An Ayurvedic management of Pittashmari (Cholelithiasis): A Case Study

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CASE REPORT September 2024 Journal of Ayurveda and Integrated Medical Sciences | September 2024 | Vol. 9 | Issue 9 316 An Ayurvedic management of Pittashmari (Cholelithiasis): A Case Study Mayur A. Gaikwad 1 , Jayant D. Gulhane 2 1 Post Graduate Scholar, Department of Kayachikitsa, Government Ayurved College and Hospital, Nagpur, Maharashtra, India. 2 Associate Professor and HOD, Department of Kayachikitsa, Government Ayurved College and Hospital, Nagpur, Maharashtra, India. I NTRODUCTION Ayurveda states that it is not always possible to name every disease but one can treat a disease based on its Nidanpanchak [1] There are many new diseases emerging nowadays but we don’t find their mention in our Ancient Samhitas . But by identifying the proper Dosha , Dushya and Samprapti of the disease any ailment can be cured by the presence of Chatushpad Address for correspondence: Dr. Mayur A. Gaikwad Post Graduate Scholar, Department of Kayachikitsa, Government Ayurved College and Hospital, Nagpur, Maharashtra, India. E-mail: mayurg 426@gmail.com Submission Date: 09/08/2024 Accepted Date: 17/09/2024 Access this article online Quick Response Code Website: www.jaims.in DOI: 10.21760/jaims.9.9.51 These diseases are referred to as Anukta Vyadhi . Ayurveda describes Ashmari Vyadhi in detail. The word Ashmari stands for stone, which is described only in the context of Bastigata Ashmari based on their given symptoms [2] According to Contemporary Science the primary role of Gall bladder is to store and concentrate the bile secreted by liver and then deliver it into the intestine for digestion and absorption of fat. When bile is stored in the Gall bladder for a long time due to any cause it hardens into a stone like material. This is known as Cholelithiasis. Patients with Cholelithiasis have significantly increased in number over the past few decades owing to our sedentary lifestyle, better socioeconomic conditions, and accessibility to processed high-calorie foods The bile is correlated with Achha Pitta [3] which is stored by Gall Bladder hence it is known as Pittashaya [4] and the stone formed in it is called as Pittashmari . Most of the people with gallstones never have symptoms and, in some cases, the clinical presentations can vary from dyspepsia to severe forms like pancreatitis and perforation of the A B S T R A C T Background: Ayurveda states that it is not always possible to name every disease but one can treat a disease based on its Nidanpanchak . The diseases not mentioned in Samhitas are said to be Anukta . One such disease is Cholelithiasis having prevalence rate of 5-6% in India which is increasing day by day. We can call it Pittashmari because the stone formation occurs in Pittashay . Cholecystectomy is considered to be gold standard treatment but its long-term side effects are unavoidable. The post cholecystectomy syndrome is a medical condition found in 40% of patients that underwent Cholecystectomy. Purpose of Study: A suitable non-surgical treatment approach is urgently required for Pittashmari (Cholelithiasis) due to, expensive surgical treatments, surgical risks, patient's unwillingness to undergo surgery or their long-term negative repercussions. Methodology: This is a single case study of 39 yr Male patient, having clinical signs and symptoms of Cholelithiasis and USG showing calculi within Gall bladder. For treatment various Ayurveda texts, Contemporary texts and research articles on Yakrit-uttejak Dravya , Cholelithiaisis and Pittashmari were studied. Result: There are no calculi seen after 3 months of treatment and the symptoms also completely resolved. Conclusions: Pittashmari (Cholelithiaisis) can be effectively treated with Ayurveda without the risks or side effects of surgery, and it is also relatively inexpensive. Key words: Anuktavyadhi, Pittashay, Yakrit-uttejak, Post cholecystectomy syndrome.

