomiting, right shoulder ache, right upper quadrant pain, cough, dyspnea, anorexia, etc. A 20 years old male patient presented with symptoms of fever, chills, malaise, right shoulder pain, and right upper quadrantpain.The patient was treated with Virechan Karma (therapeutic purgation) followed by oral Ayurvedic medicines such as Varunadi Kwatha , Kanchanar Guggulu, and Aarogyavardhini Vati. Pathyaapathy (wholesome-unwholesome diet) based on Ayurveda perspectives was also advised to the patient. The total duration of the treatment was four months, and follow-up was done for one month. Improvement was assessed based on relief in the symptoms and abdomen USG. Complete relief in all symptoms was noted after completion of the treatment. The USG findings revealed a reduction in hypoechoic lesion to size 5.1*5.1 cm with calcified margins in the right lobe segment VIII of the liver. Any complications or adverse events due to treatment were not observed during the treatment period. This case report demonstrates the effectiveness of Ayurvedic approaches in managing Liver abscesses. Keywords – Ayurveda, case report, Liver abscess, Virechana , Yakrit Vidradhi ,

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[Find the meaning and references behind the names: Main, Rock, Lam, Green, Min]

Jitendra et.al , “Ayurvedic Management of Yakrit Vidradhi (Liver Abscess) – A Case Report.” : 2023; 6 (4):38-48 39 Pyogenic Liver Abscesses (PLAs) have a global distribution; however, the incidence differs considerably between regions, spanning more than 900 incidences in Asian countries in the last ten years 7 The annual incidence rate has been estimated to be around 2.3 cases per 100,000 individuals. Males are more prone to be affected by PLAs than females 8 Diabetes, cirrhosis, male gender, the elderly, immunocompromised conditions, and people using proton pump inhibitors are all risk factors for developing liver abscesses 9 Symptoms of a liver abscess include fever, chills, night sweating, malaise, nausea, vomiting, right shoulder pain, right upper quadrant pain, cough, dyspnea, anorexia, and recent unexplained weight loss. An abdominal ultrasonography (USG) is the initial diagnostic test of choice to detect hyper or hypoechoic lesions in the liver with occasional debris or septation. Abscess drainage and antibiotic therapy are the main lines of treatment for PLAs 10 The disease PLAs can be correlated with Yakrit Vidradhi , one of the ten Antarvidradhi (internal abscess) narrated in Ayurveda. In Sushruta Samhita, diagnosis and treatment of liver abscess have been described with sufficient details 11 A case report of a patient suffering from a liver abscess and treated with Ayurvedic therapies is presented in this study. This case resembles Pittaja/Raktaja Vidradhi (abscess due to perturbed Pitta/Rakta ). The uniqueness of this case report is that the patient with a liver abscess was treated following the guidelines suggested in the Ayurveda treatise. Patient Information A 20 years old male patient was suffering from fever, chills, nausea, excessive thirst ,abdominal pain, and occasional vomiting for a week. The symptoms were initially mild, but their severity increased gradually. The sickness had a severe manifestation when the patient came for