AUTHOR: Dr. Prasad Pandkar (Asso. Prof. & Ayurveda Physician) Bharati Vidyapeeth Deemed to be University College of Ayurveda, Pune-43

1. Ayurvedic Approach Towards Gall Stone & A Case Study
1
(Asso. Prof. & Ayurveda Physician)
Bharati Vidyapeeth Deemed to be University
College of Ayurved, Pune-43
Dr. Prasad Pandkar

2.  Definition & related Terms
 Epidemiology
 Etiology, Pathology & Clinical features
 Standard Treatment Modalities
 Need for conservative approach
 Gall Stone in Ayurveda?
 Tacit Diseases & Ayurveda Diagnostics / treatments
 Case Study and medication details
 Discussion & Conclusion
2
Content:

3. 3
Modern & Ayurvedic Approach
Towards Gall Stone

4.  Gallstones: hardened deposits of cholesterol, bile salts, bilirubin in
gallbladder or CBD.
 Cholesterol stones: Gallstones formed mainly from cholesterol
 Pigment stones: Formed mainly from bilirubin
 Mixed Stones: Formed mainly from Cholesterol calcium
carbonate, palmitate phosphate, bilirubin and other bile pigments
 Cholecystitis: inflammation of the gallbladder.
 Choledocholithiasis: the presence of gallstones in the common bile
duct (CBD)
 Cholelithiasis: the presence of gallstones or to the diseases caused by
gallstones
 Cholangitis: Infection of bile duct
4
Gall Stone: Definition & related Terms

5.  The overall prevalence of GS disease in most developed
nations, including US, UK, Italy and the Scandinavian nations,
is between 10% and 20%.
 The prevalence increases with age in both males and females.
 At the age of 65, about 30% of women have GS, and by the
age of 80 years, 60% of both males and females have GS.
 The large majority of these (70–85%) are asymptomatic
5
Epidemiology: Global picture

6.  First Indian epidemiological study: 7 times more North Indian workers
than South Indian workers. (Malhotra SL 1968)
 Higher predominance in North Indians (both gallbladder & CBD) stones.
South Indians have a predominance of pigment gallstones both in the
gallbladder and the CBD.( Rakesh K Tandon 2000)
 A study from east India: mean age of the patients as 38 years , male-
female ratio of 1:3. Mixed type of stone are more common than alone
cholesterol and pigmented stones and are more prevalent in a mixed
diet than vegetarian. (AlokChandra Prakash 2016)
 Gallstones are common with prevalence as high as 60% to 70% in
American Indians in comparison with 10% to 15% in white adults of
developed countries.(Stinton LM 2010)
6
Epidemiology: Indian Scenario

7.  Age: 40+, Gender: Female
 Lack of melatonin
 increasing age, and ethnicity/family (genetic traits).
 obesity, the metabolic syndrome
 rapid weight loss,
 certain diseases (cirrhosis, Crohn disease, diabetes, ceoliac disease, liver
disease),
 gallbladder stasis (from spinal cord injury or drugs, such as somatostatin),
and lifestyle.
 birth control pills, pregnancy,
 family history of gallstones,
 Biochemical parameters such as plasma total cholesterol, triglycerides, and
LDL cholesterol level were independently associated with GSD. (Deepak
Dhamentia 2018)
7
Risk Factors

8.  OC pills and Pregnancy
 Family History gall stone
 Constipation
 Less meals per day, Low fluid consumption
 Low intake nutrients (Folate, Calcium, magnesium,
Vit C)
 High intake of carbs, fat, high glycemic index diet
 Drugs containing estrogen, drugs for higher
cholesterol, proton pump inhibitor
 For pigment stones: Hemolytic anemia, Sickle cell
anemia, cirrhosis, biliary track infection
 Bile acid malformation 8
Risk Factors

9.  Preceded by Biliary Sludge (semi-solid slurry).
 Bile with too much of cholesterol and not enough bile salts.
 Hyper secretion of cholesterol due to altered hepatic cholesterol
metabolism
 Bile supersaturated with cholesterol, glycoproteins, calcium
deposits, and cholesterol crystals in the gallbladder or biliary ducts
 Role of gallbladder contractions: Incomplete and Infrequent
emptying of the gallbladder.
 Proteins in the liver and bile promoting or inhibiting cholesterol
crystallization into gallstones.
 Estrogen, (Pregnancy or hormone therapy, ,hormonal
contraception) probably increases cholesterol levels in bile and
decreases gallbladder motility.
9
Pathology