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Mayur A. Gaikwad et al. An Ayurvedic management of Pittashmari (Cholelithiasis) ISSN: 2456-3110 CASE REPORT September 2024 Journal of Ayurveda and Integrated Medical Sciences | September 2024 | Vol. 9 | Issue 9 317 gall bladder. Conservative treatment for Cholelithiaisis in modern medicine does not show promising results, hence the Laproscopic Chlocytectomy is considered as the gold standard treatment for Cholelithiasis. The post cholecystectomy syndrome is a medical condition found in 40% of patients that underwent Cholecystectomy. Hence a better and much effective non-surgical treatment plan is needed for Pittashmari . This article focuses to plan a treatment protocol for Pittahmari by applying basic concepts of Ayurveda . A IM AND O BJECTIVE To evaluate the role of Shaman Chikitsa in the management of Cholelithiasis. C ASE R EPORT A 39-year-old male patient reported at Kayachikitsa OPD of Government Ayurved Hospital, Nagpur in March 2024 as a diagnosed case of Cholelithiasis with its full-fledged signs and symptoms since 1 month. 1 Udar shool (Pain in Abdomen - right hypochondriac region radiating to epigastric region) 2 Amlodgar (Eructation) 3 Hrillasa (Nausea) 4 Chhardi (Vomiting intermittently) 5 Malavibandha (Constipation). History of Present Illness Patient was fine 1 month ago but in February 2024 he experienced moderate abdominal pain which didn’t subside even after taking analgesic and antispasmodic, hence patient was advised for USG Abdomen which revealed Cholelithiasis, hepatomegaly & Grade 1 fatty infiltration of Liver. He was advised Cholecystectomy by Allopathic doctors, but as he was reluctant to not get operated, he came to Kayachikitsa OPD of GAC, Nagpur for Ayurvedic treatment. Past Medical History ▪ No/H/O – Hypertension / DM-2 / Hypothyroidism / hyperthyroidism. ▪ No/H/O - Bronchial Asthma / Pulmonary Tuberculosis / COPD / Emphysema / Covid-19. ▪ No/H/O - Angina / Myocardial Infarction. ▪ No/H/O - HIV 1 / HIV 2 / Hepatitis B. ▪ No/H/O - other major illness. ▪ No surgical history found. Personal History ▪ Ahar - Katu-Lavan Amla Rasa, Virudhha Ahar, Ruksha Anna, Paryushit Aahar, Vishamashana, Ushapan (2 glass of lukewarm water at 6:00 am). ▪ Vihar - Diwaswap - 1-2 hrs, Ratrijagaran - No, Kshudha Vega Dharan. ▪ Manasik Hetu - Chinta ++, Bhay++ ▪ Addiction history - No ▪ Occupation - Rikshaw driver. Ashtvidha Parikshan ▪ Nadi (pulse) - 79/min. ▪ Mala (stool) - Malavastambha (1 time/alternate day) ▪ Mutra (urine) - Ishat Peet (Pale yellow) ▪ Jeehva (tounge) - Saam (Coated) ▪ Shabda (speech) - Prakrut (Normal). ▪ Sparsh - Anushna Shit ▪ Druka (eyes) - Prakrut ▪ Akruti - Madhyam (Medium) BMI - 21.2 kg/m 2 Systemic Examination ▪ Blood Pressure - 110/70 mm/Hg. ▪ Pulse - 77/min ▪ SPO 2 - 98% O 2 ▪ S 1 S 2 - Normal ▪ Respiratory rate - 19/ min ▪ Temperature - 98.2°F Per Abdomen ▪ Inspection - Distended abdomen ▪ Palpation - Tenderness in the right Hypochondriac region.