Ayurvedic treatment. The patient had taken analgesic and antispasmodic drugs (Mefenamic acid 250 mg and Dicyclomine HCL 10 mg; as and when needed) without consultation with a physician. The patient worked as a driver and occasionally drank alcohol. The patient had no reported history of any chronic disease or surgeries. Clinical Findings: On examination, the patient's body temperature was 102.3 ℉; his blood pressure was 118/82 mmHg, and his pulse rate was 86/min. During the examination, the patient was well conscious and responded satisfactorily. On inspection there was no scar , protrusion or prominent vein shown over abdomen. On palpation of the abdomen, mild tenderness was observed in the right hypochondriac region, though no organomegaly was noted. On percussion dull sound was present over right hypochondriac region. There was normal bowel sound heard on the auscultation over abdomen. Ashtavidha Pariksha (eightfold examination of the patient) was done and mentioned in Table no.1 Timeline : The timeline of the case report is depicted in table 2. Diagnostic Assessment The diagnosis was made by laboratory investigations such as USG abdomen, Complete Blood Count (CBC), and Liver Function Tests (LFT). The USG findings revealed a hypoechoic lesion of size 8.7*7.7*7.3 cm; a volume of 259.9 cc in the right lobe, segment VIII of the liver. Biomarkers of CBC and LFT were in the normal range. Based on the USG findings, the diagnosis of the liver abscess was decided. Due to the patient's financial constraints, a fine needle biopsy could not be performed to differentiate between PLAs and amoebic liver abscesses. From Ayurveda's perspective, this condition correlates with Yakrit Vidradhi (liver abscess) . (Tables 4 and 5) Therapeutic Intervention As the liver is the site for Pitta Dosha and Rakta Dhatu, treatment was planned according to Pitta/Raktaja Vidradhi (abscesses due to vitiated Pitta/Rakta ). The therapy includes Virechana Karma (therapeutic purgation) [Table 3; Figure 2] followed by oral medications such as Varunadi Kwath 20 ml to be taken on an empty stomach in the morning; Aarogyavardhini Vati (250 mg), two tablets twice daily with lukewarm water, after the meal and Kanchanar Guggulu (250 mg), two tablets twice daily with lukewarm water, after dinner [Table 2]. The total duration of treatment was four months. Follow-up was taken after every two weeks for a month. Advises related to Pathya-Apathya (wholesome-unwholesome diet) were given during the treatment and follow-up period. Pathya (wholesome dietary regimen and activities): The patient was advised to take an ample amount of green gram ( Vigna radiata (L.) R. Wilczek) boiled and roasted form with Trikatu Churna (powder made up of dried rhizome of Zingiber Officinalis Ros., dried fruit of Piper longum L., and Piper nigum L.), soup made from green gram ( Macrotyloma uniflorum (Lam.) Verdc.), Saindhav Lavan (rock salt) and barley ( Hordeum vulgare L.) or wheat ( Triticum aestivum L.). The patient was advised to eat a dish prepared from drumstick ( Moringa oleifera Lam) and Indian plum ( Ziziphus mauritiana Lam.) and to take jaggery with Shunthi Churna ( Zingiber officinale Ros.) in 1:1 proportion after the meal. Advises were also given to, the patient is to take sufficient rest and

