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\begin{document}


\def\RunningAuthor{ Shweta Dadarao Parwe and Milind Abhimanyu Nisargandha}
\firstPage{5902}
\articleType{Case Report}
\receivedDate{15 Jun 2020}
\acceptedDate{23 Jul 2020}
\revisedDate{03 Jul 2020}
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\journalDoi{ijrps.v11i4.3247}
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\title{\textbf{Clinical evaluation of Nitya Virechana in Hepato cellular Jaundice {\textendash} A Case Study}}
\author{Shweta~Dadarao~Parwe\textsuperscript{*}\textsuperscript{1}, 
            Milind~Abhimanyu~Nisargandha\textsuperscript{2}~\\[5pt]{\textsuperscript{1}Department of Panchakarma, MGACH \& RC, Salod (H), Wardha, Datta Meghe Institute of Medical Sciences (DU), Nagpur, Maharashtra, India}~\\{\textsuperscript{2}Department of Physiology, Ashwini Rural Medical College, Hospital and Research Centre, Solapur (MH), Maharashtra, India}}

\begin{abstract}
Kamala is a Vikar of the pittapradoshja. The symptoms are analogous to those of jaundice. Hepatocellular jaundice is an infectious condition which affects the liver. Due to lifestyle modification, society can't follow these concepts about `Aahar'\&Vihar' (Diet and behavioural regime) (e.g. fast food, Chinese style food, late-night sleep and day sleep. So now the maximum people in a day are going to suffer from GIT problem. Pittakar-ahar  likes Vada-Pav, highly spiced food and propensity to consume alcohol is also rising gradually. Ayurveda has historically been highly proficient and has been treating liver disorders for centuries, and the drug toxicity tends to be lower than conventional medicine. Therefore the case study, like NityaVirechana, is based on Ayurvedic Medicine and Purification Therapy (Panchakarma Procedure). Acharya Charak  stated the Classical Virechana is management, but the patient was lean, and his strength was not as much of, so incapable of performing classical virechan. His body structure and his strength and working pattern kept in mind, we planned Nityavirechan (daily purgation) and got a very good outcome and also saved his time for hospitalisation.
\end{abstract}\def\keywordstitle{Keywords}

\begin{keywords}Nitya virechan,\newline Kamala,\newline Hepatocellular Jaundice,\newline Panchakarma,\newline Pittakarahar,\newline yakrit plihari lauha
\end{keywords}
\twocolumn[ \maketitle {\printKwdAbsBox}]
\makeatletter{\raggedright\textsuperscript{*}Corresponding Author\par Name:\ Shweta~Dadarao~Parwe~\\ Phone:\ +91-95 11659185~\\  Email:\ drshwetaparve@gmail.com
        \par}\vspace*{-11pt}\hrulefill\par{\fontsize{12}{14}\selectfont ISSN: 0975-7538}\par% 
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\section{Introduction}
In the current scenario of industrialisation, life becomes more threatening and brings lifestyle changes due to sedentary living, and many patients become sick and fatigued. Further, they may be diagnosed as Kamala (jaundice). This kind of incidences increased day by day. 

``Charkacharya is advised in `Nidansthana',  but because of fast life or changing lifestyle, society can't follow these concepts about 'Aahar'\&Vihar'(Diet and behavioural regime)(e.g. Pav or Bread, fast food, Chinese, Ratri Jagarana.) Hence now a day's, people are suffering from the problem of GIT'' \unskip~\citep{848730:19973072}.

``Pittakar-ahar like Vada-Pav spicy food, missal, etc., and a tendency to drink alcohol is also increasing day by day. Ayurveda has traditionally been skilful and has been treating liver diseases for centuries, and the drug toxicity appears to be smaller than traditional medicine. Nearly 290,000 cases of viral hepatitis were reported in India in 2013, i.e. 2.8 per cent of the population'' \unskip~\citep{848730:19973082}.

An Ayurvedic text stated hepatocellular jaundice as a Kamala (Kamala bahupitta). It is a severe form of jaundice which yellowish the skin and urine, indicating excess bilirubin, a bile pigment in the blood. Patients also complain of anorexia, nausea and exhaustion \unskip~\citep{848730:19973071}.

