PROF. DR. S N OJHA

HEPATOBILIARY DISEASES FROM CHARAK SAMHITA-

PART 1

PROF. DR. S N OJHA DIRECTOR & PRINCIPAL

HON ANNASAHEB DANGE AYURVED MEDICAL COLLEGE

ASTHA, SANGLI MAHARASHTRA

Introduction

• Yakrit is considered as one of the koshtanga.

• It is Matruja avayava.

• Yakrit is the moolasthana of raktavaha srotas which maintains the quality as well as quantity of rakta.

• Yakrit has its origin in Garbhavasta from Rakta dhatu.

• ASHRAYA.................... ASHRAYI sambandha

• Raktavaha srotas............ Yakrit

• Raktadhatu VITIATED Yakrit

• In Samhita there is no specific importance given to Yakrit as avayava whereas the classic have given importance to raktavaha srotas and rakta dhatu.

• Need of the hour to understand the Ayurvedic approach to Hepatic and Biliary disorders in Modern parlance.

• Vidhishonitiya Adhyaya (Ca. Su. 24) mentioned the

general causes of Rakta dusti and described the

symptoms.

• All the hetu mentioned may be classified as:

1. some vitiating the dhatvagni

2. some vitiating the srotas ashrita vata

3. some acting on the srotas.

Those acting on the srotas will be considered here.

MADYA

• Pradustha, bahu, tikshna, ushna Madya and wrongly prepared and administered madya leads to rakta and yakrit dushti.

• Madya when taken by following rules and regulation acts like Amrita otherwise it acts like the Visha. (Ca. Ci. 24/28)

• Madya by its ten qualities which are opposite to Oja, help in vitiating raktadi dhatu and Oja.

Madya

VYAVAYI GUNA

changes gut permeability

LAGHU GUNA

absorption of endotoxins

released by bacteria in the gut.

Alpa VyadhiVighata Bhava In response to endotoxins

impaired liver can no longer detoxify

Kupffer cells release free radicals, oxidative damage

Oxidative Stress

USHNA TIKSHNA GUNA

Cell necrosis and apoptosis

Hepatocyte loss

Vyadhi Vighatkar Bhava unable to regenerate normal cells

Fibrosis CIRRHOSIS

(excess of type I collagen and extracellular matrix)

sinusoids narrow, limiting blood flow

PORTAL HYPERTENSION

• Sura, Sauvira, Sukta, are the different types of

madya which contribute to Yakrit vikar when taken

in excess or in improper manner.

• Madya has been the cause for Raktapitta, Shoth,

Udara, Madatyaya.

• These are all the diseases where Rakta is among the

main dusya and involvement of Yakrit is observed.

GURU, SNIGDHA, PISTANNA, ABHISYANDHI, SANTARPANOTHA AAHAR

CHOLESTEROL

ENRICHED

DIET

PRITHVI + AAP MAHABHUT PRADHAN

↑KAPHA

JATHARAGNI MANDYATA

BHUTAGNI MANDYATA (PRITHVI + AAP BHUTAGNI)

DHATWAGNI MANDYATA(MEDAGNI) ATIMATRA MEDASWINO

MEDA EVA UPACHIYATE

NA TATHA ITARE DHATAWA

ALTERED PERMEABILITY OF SROTAS

CIRCULATING FREE FATTY ACIDS (FFA) (APACHITA MEDA/ SAMA MEDA)

EFFECT ON LIVER

NON ALCOHOLIC FATTY LIVER DISEASE

1. END STAGE LIVER DISEASE

2. HEPATO- CELLULAR CARCINOMA

Sanklishta, Vyapanna Madya

(contaminated food and water)

Cysts of Entamoeba

Mansa ashraya (Invasion of the intestinal lining)

(vyadhi vighata abhava)

TRIDOSHA PRAKOPA (Ca. Su. 17/185)

Raktatisara Rakta Ashraya

If enters blood stream

spread through the body

YAKRITA (KHA VAIGUNYAT)

YAKRITA VIDRADI (Liver Abscess)

MADYA

VARUNYASCHA ATISEVANAT

MEDOVAHA SROTAS DUSHTI

CIRCULATING FREE FATTY ACIDS (FFA) (APACHITA MEDA/ SAMA MEDA)

If Kha vaigunya in YAKRIT due to madya

ALCOHOLIC FATTY LIVER DISEASE

Lavana Rasa Atyadhik Sevan

• Lavana again contains Ushna, tikshna, sukshma guna.

• पऩत्त ं कोऩयति,रक्ि ं वधधयति, कुष्णाति मांसातन, पवषं वधधयति,

शोपान ्स्पोटयति.