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[Find the meaning and references behind the names: Vega, Mukul]

Jitendra et.al , “Ayurvedic Management of Yakrit Vidradhi (Liver Abscess) – A Case Report.” : 2023; 6 (4):38-48 40 perform Pranayama (control of breath) such as Anuloma Viloma , Bhramari , and chant Omkara for 10 minutes in the morning. Apathya (unwholesome dietary regimen and activities): The patient was advised to strictly prohibit sour, salty, oily food items which are heavy to digest, green leafy vegetables, meat, milk, and curd. The patient was likewise recommended to avoid traveling and performing strenuous physical activities, and day sleep was also proscribed. [Figure 1] Method of Virechana Karma (therapeutic purgation): Deepana (appetizer) and Pachana (digestives) with Hariatki Churna (Terminalia chebula Retz.)- 2 gm and Shunthi Churna (Zingiber Officinalis Ros.) 2 gm twice a day, half an hour before meals, with lukewarm water, were done for three days; from the fourth day, Snehapana (internal oleation) was done with Panchatikta Ghrita (30 ml) for the next five days in an increasing dose (10 ml per day) as per Koshtha and Agni . On the 9 th day, Sarvanga Abhyanga and Swedana (external oleation and fomentation) were performed for the next three days. On the 12 th day, Virechaka Kashaya was administered on an empty stomach. The total number of Vega (defecation) was 26 [ Kaphanta (when Kapha is expelled at the end)] with appropriate Samyak Virechan Lakshana (signs of proper therapeutic purgation). After Virechana, Sansarjana Krama (post-therapy dietetic regimen for revival) was advised for seven days. [Figure 2] (Table 3) Follow-Up And Outcomes Follow-up was taken for one month on a fortnight basis, during which clinical assessment was done based on the improvement of the patient's symptoms and the findings of the USG abdomen. These parameters showed improvement at the end of four months (Tables 3 and 4). On 20 th August 2021, the size of the hepatic lesion was 8.7*7.7*7.3 cm, and the volume was 259.9 cc; on 13 th October 2021, it reduced to 6.0*5.8*5.7 cm; the volume was 105.6 cc. An old healed abscess with calcified margins was observed on 29 th December 2021 (Figure 3). No complications, new symptoms, or adverse events were observed during the entire treatment and follow-up period. Clinical adherence was assessed using the medicine dosage history provided by the patient. DISCUSSION Sushruta has described ten types of Antarvidradhi (internal abscess) and included Yakrit Vidradhi (liver abscess) as one 12 In the same context, Sushruta has mentioned predicting Doshik involvement in the pathogenesis of Antartvidradhi based on similarity with characteristics of Bahya Vidradhi (external abscess). Since the symptoms in the studied case were similar to Paittik/Raktaja Vidradhi (abscess due to perturbed Pitta/Rakta ), it was treated based on the principles of Paittika/Raktaja Vidradhi . Virechana is appreciated in Shashtiupkrama (sixty therapeutic measures for wounds) for both Pitta Pradhana Vrana (wound due to perturbed Pitta Dosha ) 13 as well as Vidradhi Chikitsa (treatment of abscess) 14 In this case, there were two medications, Kanchanar Guggulu 15 and Varunadi Kashayam, 16 which were prescribed for Vidradhi Chikitsa . Aarogyavardhini Vati is another well-known remedy for liver disorders. Cholangitis is responsible for almost half of all bacterial cases of liver abscess 17 Bacteraemia of the hepatic artery or portal vein, diverticulitis, cholecystitis, or penetrating trauma are less likely reasons 18 Despite E. coli, Klebsiella, Streptococcus, Staphylococcus, and anaerobic organisms being the most widespread, infections are very often polymicrobial. Pyogenic liver abscesses are commonly associated with bowel content leakage and peritonitis. Bacteria travel to and lodge in the liver via the portal vein. Furthermore, the infection can emerge in the biliary system 19,20 Kanchanar Guggulu is primarily composed of Kanchanara and Guggulu . Additionally, it has Triphala (combination of three myrobalans viz. T. chebula , T. bellarica , and E. officinalis ) and Trikatu (combination of Z. Officinalis , P. longum , and P. nigrum ). Guggulu ( C. mukul ) possesses substantial antibacterial activity against Gram-positive bacteria 21,22 Myrrhanol A, a triterpene isolated from Guggulu , has a potent anti-inflammatory effect on exudative pouch fluid, angiogenesis, and granuloma 23 Kanchanar ( B. variegata L.) possessed excellent antibacterial properties 24 The ethanolic extract of B. variegata stem bark exhibited antimicrobial activity 25 The anti-inflammatory efficacy of a novel flavonol glycoside (5,7,3,4-tetrahydroxy-3- methoxy-7-o—L-rhamnopyranosyl (13) –o—dgalactopyranoside) of B. variegata has been observed 26 Triphala aqueous extracts are potent against E. coli and S. aureus 27 Triphala suppressed the proinflammatory cytokines Tumor Necrosis Factor- α (TNF- α). Furthermore, it decreased hepatic damage, as revealed by decreased ALP, ALT, and AST levels and substantiated by histological observations 28 Triphala is remarkably efficient when used topically and has been

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[Find the meaning and references behind the names: Gomes, Santos, Silva, Hansen, Costa, Chan, Souza, Govinda, Nil, Med, Paulo, Mishra, Oliveira, Jan]