Kamala is described under raktavahastrotas  \unskip~\citep{848730:19973079}.  Hepatitis or jaundice is recognised as Kamalaroga in Ayurveda, caused by impairment of the pittadosha(one type of toxins) and raktadhatu  (blood metal). Because of Kosthagata Pitta  (toxin in GIT), Pitta Raktadusti  (blood and toxin-related pathology) and Yakritasrita Pitta dusti(liver pathology). Aggravated pitta dosha further vitiates rakta and mamsa  (muscle) in this condition, and produces Kamala \unskip~\citep{848730:19973076}.

Thus, ancient Acharya listed "kamalituvirechanama" as the main principle of treatment of Kamala (Jaundice) Treatment begins with purgation. This is one of the Panchakarma procedure, and it takes nearly a week to perform. And Nitya virechan (daily purgation) is a type of virechan  (purgation therapy). Whenever there is a large number of toxins present in the body, we have to remove it in small quantities daily. So a daily purgation is recommended for the patient.


\begin{table*}[!htbp]
\caption{\boldmath {Treatment administered with List of Internal Medicines with dose and duration and time} }
\label{tw-ac67d57838aa}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.1738\linewidth-2\tabcolsep}p{\dimexpr.3262\linewidth-2\tabcolsep}p{\dimexpr.25\linewidth-2\tabcolsep}p{\dimexpr.25\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Sr. No. & Given Drugs  & Dose  & Duration\\
\tblmidrule 
1. &
  Yakritapliharilauha &
  2 tab Once a day at Morning &
  For first 15 days for Nityavirechan\\
2.  &
  Arogyavardhini &
  250mg Twice a day after food &
  After Nityavirechan for 15 days\\
3.  &
  Syrup Livomyn &
  20 ml Twice a day after food &
  After Nityavirechan for 15 days\\
4.  &
  Capsule Amlicure D.S. &
  Cap 1 Twice a day after food &
  After Nityavirechan for 15 days\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Blood investigations before and after treatment} }
\label{tw-d6650336edff}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.1445\linewidth-2\tabcolsep}p{\dimexpr.2555\linewidth-2\tabcolsep}p{\dimexpr.20\linewidth-2\tabcolsep}p{\dimexpr.20\linewidth-2\tabcolsep}p{\dimexpr.20\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Sr. No. & Assessment Parameters & Before treatment (14/12/2017) & 27/12/2017After Nitya Virechan & After administration of medicine \mbox{}\protect\newline \\
\tblmidrule 
1. &
  Sr. Bilirubin Total \mbox{}\protect\newline (mg \%) &
  1.69 &
  1.3 &
  0.3\\
2. &
  Direct (mg\%) &
  0.61 &
  0.4 &
  0.3\\
3. &
  Indirect (mg \%) &
  1.08 &
   &
  0.97\\
4. &
  SGOT(IU/L) &
  84 &
  52 &
  31\\
5. &
  SGPT(IU/L) &
  103 &
  84 &
  53\\
6. &
  Sr. Alkaline Phosphate \mbox{}\protect\newline (IU/L) &
  236 &
  228 &
  136\\
7. &
  Sr. Protein (gm\%) &
  8.4 &
  7.2 &
  6.6\\
8. &
  Sr. Albumin (gm\%) &
  4.7 &
  4.5 &
  4.3\\
9. &
  Sr. Globulin(gm\%) &
  3.7 &
  3.2 &
  2.1\\
9. &
  Urea (mg\%) &
  26 &
  21 &
  18\\
10. &
  Creatinine (mg\%) &
  0.74 &
  0.84 &
  0.89\\
11 &
  ESR(  mm/1st hour) &
  34 &
  15 &
  5\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Composition of Yakrut-PleehariLoha} }
\label{tw-24a29b839b95}
\def\arraystretch{1.1}
\ignorespaces 
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\begin{tabulary}{\linewidth}{p{\dimexpr.1775\linewidth-2\tabcolsep}p{\dimexpr.4825\linewidth-2\tabcolsep}p{\dimexpr.34\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Sr. No & Sanskrit Name & Proportion\\
\tblmidrule 
1 &
  HingulothtaParad &
  1 part \\
2 &
  ShudhaGandhaka &
  1 part \\
3 &
  LauhaBhasma &
  1 part \\
4 &
  AbhrakaBhasma &
  1 part \\
5 &
  TamraBhasma &
  2 part \\
6 &
  ShudhaManashila &
  2 part \\
7 &
  Haridra &
  2 part \\
8 &
  Jayapala &
  2 part \\
9 &
  Tankanabhasma &
  2 part \\
10 &
  Shilajatu &
  2 part \\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Bhavana dravya of Yakrut- pleehariLauha.} }
\label{tw-9cdbad7f88ff}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.18209999999999997\linewidth-2\tabcolsep}p{\dimexpr.4779\linewidth-2\tabcolsep}p{\dimexpr.34\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Sr.No. & Dravya and quantity  & Time\\
\tblmidrule 
1 &
  Dantiswaras(Rt.) Q. S &
  2 times\\
2 &
  Trivruttaswaras(Rt.) Q. S &
  2 times\\
3 &
  Chitraka rasa (Rt.) Q. S.  &
  2 times\\
4 &
  Nirgundi rasa (Lf.) Q. S.  &
  2 times\\
5 &
  Tryushana(Shunthi Marica Pippali) kvatha Q. S.  &
  2 times\\
6 &
  Ardraka rasa (Rz.) Q. S.  &
  2 times\\
7 &
  Bhringaraja rasa (Pl.) Q. S.  &
  2 times\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}
\textbf{Case Presentation}