• Excess intake of lavana is among the cause for Impaired

Rakta Vridhi.

• High-salt diet exacerbated nonalcoholic

steatohepatitis (NASH) in individuals involved in high-

fat diet.

LAVANA RASA (Taken in Excess)

Ushna Tikshna Vyavayi

Oxidative stress

Vyadhi Vighat Bhava Vyadhi Vighat Abhava

balance between the production of reactive oxygen species (free radicals) and antioxidants is upset

increase inflammatory cells

death of liver cells progressive fibrosis

Katu rasa & Amla rasa

• Katu rasa helps in शोणणिसङ्घािं भिनपत्त in normal

quantity but when taken in excess it is the cause for

bleeding tendency.

• Amla rasa causes Pitta vridhi and rakta dusthi which

together is cause for yakrit dushti.

• कपं पवऱाऩयति, मांस ंपवदहति are the other actions of

Amla rasa.

Amla, Katu, Lavana Rasa Atisevan

Pitta Vriddhi

Pittam Raktam Prapadyate

Dravo Dhaturdhatoh (Mansadi) Prashichyate

Coagulatory factors & vitamins are proteins

(Mansa Dravya)

Swidyastyena samvruddi

Drava Rupa Rakta vriddhi

(Yakrit, Pleeha and raktavaha sira)

RAKTAPITTA

(INR, PT, PTT test are important

to be analysed by Ayurvedic Practitioner)

Visha (Hepatotoxic Drugs & Metals)

• Visha like madya has qualities opposite to Oja.

• Especially the Ushna, Tikshna, Vyavayi and Vikashi guna which helps the poison to cross all the protective barriers within the body.

• Visha also has deteriorating effect on yakrit.

• Drug-induced liver injury is responsible for 5% of all hospital admissions and 50% of all acute liver failures.

Heavy Metals, Drugs, Chemical Reagents

Vyavayi Guna

Easy Absorption in GI Tract

from gastrointestinal

organs

Blood Coming To The Liver

bring drugs and xenobiotics in near-undiluted form

Ushna Tikshna

Damage the Mitochondria

Oxidative Stress

Cell Apoptosis

Injury to hepatocytes and bile duct

Sanga of Drava gunatmak Pitta (Bile obstruction)

Yakrit Vikriti (Liver damage)

Vyadhi Vighatkar Bhava

Pro-Inflammatory factors (Cytokines, Death Signal Pathway)

Sensitize T cells (Cytotoxic T activation B cells)

Pleehodar vis a viz Yakrutodar • Hetu are common

• Splenomegally complicate Hepatomegally.

• शोणणिं वा रसाददभ्यो पववदृ्धं िं पववधधयेि ्

• शोणणि ंवा रसाददभ्य इति अत्राददशब्दः प्रकारवाची; िने रसस्य कारणस्य वदृ््या कायधस्य रक्िस्य वदृ्धधस्िथा मांसाददभ्योऽपऩ रक्िवदृ्धधिधवति; िनेाहारपवहारेभ्यो रक्िवदृ्धधरुक्िा िवति|

• Metabolic disease such as Gaucher's disease, Niemann-Pick disease proteins, cholesterol, (मांसाददभ्योऽपऩ) get deposited in Liver and spleen Hepatospleenomegally

• Nispava, masha, pinyaka, tila taila are hetu explained for rakta dusti in Vidhishonitya adhyaya (Ca. Su. 24) & Raktpitta adhyaya (Ca. Ni. 2) where it is cause for pitta and rakta vitiation vatarakta chikitsa adhyaya (Ca. Ci. 29) where it is cause for rakta dusti.

• Further these food ingredients have low nutritional values essential for rakta formation i.e. there is rakta poshak rasa bhag alpata.

• Kullatha (Dolichos biflorus)

The presence of antinutritional components such as haemagglutinin and a protease inhibitor has been reported.

PANDU • Rakta Poshak Rasa Sara Bhag is samprapti ghatak.

• Pittakar Hetu Amlapitta

Gastritis

loss of parietal cells in the fundus body of the stomach failure of intrinsic factor production

(Rakta Poshak Rasa Sara Bhag)

vitamin B12 deficiency and megaloblastic anaemia

• Extramedullary hematopoiesis is the cause for Hepatomegally.

Pittaj Pandu 1. Jwara present in pittaj pandu explains the

infectious condition as seen in Malaria (endemic area).