Jitendra et.al , “Ayurvedic Management of Yakrit Vidradhi (Liver Abscess) – A Case Report.” : 2023; 6 (4):38-48 41 shown to aid wound healing 29 Triphala also have antimicrobial, anti-inflammatory, and wound ameliorative effects 30 Katuki is half of the content of Aarogyavardhini Vati . The aqueous extract of Kutki ( P. Kurrah ) roots exhibited moderate antibacterial activity against Staphylococcus aureus , salmonella typhi , and significant attenuation of E. coli 31 Its anti-inflammatory effects are ascribed to the apocynin in element, which has been found to exhibit potent anti-inflammatory properties in addition to limiting neutrophil oxidative burst 32 The hepatoprotective effect of a hydroalcoholic extract of the Varuna plant ( C. nurvala ) against hepatotoxicity induced by carbon tetrachloride reveals enhanced antioxidant enzymes in granuloma tissue promoting wound repair and regeneration 33 CONCLUSION Ayurvedic medicines, Virechana Karma , and proper Pathya-apthya effectively treat a liver abscess. Further research with a large enough sample size and detailed research methodologies is required to verify and substantiate the role of Ayurveda interventions in treating a liver abscess. Acknowledgment - Nil Conflicts Of Interest- Nil Source of finance & support – Nil ORCID Jitendra Varsakiya , https://orcid.org/ 0000-0002-5009-2738 REFERENCES: 1 Mischnik A, Kern WV, Thimme R. [Pyogenic liver abscess: Changes of Organisms and Consequences for Diagnosis and Therapy]. Dtsch Med Wochenschr. 2017 Jul;142(14):1067-1074 2 Sifri CD, Madoff LC. Infections of the liver and biliary system (liver abscess, cholangitis, cholecystitis) In: Bennett JE, Dolin R, Blaser MJ (eds.). Principles and Practice of Infectious Diseases , 8 th edn. Philadelphia: Elsevier Saunders, 2015,1270–9 3 De Souza Andrade-Filho J. Revista do Instituto de Medicina Tropical de São Paulo. 2012. 4 Hau T, Haaga JR, Aeder MI. Pathophysiology, diagnosis, and treatment of abdominal abscesses. Curr Probl Surg. 1984 Jul;21(7):1-82. 5 Guzmán-Silva MA, Santos HL, Peralta RS, Peralta JM, de Macedo HW. Experimental amoebic liver abscess in hamsters caused by trophozoites of a Brazilian strain of Entamoeba dispar. Exp Parasitol. 2013 May;134(1):39-47. 6 Costa CA, Fonseca TH, Oliveira FM, Santos JF, Gomes MA, Caliari MV. Influence of inflammation on parasitism and area of experimental amoebic liver abscess: an immunohistochemical and morphometric study. Parasit Vectors. 2011 Feb 28;4:27 7 Ko WC, Paterson DL, Sagnimeni AJ, Hansen DS, Von Gottberg A, Mohapatra S, et. al, Community-acquired Klebsiella pneumoniae bacteremia: global differences in clinical patterns Emerg Infect Dis. 2002 Feb; 8(2):160-6 8 Kaplan GG, Gregson DB, Laupland KB. Population-based study of the epidemiology of and the risk factors for pyogenic liver abscess. Clin Gastroenterol Hepatol. 2004 Nov;2(11):1032-8 9 Chan, K.S., Shelat, V. (2022). Pyogenic Liver Abscess. In: , et al. The IASGO Textbook of Multi-Disciplinary Management of Hepato-Pancreato-Biliary Diseases. Springer, Singapore. https://doi.org/10.1007/978-981-19- 0063-1_66 . 10 Akhondi H, Sabih DE. Liver Abscess. [Updated 2022 Jul 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK 538230/ 11 Shastri AD, editor-translator. Sushruta Samhita of Sushruta, Part–I, Nidana Sthana, ch. 9, Ver. 19-23 1 st ed., Varanasi: Chaukhambha Sanskrit Sansthan; 2012. p. 343. 12 (Shastri AD, editor-translator. Sushruta Samhita of Sushruta, Part–I, Nidana Sthana, ch. 9, Ver. 24 1 st ed., Varanasi: Chaukhambha Sanskrit Sansthan; 2012. p. 343) 13 Shastri AD, editor-translator. Sushruta Samhita of Sushruta, Part–I, Nidana Sthana, ch. 9, Ver. 8, 14 1 st ed., Varanasi: Chaukhambha Sanskrit Sansthan; 2012. p. 342. 14 Shastri AD, editor-translator. Sushruta Samhita of Sushruta, Part–I, Chikitsa Sthana, ch. 1, Ver. 11 1 st ed., Varanasi: Chaukhambha Sanskrit Sansthan; 2012. p. 8. 15 Shastri AD, editor-translator. Sushruta Samhita of Sushruta, Part–I, Chikitsa Sthana, ch. 16, Ver. 29 1 st ed., Varanasi: Chaukhambha Sanskrit Sansthan; 2012. p. 97. 16 Kaviraj Govinda Das Sen. Bhaisajyaratnavali. Siddhipada Hindi Commentary, Prof. Siddhinandana Mishra editor. 1 st edition. Kustharogadhikara, Chapter no-44, Verse no-64- 69, Varanasi: Chaukhamba Surbharati Prakashana; 2012.p.77. 17 Tripathi RD, editor-translator. Astanga Hridyam of Vridhha Vagbhatta, Part–I, Sutra Sthana, ch. 15, Ver. 21-