10. 10
Cholesterol, Mixed and Pigment stones
(respectively)

11.  Mostly asymptomatic.
 Symptomatic cholelithiasis: mild nausea and vomiting, abdominal
discomfort to biliary colic and jaundice.
 Biliary colic: u sharp postprandial epigastric or right-quadrant pain
lasting for several minutes to several hours.
 The pain may radiate to the back /right shoulder,
 nausea Upper-right-quadrant tenderness and palpable infiltrate in
the region of the gallbladder
 If obstruction of the cystic duct is persistent and fever is common.
 Murphy’s sign: discomfort so severe that the patient stops
inspiring during palpation of the gallbladder or jaundice.
 Mirizzi’s syndrome: Jaundice, when the CBD is obstructed
because of an impacted stone in Hartmann’s pouch
11
Symptoms

12.  Cholecystitis
 Pancreatitis
 Jaundice
 Cholangitis
 Gall stone ileus
 Gall bladder cancer
12
Complications

13.  Expectant management (wait and see):
 (Anu Behari & VK Kapoor 2011)
13
Pros Cons
Avoids overtreatment Potential for development of
a serious complication while
waiting
Avoids anaesthesia/surgery-
related morbidity/mortality
Need to operate on an older
patient (with co-morbidities)
or in an emergent setting
may increase morbidity and
mortality
Avoids unnecessary
cost/workload for the health
care system
Standard Treatment Modalities

14.  Total Cholecystectomy:
 (Anu Behari & VK Kapoor 2011) 14
Pros Cons
Definitive cure Overtreatment of a large
number of patients
Potential morbidity/mortality
of anaesthesia/surgery
Generally a safe procedure
with low morbidity and
mortality, especially when
performed in absence of
complications
Increased cost/workload for
the health care system
Standard Treatment Modalities

15.  Selective Cholecystectomy:
 (Anu Behari & VK Kapoor 2011)
15
Pros Cons
Theoretically ideal – only
subgroups at higher risk for
development of symptoms or
complications would be treated
Practically difficult – clear
identification of high-risk
subgroups still far from easy
Standard Treatment Modalities

16.  Long-term follow up studies from the West have consistently shown that
only a small minority of asymptomatic gallstones lead to development of
symptoms or complications.
 About 80 % of all the gall stones has evidence for no symptoms and may
continue for years.
 Majority of patients rarely develop severe, potentially life-threatening
complications, such as acute suppurative cholangitis or severe acute
pancreatitis, without first having at least one episode of biliary pain.
 Pancreatitis risk is needed to be considered if patient is diabetic.
 Physicians from countries with federal health care system have published
that asymptomatic gallstones need no intervention in most cases, thereby
saving the patient unnecessary surgery and the health care establishment
costs, both in the financial form and in manpower.(Khurshid 2007) 16
To Operate or not to Operate is The Question

17.  PCS: Post Cholecystectomy Syndrome: Occurrence of abdominal
symptoms after cholecystectomy.
 Dyspepsia , nausea, vomiting, Flatulence, bloating and diarrhea,
Persistent pain in the upper right abdomen.
 Some have reported that symptoms after Laparoscopic
Cholecystectomy settle over time. previous attacks of cholecystitis
and presence of co-morbid conditions are the only consistent risk
factors for PCS. (Arora D et.al. 2018)
 However some report that Symptoms occur in about 5 to 40
percent of patients who undergo cholecystectomy, and can be
transient, persistent or lifelong. (Sciarretta G et.al. 1992)
17
Need of Conservative Approach

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(Charaka Su 18)
18
Principle for Diagnostics & treatment of Tacit Diseases:

19.  Vikar Prakriti: dosha/ cardinal symptom
 Adhishthan: sthana
 Samuthan Vishesha:hetu
 तत्र द्वौ हेतू-समुत्तानववशेषात्कु वितत्वं स्थानान्तरप्राप्तित्च (Hemadri)
 Samuthan vishesha kupita: hetu vishesha/guna vishesha
 Sthanantar prapti: kha vaigunya sthana
19
Principle for Diagnostics & treatment of Tacit Diseases:

20.  Crystallization: a) Nucleation the step where the solute molecules or
atoms dispersed in the solvent start to gather into clusters, b) crystal
growth
 There are 2 ways the matter can be changed to its solid state. Liquid
can be changed to solid state by phenomenon of freezing. Whereas
Deposition is what makes gaseous state to directly in solid state.
 However in a living body things are far complex.
 For understanding of this stone formation process, plethora of
literature is available in basic sciences (precipitations, deposition,
condensation etc) and in modern Pathophysiology (crystallization of
bile, calcification at tissues etc).
20
Understanding Phenomenon of Stone Formation:

21.  Sharir Guna is the conceptual framework for understanding of body
phenomena.
 The ‘Compactness in composition’ is :
A) Sandra adrava,
B) Shlish alingane.
 Gall bladder: Place of Pitta: Decrease in ‘Sara’ and ‘drava’ guna of pitta
leads to stone formation
 Apt vacating of gall bladder is possible due of sara and drava guna of
pitta only
 Rooksha guna of vayu is responsible for shoshana of kapha.
 ‘Daroona guna results in shoshana at sharir avayava/bhava and results
in kathinya’ (Chakrapani on Cha su.12/4) 21
Ayurvedic understanding of Formations of gall stone

22.  Genesis of Prithvi mahabhoota is from jala. And disintegration of prithvi is
again in jala.
 Thus it is snigdha, jaliya kapha that dries up to form stones. Where as
incompetent teja and jala mahabhoota make it difficult to dissolve and it
will remain hard
 Mootrashmari samprapti mentions srotomukha sanvarana by vayu &
shoshana of Kapha by vayu.
 Interestingly incomplete vacating of gall bladder is also reported as part of
pathology of GB stone.
22
Ayurvedic understanding of Formations of gall stone

23. 23
Risk factors Interpretation
obesity, high total cholesterol, triglycerides,
and LDL cholesterol:
Raktagata aama , meda
diabetes , metabolic syndrome: Meda dushti, Santarpanotha
cirrhosis, liver disease: yakrut roga
Crohn disease, Ceoliac disease: Grahani and pakwashaya gata
roga
birth control pills, Drugs containing estrogen Vegavidharana, Meda, rakta and
shukra dushti
Constipation vayu vilomata
For pigment stones: Hemolytic anemia, Sickle
cell anemia, cirrhosis, biliary track infection,
Bile acid malformation:
Ranjaka pitta vikruti
Santarpana, Grahani dushti, yakrut dushti, ranjaka pitta dushti triggers
this stone formation
Samuthana: Risk factors:

24.  Mootrashmari: Subtype Pittashmari
 Kamala
 Gulma
 Shoola
24
Relvevant Adhikarana for GB stone

25. A Success Story of
Symptomatic Gall Stone Case
25

26.  Basic Information:
 A 50 year old , Mumbai based ,female patient
 Ethnicity: Kokani (Costal maharashtra)
 Diet: Mixed (Fish prominent)
 Home maker
26
Case Presentation

27. Case Presentation
 Presentation:
 Classical Biliary colic episodes since last 20 days. (Projectile
Vomiting, Right hypochondriac pain, nausea)
 No fever.
 Amlak
 Bhrama
27
Case Presentation

28.  Pulse: 76/min
 Blood Pressure:114/74 mm hg
 Weight: 52 kg
 Pallor: No
 GC: fair
 Nadi: Vata pradhana Pitta
 Mala: Sama, once a day.
 Mootra: Samyak
 Jivha: Sama
 Sparsha: Tenderness at right hypochondriac region
 Prakruti: Vata pradhana Pitta
 Sweda: Little excess
 Nidra: samyak
28
Clinical Examination

29.  Bhrama
 Shitapitta
 Manya shool
 Udgar bahulya
 Skandha shoola
 Epigastric pain
29
History:

30.  Diagnosis of gall stone
was done with
Sonographic evidence
(21.01.2017) of moving
gall stone measuring
17.6mm. No
cholecystitis.
30
Diagnosis

31.  Classical diagnosis: Pittaj gulma/ Shoola, Sama avastha
 Modern Diagnosis: Symptomatic gall stone
31
Ayurveda Diagnostics:

32.  Basic Chikitsa sootra of shool / Gulma
 Snehana, swedana, anulomana, Virechana, Vyadhipratyanik yoga
 Chikitsa sootra of ashmari:
 Sanshodhana, anulomana, Vyadhipratyanik yoga
 Panchakarma treatments were not possible as Patient had
insisted for internal medication. Thus option of internal
medication was opted.
32
Discussion: Chikitsa Sootra