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Mayur A. Gaikwad et al. An Ayurvedic management of Pittashmari (Cholelithiasis) ISSN: 2456-3110 CASE REPORT September 2024 Journal of Ayurveda and Integrated Medical Sciences | September 2024 | Vol. 9 | Issue 9 318 Liver - non-palpable. Murphy’s Sign - Negative. ▪ Percussion - Abdominal Guarding present. Samprapti Ghatak ▪ Dosha - Pachak Pitta, Saman Vayu, Kledak Kapha, Apan Vayu ▪ Dushya - Rasa Dhatu, Rakta Dhatu ▪ Strotas - Annavaha Strotas, Raktavaha Strotas ▪ Strotodushti - Sanga ▪ Agni - Agnimandya ▪ Adhishthana - Pittashay ▪ Sadhyata - Krichhasadhya M ATERIALS AND M ETHODS Table No. 1 shows the Therapeutic intervention given to the patient. Abdominal Pain was assessed using Visual Analogue Scale where 0 means no pain and 10 means extreme pain. Hrillasa was assessed using Nausea Severity Scale. Table 1: Therapeutic Intervention Date Aushadhi Matra Anupaan Kaal 01/03/2024 Shankhavati 1 tab (250 mg ) Once a day Koshnoda k (Lukewar m water) Apane (Before meal) Aarogyawar dhini Vati 2 tab (250 mg each) Twice a day Koshnoda k (Lukewar m water) Vyanodan e (After meal) Kumariasav 3 tsp (15 ml) Twice a day 3 tsp Koshnoda k (Lukewar m water) Vyanodan e (After meal) Kwath of Punarnva, Nimba, Haritaki, Kutki, Guduchi, Pittapapda, Shunthi and Daruharidra 20 ml Thrice a day Vyanodan e (After meal) Avipattikar Churna 3 gm twice a day Koshnoda k (Lukewar m water) Apane (Before meal) Course of Treatment ▪ Stopped Shankh Vati after 15 days. ▪ Stopped Avipattikar Churna After 15 days ▪ Continued rest all medicines upto 29/03/2024. ▪ Done USG-Abd. at 30/03/2024 ▪ Stopped Aarogyavardhini Vati and Kumariasav at 08/04/2024 ▪ Continue only Kwatha upto 30/04/2024. ▪ Done USG-Abd. at 07/05/2024 Table 2: Observations and Results Udarsho ola Amlod gar Uroda ah Hrilla sa Chhar di Mala Viband ha 01/03/ 24 +++ +++ ++ ++ + ++ 15/03/ 24 ++ + - - - - 30/03/ 24 + - - - - - 30/04/ 24 - - - - - - Table 3: USG Report Before Treatment (20/02/2024) Mid Treatment (30/03/2024) After Treatment (07/05/2024) 5 mm calculus within Gall Bladder 3 mm calculus within Gall Bladder No calculus present.

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Mayur A. Gaikwad et al. An Ayurvedic management of Pittashmari (Cholelithiasis) ISSN: 2456-3110 CASE REPORT September 2024 Journal of Ayurveda and Integrated Medical Sciences | September 2024 | Vol. 9 | Issue 9 319 Hepatomegaly with grade 1 fatty infiltration of liver. Hepatomegaly with grade 1 fatty infiltration of liver. Liver and gall bladder appears normal in size and shape. DISCUSSION Pittashmari forms due to the vitiation of all 3 Doshas. The line of treatment mainly focuses on Yakrututtejana which will ensure a good flow of Achha Pitta (bile) and will help dissolve the stone. Considering the Nidanpanchak and Samprapti Ghatak it has been observed that the Pitta and Kapha Prakopak Aahar Vihar leads to accumulation Vikrut Pitta and Kapha in Pittashay which leads to Strotorodha . This Strotorodha further leads to obstruction in the flow of Vaat leading to its vitiation. This vitiated Vaat makes the mixture of Pitta and Kapha dry due to its Ruksha Guna and leads to Ashmari formation. The drugs used have the following mechanism of action: Arogyavardhini Vati - Its contents due to their cholagogue nature helps in stimulation of secretion of bile from the liver and also aids in washing out excessive bile from the body before being absorbed, and thus helps in prevention of liver, spleen and gall bladder disorders. Almost 50% of its content is Kutaki . Kutaki is bitter in taste, cooling and removal of excessive fire energy from the body, best of removal of excessive Pitta from the body via colon. Kutaki helps in restoration of Liver functions by overcoming fatty liver changes [2] It also promotes liver regenerating activities by restoring cytochrome [5,6] Avipattikar