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Jitendra et.al , “Ayurvedic Management of Yakrit Vidradhi (Liver Abscess) – A Case Report.” : 2023; 6 (4):38-48 42 22, 1 st ed., Varanasi: Chaukhambha Sanskrit Sansthan; 2012. p. 97. 18 Lardière-Deguelte S, Ragot E, Amroun K, Piardi T, Dokmak S, Bruno O, Appere F, Sibert A, Hoeffel C, Sommacale D, Kianmanesh R. Hepatic abscess: Diagnosis and management. J Visc Surg. 2015 Sep;152(4):231-43 19 Hau T, Hartmann E. [Pathology, diagnosis and therapy of liver abscess]. Zentralbl Chir. 1987;112(9):529-47 20 Peterson CT, Denniston K, Chopra D. Therapeutic Uses of Triphala in Ayurvedic Medicine. J Altern Complement Med. 2017 Aug;23(8):607-614. doi: 10.1089/acm.2017.0083. Epub 2017 Jul 11. PMID: 28696777; PMCID: PMC 5567597. 21 Vaidya AB, Antarkar DS, Doshi JC, et al. Picrorhiza kurroa (Kutaki) Royle ex Benth as a hepatoprotective agent-- experimental & clinical studies. J Postgrad Med. 1996;42(4):105-108. 22 P. Goyal, A. Chauhan, and P. Kaushik, “Assessment of Commiphora wightii (Arn.) Bhandari (Guggul) as potential source for antibacterial agent,” Journal of Medicine and Medical Sciences , vol. 1, no. 3, pp. 71–75, 2010. 23 C. D. Romero, S. F. Chopin, G. Buck, E. Martinez, M. Garcia, and L. Bixby, “Antibacterial properties of common herbal remedies of the southwest,” Journal of Ethnopharmacology , vol. 99, no. 2, pp. 253–257, 2005. 24 Kimura I, Yoshikawa M, Kobayashi S, Sugihara Y, Suzuki M, Oominami H, et al.,New triterpenes, myrrhanol A and myrrhanone A, from guggul-gum resins, and their potent anti-inflammatory effect on adjuvant-induced air-pouch granuloma of mice, Bio org Med Chem Lett , 11(8) (2001) 985. 25 Parekh Jigna, Karathia Nehal, Chanda Sumitra., Screening of some traditionally used medicinal plants for potential antibacterial activity. Indian journal of Pharmaceutical Science 2006; 68(6): 832-834. 26 Pokhrel NabuRaj, Adhikari RP, B aral., In vitro evaluation of antimicrobial activity Bauhinia variegata, locally known as Koiralo. World Journal of Microbiology & Biotechnology 2002; 18: 69-71. 27 Yadava RN, Reddy Madhusudhan., Anti-inflammatory activity of a novel flavonol glycosides from Bauhinia variegata Linn. Natural Product Research 2002; 17(3): 165-169. 28 Biradar YS, Jagatap S, Khandelwal KR, Singhania SS. Exploring of antimicrobial activity of Triphala mashi–an Ayurvedic Formulation. Evid Based Complement Alternat Med 2008;5:107-113 29 Rasool MK, Sabina EP, Kumar L, Nithya P. Therapeutic effect of Indian Ayurvedic herbal formulation Triphala on Acetaminophen-induced hepatotoxicity in mice. J Pharmacol Toxicol 2007;2:725-731. 30 Kumar MS, Kirubanandan S, Sripriya R, Sehgal PK. Triphala promotes healing of infected full-thickness dermal wound. J Sur Res 2008;144:94-101. 31 Vohora, S.B.; Kumar, I.; Naqvi, S.A.H. and Afaq, S.H. (1972) Ind. J. Pharmacol., 34, 17. 32 Simons, J.M.; ‘t Hart, B.A. and Ip Vai Ching, T.R. (1990) Free Radic. Biol. Med., 8, 251-258. 33 Asuti N. Wound healing property of alcoholic extract of root bark of Crataeva nurvala. Journal of Pharmacy Research 2010; 3(5): 1121-3. How to cite this article : Varsakiya J, Kathad D, Kumari R, Nayak S, “Ayurvedic Management Of Yakrit Vidradhi (Liver Abscess) – A Case Report” IRJAY. [online]2023;6(4); 38-48. Available from: https://irjay.com DOI linkhttps://doi.org/ 1 0.47223/IRJAY.2023.6406