33.  Shankha vati 250 mg twice a day.
 Patolkaturohinyadi kashayam: fresh kashaya prepared from 2gm mixture of :
Patoladi gana (Patol, Kutki, Shweta chandana & rakta chandana, Moorva, Amruta,
Patha)
 Ingredients of ‘Kushadya ghruta’ (Bhaishajya ratnavali ashmari chikitsa) in churna
form (Kusha, Kasha, Shara, Ikshu, Amruta, Morat, Pashanbhed, Darbha, Vidari,
varahikanda, Shalimoola, Trikantaka, Patha, Shonak, Patla, sahachara, punarnava,
shirish, shilajit, yashti, kamal beej, trapusha) (All Except underlined ingredients as
they were unavailable.)+ Sootshekhara rasa (3.5 gram)+ Kravyad rasa 2 gram)+
Tamra parpati 1gm+ Hajral yahud pishti 2gram+ (Kavachbeej+Gokshur+Shatavari+
bala+ yashtimadhu a classical formulation indicated in pittapradhana ashmari)+
Trivikram rasa1gm
 Kumari asava (mfg by Sandu) (15 ml twice with added hot water)
 Aarogya vardhini: 250mg twice a day.
33
Treatment Given

34.  Patient was relieved from biliary colic. Only a single mild attack of biliary
colic was there.
 Clinical examination: No significant change
 Medication:
 The prescription was same with following 2 additions.
 1) In Kashayam Preparation along with patolkaturohinyadi formulation+
Rohitaka and haritaki were added as this duo combination is mentioned in
Yakrutpleeha rogaadhikara in Bhaishajya Ratnavali.
 2) Punarnava mandura 250 mg twice
34
First Follow-up after 15 days

35.  Similar prescription with minor changes was continued
for 6 months with all necessary changes time to time.
 During which patient got complete relief for all related
the clinical complaints including nausea, vomiting, right
hypochondriac pain.
 Bhrama too was diminished.
 A abdominal sonography was advised as 100% clinical
relief was achieved since 3 months.
35
Next follow-ups

36.  The ultrasound reflects (31. 07. 2017) :
 Gall bladder is physiologically distended
 Wall thickness is normal
 There is no calculi
 CBD appears normal.
36
Repeat Ultrasound After 6 months

37.  The patient has no any clinical symptom of biliary colic since
then (July 2017) upto today (Oct 2019).
37
Non Recurrence:

38.  Shankha vati is a classical preparation with kshara. It is indicated in
sama pitta conditions particularly for shoola condition.
 The bhedana action as well pachana of kshara is important. Kledana
followed by bhedana is unique action of kshara.
 Dravaikarana is achieved with kledana action of kshara (also by kumari
asava)
 Increasing Drava guna and sara guna is important treatment principle.
38
Discussion: Choice of Drugs

39.  Pachana: Kravyada rasa is having pachana as well
bhedana action. It is recommendable particularly for
pachana in mixed dietarians.
 Soota shekhara is a drug of choice in sama pitta
conditions
 Parpati kalpana of Tamra was used for gamitwa.
39
Discussion: Choice of Drugs

40.  Yakrut bhedana:it is always important to use aushadhi with
apt gamitwa.
 kumari Asava
 Arogya Vardhini
 Punarnava Mandur
 Patolkaturohinyadi kshaya
 Yakrut pleeha rogadhikara is specifically mentioned in
Bhaishajya Ratnavali. Apt study of this chapter gives not only
insights but also drugs of choice for different hepatobiliary
conditions. 40
Discussion: Choice of Drugs

41.  Ashmari pratiniyat
 Kushadya ghruta, hajral yahud bhasma, trivikrama rasa.
(All three drugs are recommended by Late Rajeshwar
Datta Shastriji for Gall stones).
 Use of Tamra kalpa: Mandur, loha and tamra kalpa are
observed to be more teekshna increasing order. Mild to
moderate lekhana can be achieved with mandura/ loha
kalpa. For disintegration of gall stone tamra kalpana is a
must.
41
Discussion: Choice of Drugs

42. 42
Concluding Remarks

43.  Gall stone with Acute Conditions with complications
 Gall stone in CBD will need more careful observations and follow ups.
 Diabetics. As crushed stone particles if refluxed can cause pancreatitis
 Pregnancy. As the choice of lekhana / teekshna internal medication
becomes least.
43
Probable Limitations in dealing with GB stone cases:

44.  Anukta vyadhi like gall stones can be treated.
 Classics have already mentioned standard protocols for different clinical
conditions. There is need of better interpretations of modern conditions
into classical ayurvedic terms/ conditions.
 Purusham Purusham Veekshyam and changes in management according
to awastha remains the key.
 Bhaishajya ratnavali is an important classic that bridges modern and
classical language.
44
Conclusions/ Take Home Message

45. 45