Churna has Rechana and Shothahara property leading to excess Pitta Virechana. It has shown anti-secretory and anti-ulcerogenic effects [7] Essential oil of Ela , Lavanga , Tamala Patra and possess carminative and antispasmodic effect, thereby reduce colicky pain [8] One of the contents of Shankh Vati is Vatsanabh which has antispasmodic as well as has analgesic properties hence it helps to relieve colicky pain. Kumariasav - It acts as Mridu Virechak and also leads to Agni Deepan . It has also shown evidence in reduction of serum SGOT, SGPT, ALP levels and is hepatoprotective in nature [9] Kwath of Punarnava, Nimba, Haritaki, Kutki, Guduchi, Pittapapda, Shunthi and Daruharidra contents combinedly shows actions like Pitta Kaphaghna , Saam Pitta Pachak , Bhedan , Pittarechak , Yakrutottejak . Also, it acts as antispasmodic, anti-inflammatory, regulates liver functions, bile regulation, helps breakdown stone, maintain metabolism of cholesterol, detoxifies liver. Thus, helps in dissolving gall bladder stone. CONCLUSION This case study has shown encouraging results for the treatment of Cholelithiasis just by using Shaman Chikitsa . Not only the patient got rid of the stone but also there was marked improvement in his overall health. Based on the observations and results of this study it can be concluded that Ayurveda principles when applied accurately gives positive results and also help prevent the reoccurrence of the disease. Following images shows Sonography reports (Before, Mid and After treatment) Before treatment (20/02/2024)

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Mayur A. Gaikwad et al. An Ayurvedic management of Pittashmari (Cholelithiasis) ISSN: 2456-3110 CASE REPORT September 2024 Journal of Ayurveda and Integrated Medical Sciences | September 2024 | Vol. 9 | Issue 9 320 Mid treatment (30/03/2024) After treatment (07/05/2024) REFERENCES 1 Tripathi B, Charak-Samhita, vol.1, Caraka-Chandrika hindi commentary, Chaukhamba Surbharati Prakashan, Varanasi;2013 , Sutrasthana,adhyay 18 , verse no.44-47,page no. 378. 2 Sharma A R, Sushrut Samhita, Sushrut Vimarshini hindi commentary, Vol-1, Chaukhamba Surbharati Prakashan, Varanasi, Reprint 2015, Nidansthan, Adhyaya 3, verse 4, Page No. 481 3 Verma M, Gupta A, Review Article of Pittashmari W.S.R To Cholelithiasis. International Ayurvedic Medical Journal, 2020. 4 Dasi P, Maheshwar T, Anuradha D, Arogyavardhini Vati - A Boon for Liver Disorders from Ayurveda (Fatty Liver). AYUSHDHARA, 2021;8(4):3418-342 5 Rajkumar V, Gunjan G, Ashok KR (2011) Antioxidant and antineoplastic activities of Picrorhizakurroa extracts. Food ChemToxicol 49: 363-369 6 Girish C, Pradhan SC (2012) Hepatoprotective activities of picroliv, curcumin, andellagic acid compared to silymarin on carbon-tetrachloride-induced liver toxicity in mice. J Pharmacol Pharmacother 3: 149. 7 Gadad G G, Gudaganatti K S, Critical Analysis of Formulation and Probable Mode of Action of Avipattikara churna: A Comprehensive Review, Ijppr.Human, 2021; Vol. 22 (2): 301- 311. 8 Heghes SC, Vostinaru O, Rus LM, Mogosan C, Iuga CA, Filip L. Antispasmodic Effect of Essential Oils and Their Constituents: A Review. Molecules. 2019 Apr 29;24(9):1675. doi: 10.3390/molecules 24091675. PMID: 31035694; PMCID: PMC 6539827. 9 Khan MA, Gupta A, Sastry JL, Ahmad S. Hepatoprotective potential of kumaryasava and its concentrate against CCl 4- induced hepatic toxicity in Wistar rats. J Pharm Bioallied Sci. 2015 Oct-Dec;7(4):297-9. doi: 10.4103/0975-7406.168029. PMID: 26681887; PMCID: PMC 4678989. How to cite this article: Mayur A. Gaikwad, Jayant D. Gulhane. An Ayurvedic management of Pittashmari (Cholelithiasis): A Case Study. J Ayurveda Integr Med Sci 2024;9:316-320. http://dx.doi.org/10.21760/jaims.9.9.51 Source of Support: Nil, Conflict of Interest: None declared.

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