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[Find the meaning and references behind the names: Arun, Mala, Ama]

Jitendra et.al , “Ayurvedic Management of Yakrit Vidradhi (Liver Abscess) – A Case Report.” : 2023; 6 (4):38-48 43 Table No.1: Ashtavidha Pariksha (eightfold examination of the patient) Sr. No Examination Findings 1 Nadi (pulse) Vatika 2 Mootra (urine) Peeta Varna (reddish yellow in colour) 3 Mala (faeces) Samaja (associated with Aama ) 4 Jhwa (tongue) Kaphaja (white, sticky) 5 Sabdam (voice) Aspashta (weak) 6 Sparsham (touch) Ushna (hot), Ruksha (dryness); 7 Druka (eyes and vision) Arun Varna (pinkish discoloration), Antarpravishta (sunken) 8 Akriti (general body built) Madhyam (moderate). Table 2: Timeline of the studied case S.N. Date Signs & Symptoms Investigations Managements 1. August 2021 The onset of rising body temperature, chills, nausea, abdominal pain, and occasional vomiting - - 2. 18 th August 2021 [First visit to the hospital] Symptoms- The intensity of the all the above symptoms increases Signs - • Mild tenderness in right Hypochondric region - • Varunadi Kwath 20 ml. empty stomach in the morning • Aarogyavardhini Vati (250 mg) - 2 tablets twice daily with lukewarm water, after meals. • Kanchanar Guggulu (250 mg) - 2 tablets twice daily with lukewarm water after meals. 3. 20 th August 2021 - • USG (Abdomen)- Hypoechoic lesion of size 8.7*7.7*7.3 cm. vol. 259.9 cc in right lobe of liver segment VIII - 4. 23 rd August 2021 - • SGOT- 21.44 mg/dl • SGPT-28.63 mg/dl • TLC – 7,600/mm 3 - 5. 25 th August 2021 • No relief in symptoms, and the sign also persist. - The patient got IPD admission for Virechana Karma (therapeutic purgation) 6. 13 th September 2021 [discharged from hospital] • Fever and chills subsided. • Relief in nausea, frequency of abdominal pain, and vomiting. • Tenderness in the right hypochondriac region was relived. - • Varunadi Kwath 20 ml. empty stomach in the morning • Aarogyavardhini Vati (250 mg)- 2 tablets twice daily with lukewarm water, after meals. • Kanchanar Guggulu (250 mg)- 2 tablets twice daily with lukewarm water after meals.