2. Various viral Hepatitis

3. Various viral infections can trigger haemolysis as in paroxysmal cold haemoglobinuria.

4. Jwara may be also caused by endogenous causes (ama) PITTA VRIDHI

Immune cytokines interfere with the body ability to absorb iron (rasa bhaga)

Trigger intravascular haemolysis Yakrit Vikar

Marmopaghata • It is explained As Hetu In Shoth is again a cause for

Yakrit vikar.

Hridroga (Congestive heart failure)

blood to back up from the heart

into the inferior vena cava.

pressure in the inferior vena cava

including the hepatic veins

Liver becomes engorged (congested)

SHOTH

Shwas is also a cause for Yakrit Vikar SHWAS (COPD)

PRANVAHA SROTOMULA DUSHTI

(HRIDAYAM MULAM RASAVAHA DHAMANI)

HRIDROGA (CORPULMONALE)

back pressure leads

HEPATOMEGALLY

Jwar • रक्तधात्वाश्रयः प्रायो दोषः सततकं ज्वरम ्

• Vishamjwara having ashraya in raktadhatu will affect the rakta dhatu and inturn yakrit.

• Salmonella enterica serotype typhi is the causative agent.

• Hepatic involvement with Salmonella occurs via both hematogenous seeding of the liver during bacteremic periods and from infection of cells of the reticuloendothelial system.

• Reverse pharmacology of Pippalyadi ghrit mentioned in jwara has its use in visham jwar and halimaka as its phalashruti.

Krimi And Yakrit Vikar

• Krimi which are raktaja have ashraya in raktavaha

dhamani so they will have impact on Yakrit.

• Shleshmaja krimi and purishaja krimi in late process

may involve the yakrit.

• Puti, Klinna, Sankirna, Viruddha, Asatmyaja, Ajirna is

cause for Rakta dusti as well as for Raktaj, Shleshmaja

and Purishaja Krimi.

Sr. No.

Parasitic Disease

Liver Pathology associated with infection

1 Ascariasis Biliary hyperplasia

2. Babesiosis Kupffer cell hyperplasia or infection

3. Plasmodium species (malaria)

Kupffer cell hyperplasia, rarely hepatic necrosis

4. Toxoplasmosis Hepatitis, hepatocyte necrosis

5. Schistosomiasis Portal fibrosis, portal hypertension

Gulma also contribute to liver diseases • कट्वम्ऱिीक्ष्णोष्ण पवदादह रूऺ क्रोधातिमद्याकध हुिाशसेवा|

आमाभिघािो रुधधरं च दषु्टं ऩैत्तस्य गुल्मस्य तनभमत्तमुक्िम ्||१२||

• Pittaj gulma (pancreatitis) leads to fatty liver.

• Cyst formation, pseudocyst formation, Calcification process, tumours (benign or malignant) have their pathophysiology as like gulma.

• If they get formed in yakrit it will lead to hepatic diseases and if the same occur in pancreas then as complication yakrit involvement is observed.

General Symptoms of Yakrit Vikar

• Mukhpaka: Nutritional deficiencies of iron, vitamin

B, and vitamin C may cause mouth sores due to

hepatic damage.

• Asyagandha: Fetor hepaticus occurs when breath

has a strong, musty smell.

• Raktapitta, Pradar, Upakusha results due to

Coagulatory failure due to Hepatic Involvement

• Klama/ Ati-daurbalya: Lethargy, Fatigue, weakness,

and exhaustion.

• Agnisada (Loss of appetite), often with nausea and

weight loss.

• Santapa (Fever)

• Vidradi (abscess)

• Krodha prachurata: Uninhibited behavior, Marked

personality change observed in hepatic

encephalopathy.

मदः कम्ऩः िन्द्रा तनरातियोगश्च िमसश्चातिदशधनम ्

Madya

Raktavaha (Yakrita), Rasavaha (Hridaya),Sadnyavaha (Mana) Srotas alongwith Kupita tridosha

Raja, Moha, Avrutat Mana

MADA MURCHA SANYASA

• The most frequent alcohol-associated tremor is postural.

• Asterixis is a tremor of the hand when the wrist is extended, sometimes said to resemble a bird flapping its wings (Flapping tremors).

• It can be a sign of hepatic encephalopathy, damage to brain cells presumably due to the inability of the liver to metabolize ammonia to urea.

• Mada (Confusion) is followed by Kampa (Asterixis) are early sign of Hepatic Encephalopathy.

Hepatic encephalopathy grading Hepatic

Encephalo-pathy Type

Manifestation

I Changes in behavior , mild confusion (Moha) , slurred speech , distorted sleep.

II Lethargy , moderate confusion (Mada)

III Marked confusion {stupor} incoherent speech , sleeping but arousable (Murcha)

IV Coma unresponsive to pain (Sanyasa)

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