Ayurveda is an Indian system of medicine which has been in practice for thousands of years. Ayurvedic medications have been shown to be effective in the treatment of several disorders of the liver including liver cirrhosis, hepatitis and fatty liver. This case report describes an unusual intervention utilizing Ayurvedic treatment for hepatic encephalopathy. A patient with miliary tuberculosis undergoing anti-tubercular treatment developed hepatic encephalopathy presenting with coma, severely increased liver function tests (LFTs) and other abnormalities. Treatment based on Ayurvedic diagnosis and medication was deployed. It resulted in improvement in liver function, with normalization of LFTs and restoration of consciousness within a short period of time. This case report indicates a possible role for Ayurveda in hepatic encephalopathy and warrants further investigation. The condition described in this case report is considered to be caused by an extreme disturbance of Pitta (Fire and Water), eventually affecting the liver and leading to liver impairment and disturbance of the senses. Ayurvedic treatment has been reported to be effective for liver disorders including hepatitis, cirrhosis and fatty liver etc.4-7 Ayurvedic texts such as Ashtang Hruday and Charak Samhita describe the management of such conditions.8A 69 year old Indian female patient presented to the hospital for general debility and weakness on October 12th 2012. The weakness and debility had been present for over six months. This was the main reason for which the patient was admitted to the hospital. Initially the patient could easily walk, with only slight weakness. This progressed until regular activities became difficult. Her medical history was negative for infection or miliary tuberculosis. Past HistoryThe patient had suffered from facial palsy in April 2012 and a fracture of the femur neck in 2009 which contributed to overall weakness. The patient had also suffered from painful hemorrhoids for more than three years. Traveling and spicy food aggravated most of the symptoms. The patient was a known hypertensive for more than five years and was under Western medication for the same.
In the course of investigation by the physician at the hospital, MRI scans showed a probable tubercular lesion leading to a diagnosis of miliary tuberculosis. At that time, the patient was put on a course of Anti Koch’s Treatment / Anti Tubercular Treatment (ATT) which included rifampicin, isoniazid, ethambutol and pyrazinamide. Over the course of the ATT, the patient complained of feeling drowsy; gradually her level of consciousness dropped, bowel movements ceased and she became comatose (on October 22nd 2012). The patient became unresponsive. At this point, ATT was discontinued but fluids were given intravenously.
At that time, the patient’s clinical biochemistry was found to be abnormal, with prominent changes in LFTs and elevated serum glutamic oxaloacetic transaminase (SGOT) and serum glutamic pyruvate transaminase (SGPT), which were 10 and 30 times above the normal range, respectively (see Table 1).
Table 1. Ayurvedic elements and doshas.
Earth + Water
Fire + Water
Air + Space
The examination was carried out using Ayurvedic clinical methods including pulse examination and abdominal examination using percussion. Apart from weakness, the patient showed neither any specific neurological symptoms nor liver related specific symptoms. She had well maintained blood pressure and stable weight.
Based on the patient’s examination and test results, she was diagnosed with hepatic encephalopathy due to hepatotoxicity of ATT used for Miliary Koch’s.9 The overall health condition of the patient was poor and she was maintained in the Intensive Care Unit.
Ayurveda specifically describes liver inflammation in the form of jaundice when Pitta vitiating medicines or diet are consumed in the condition where rasa dhatu is depleted.
The present condition of the patient created Pitta vitiation to a greater extent afflicting the liver and eventually causing the loss of senses. This condition of accumulation of vitiated Pitta in the liver can be treated with herbs that specifically work on Pitta and open the channels facilitating elimination of excess Pitta.10
Therapeutic focus and assessment
The patient was then referred for Ayurvedic treatment (AT), which began on the fifth day of coma (27th October 2012). At the time of initiation of AT, the patient was under the medical supervision of a physician at an allopathic hospital in Pune, India and was referred for alternative treatment due to non-response to allopathic treatment. The patient’s treating physician assigned permission for treatment by Ayurveda methods. The patient was being given IV fluids and nutrition was given via feeding tube. In addition, she was receiving albumin as supportive treatment for severe decubitus ulcers on the back and hip region.
AT consisted of the following combinations of herbal and metal therapeutic agents: Falatrikadi Guggul11 (1000 mg/d), Tamra Bhasma12-15 (60 mg/d), and Shwadanshtradi Guggul16 (500 mg/d) administered for the first two days of treatment. Ayurvedic medicines were administered via the feeding tube. Falatrikadi Guggul is a combination of herbs containing Haritaki (Terminalia chebula), Amalaki (Emblica officinalis), Bibhitaki (Terminalia belerica), Vasa (Adhatoda vasica), Nimba (Azardiracta indica), Kutki (Picrorrhiza kurroa), and Guduchi (Tinospora cordifolia), formulated as a preparation with guggul per the Ayurvedic texts. It is commonly used for the purpose of treating liver disorders like fatty liver, liver cirrhosis etc.
Tamra bhasma is a calx – ash powder made from copper metal. The copper is processed with various decoctions and liquids to improve bioavailability, and then subjected to heat treatment to create the calx. This preparation is known to have a beneficial effect on the liver. It helps to tone the liver by removing accumulated vitiated doshas in it.18
Shwadanshtradi Guggul is combination of herbs containing Gokshur (Tribulus terrestris), Haritaki (Terminalia chebula), Amalaki (Emblica officinalis), Bibhitaki (Terminalia belerica), Shunthi (Zinziber officinalis), Pippali (Piper longum), Marich (Piper nigrum), Pashanbheda (Bergenia ciliata) and Dhamasa (Fagonia arabica).19 It helps to eliminate the vitiated doshas from the body through urine.
On the 3rd day the patient was administered Brahmi vati + Tamra bhasma + Guduchi + Nirgundi (Vitex nigundo) + Shwadanshtradi Guggul, a total of 750 mg per day in divided doses. Falatrikadi Guggul was not administered on this day. On 4th day the patient was again given Falatrikadi Guggul + Shwadanshtradi guggul + Tamra bhasma, 1500 mg per day in divided doses. After the 4th day, the same treatment regimen was repeated without any changes.