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Jitendra et.al , “Ayurvedic Management of Yakrit Vidradhi (Liver Abscess) – A Case Report.” : 2023; 6 (4):38-48 44 7. 27 th September. 2021 • Vomiting subsided. • Occasional abdominal pain and nausea. • Tenderness in the right hypochondriac region was subsided. • Varunadi Kwath 20 ml. empty stomach in the morning • Aarogyavardhini Vati (250 mg)- 2 tablets twice daily with lukewarm water, after meals. • Kanchanar Guggulu (250 mg)- 2 tablets twice daily with lukewarm water after meals. 8. 13 th October 2021 - • USG (Abdomen)- Hypoechoic lesion of size 6.0*5.8*5.7 cm. vol. 105.6 cc in right lobe of liver segment VIII - 9. 14 th October 2021 • Occasional mild abdominal pain and nausea - • Varunadi Kwath 20 ml. empty stomach in the morning • Aarogyavardhini Vati (250 mg)- 2 tablets twice daily with lukewarm water, after meals. • Kanchanar Guggulu (250 mg)- 2 tablets twice daily with lukewarm water after meals. 10. 28 th October 2021 • Occasional mild abdominal pain and nausea - • Varunadi Kwath 20 ml. empty stomach in the morning • Aarogyavardhini Vati (250 mg)- 2 tablets twice daily with lukewarm water, after meals. • Kanchanar Guggulu (250 mg)- 2 tablets twice daily with lukewarm water after meals. 11. 11 th November 2021 • Occasional mild abdominal pain and nausea - • Varunadi Kwath 20 ml. empty stomach in the morning • Aarogyavardhini Vati (250 mg)- 2 tablets twice daily with lukewarm water, after meals. • Kanchanar Guggulu (250 mg)- 2 tablets twice daily with lukewarm water after meals 12. 25 th November 2021 Relief in abdominal pain and nausea - • Varunadi Kwath 20 ml. empty stomach in the morning • Aarogyavardhini Vati (250 mg)- 2 tablets twice daily with lukewarm water, after meals. • Kanchanar Guggulu (250 mg)- 2 tablets twice daily with lukewarm water after meals

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Jitendra et.al , “Ayurvedic Management of Yakrit Vidradhi (Liver Abscess) – A Case Report.” : 2023; 6 (4):38-48 45 Table 3: Drugs and dosage forms used in Virechana Karma. Table 4: Criteria of the symptomatic assessment. Severity level Gradation Scale 0 Absent 0 + Mild 1 ++ Moderate 2 +++ Severe 3 ++++ Agonising 4 13. 9 9 th December 2021 Relief in abdominal pain and nausea No fresh complaints. - • Varunadi Kwath 20 ml. empty stomach in the morning • Aarogyavardhini Vati (250 mg)- 2 tablets twice daily with lukewarm water, after meals. • Kanchanar Guggulu (250 mg)- 2 tablets twice daily with lukewarm water after meals 14. 23 rd December 2021 • Pain in the abdomen and nausea subsided. • No fresh complaints. - • Medications ceased. • Only Pathya-apathya continues 15. 29 th December 2021 - USG (Abdomen)- Hypoechoic lesion in liver of size 5.1*5.1 cm. with calcified margins. Old healed abscess at right lobe of the liver . - 16. 6 th January 2022 (First follow-up) No fresh complaints/complicatio ns. - Advised to continue Pathya-apthya for two more weeks. 17. 20 th January 2022 (Second followup) No fresh complaints/complicatio ns. - Treatment terminated. Procedure Drug & dosage form Duration Deepana and Pachana (Improvement of digestion and metabolism) Hariatki Churna ( T. chebula Retz.)-2 gm + Shunthi Churna ( Z. officinalis Ros.) 2 gm thrice a day with lukewarm water after meal. Three days Snehapana (therapeutic internal oleation) Panchatikta Ghrita (as per Koshtha and Agni ) in increasing dose. Five days Abhyanga and Vashpa Svedana (therapeutic external oleation and therapeutic fomentation) Laghu Visagarbha Taila , For Vashpa Sveda Dashamoola Kwatha was used. Three days Virechana Karma (Bio-purification therapy) Nishotha Churna ( Operculina turpethum (L.)10 gm Triphala Kwatha 100 ml Draksha Kwatha ( Vitis vinifera Linn.) 100 ml Sansarjana Krama (post-therapy dietetic regimen for revival) Regulatory diet regimen as per Shuddhi Seven days

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[Find the meaning and references behind the names: Rita, San]

Jitendra et.al , “Ayurvedic Management of Yakrit Vidradhi (Liver Abscess) – A Case Report.” : 2023; 6 (4):38-48 46 Table 5 : Assessment of symptoms of the patient during the study. Symptoms 18 th Aug. 2021 25 th Aug. 2021 13 th Sep. 2021 27 th Sep. 2021 14 th Oct. 2021 28 th Oct. 2021 11 th Nov. 2021 25 th Nov. 2021 9 th Dec. 2021 23 rd Dec. 2021 First follow up Second follow up Fever 3 3 0 0 0 0 0 0 0 0 0 0 Chill 3 3 0 0 0 0 0 0 0 0 0 0 Abdominal pain 3 3 2 1 1 1 1 1 1 0 0 0 Tenderness in right hypochondriac region 3 3 2 0 0 0 0 0 0 0 0 0 Nausea 2 2 2 1 1 1 1 0 0 0 0 0 Vomiting 2 2 1 0 0 0 0 0 0 0 0 0 Flow Chart Treatment. Figure 2: Details of Virechana Karma (therapeutic Purgation • Grains-Barley, Wheat • Pulses- Green gram, Horse gram • Vegetable- Drumstick • Fruit-Indian Plum • Activities- Proper rest, Pranayama Pathya • Sour, salty, oily, heavy food items • Vegetable- Green leafy vegetables • Milk, curd, ghee, meat • Activities- Traveling, strenuous physical activities, day sleep Apathya D ee pa n a an d Pacha n a (Fo r th ree da ys ) Hariatki Churna - 2 gm + Shunthi Churna 2 gm thrice a day with lukewarm water before meal Sn eh a p a n a (Fo r fi ve d a ys ) Panchatikta Ghrita (as per Koshtha and Agni ) started with 30 ml and increased by 30 ml on each consecutive day, early morning empty stomach, with lukewarm water. A bh yan ga an d Vas h pa S ve da n a for the next three days Abhyanga (whole body massage ) was done with Laghuvishagarbha Taila , twice a day for 20 minutes. Sarvanga Vashpa Sweda (steam fomentation) with Dashamoola Kwatha was performed for 10 minutes or until the patient feels comfortable. Vi recha n a K arma Virechana Yoga of Nishotha Churna 10 gm, Triphala Kwatha 100 ml, Draksha Kwatha 100 ml was given empty stomach (9 AM approx.). The patient had an urge for the first Vega (natural urges (for elimination)) after 70 minutes. The total number of Vega was 26. San sarjana Kr am a (Fo r s ev en d ays ) Regulatory diet regimen which including Peya (thin gruel of rice), Vilepi (thick gruel of rice), A k rita Yusha (nonprocessed soup of vegetables and/or pulses), and Krita Yusha (processed soup of vegetables and/or pulses) in a sequential manner as per Shuddhi (cleansing), i.e., for seven days.

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Jitendra et.al , “Ayurvedic Management of Yakrit Vidradhi (Liver Abscess) – A Case Report.” : 2023; 6 (4):38-48 47 Figure 3: Improvement in USG (abdomen) with date. Before Treatment USG Report. 20 th August 2021 Hypoechoic lesion of size 8.7*7.7*7.3 cm., vol. 259.9 cc in the right lobe of liver. 13 th October 2021 Hypoechoic lesion of size 6.0*5.8*5.7 cm. vol. 105.6 cc in the right lobe of liver. 29 th December 2021 Hypoechoic lesion of size 5.1*5.1 cm. with calcified margins in the right lobe of liver Old healed abscess

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Jitendra et.al , “Ayurvedic Management of Yakrit Vidradhi (Liver Abscess) – A Case Report.” : 2023; 6 (4):38-48 48 After treatment USG Reports

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Sushruta-samhita, Bhramari, Raktadhatu, Panchatiktaghrita, Pittadosha, Ayurvedic medicine, Internal abscess, Wound healing, Triphala combination, Virechan Karma, Case report, Therapeutic Purgation, Ayurvedic Management, Anti-inflammatory properties, Complete blood count, Triphala Churna, Deepana Pachana, Anti-inflammatory effect, Hepatoprotective effect, Ashtavidha Pariksha, Pitta Pradhana, USG report, Ethanolic extract, Kanchanar Guggulu, Aarogyavardhini Vati, Varunadi Kwatha, Gram positive bacteria, Internal oleation, Liver function test, Portal vein, External oleation, Anulomaviloma, Abdominal ultrasonography, Proinflammatory cytokine, Bahya Vidradhi, Corresponding author, Liver abscess, Pyogenic Abscess, USG abdomen, Pathya-Apthya, Shunthi Churna, Hepatic artery, Flavonol glycoside, Kapha is expelled, Post therapy dietetic.