A 26-year-old male patient residing at Sawangi Meghe, Wardha visited the OPD of Panchakarma in MGACH for a checkup, after the clinical examination,  the following symptoms were noted, fatigue, anorexia, fever and he complained of weight loss, about 4 to 5kg in one month. Before treatment, he was advised to perform some routine investigations to rule out the cause for his weight loss. 

\textbf{History of Illness }

 One and a half month ago, the patient was healthy. After that, he had a fever, Anorexia and Nausea, Discolouration of the skin, and the urine was not found in his history.

\textbf{Personal History }

 Addiction- alcohol consumption, frequent consumption of junk, oily and spicy food was observed.

\textbf{Clinical examination}

We found

Nadi (Pulse) - 68 /minute 

Mala (Stool) {\textendash} Malavstambha(constipation) 

Mutra (urine) -  slightly Pitavarniya (yellowish). 

Jihwa (tounge) -slightly coated

Agni (digestive fire) - weak 

Shabda (speech) - Normal 

Touch -   slightly ushna (worm)

Druka (eyes)  - slighltlyNetrapitata(yellowness)

Akruti(body structure)- small. 

Bala( strenghth) - Hina. 

Blood Pressure - 110/80 mm/Hg.

Temperature - 99\ensuremath{^{0}}

\textbf{Investigation}

1. SGOT (serum glutamic oxaloacetic transaminase),

2. SGPT (Serum glutamic pyruvic transaminase,

3. Serum bilirubin, 

4. Kidney function test etc.

\textbf{Progress of Treatment and Assessment}

In this case study, we administered the treatment with a list of internal medicines with doses and duration as in Table~\ref{tw-ac67d57838aa}.

\textbf{Assessment of Treatment}

In this patient, blood investigations were carried out, and we found the changes before and after the treatment in Table~\ref{tw-d6650336edff}

\textbf{Discussion}

``In the Ayurvedic literature, Kamala is described as a pitta dominating liver disease. `Charaka describes that Kamala is a predominant stage (Purva Rupa) of Pandu but, Susruta has mentioned it is as a complication (Upadrava) of Pandu rogas as well as other diseases also where Vagbhata also describes it as a separate disease'' \unskip~\citep{848730:19973077}.

``Virechana(purgation therapy) is the primary procedure at Kamalavyadhi (disease). Also, in pittajavikara, Virechana is the main principle of treatment. Acharyas mentioned anulomana(correcting Vata's direction) and Mruduvirechaka(mild purgative) in Kamala and Pittaja Vikaara virechana karma medications'' \unskip~\citep{848730:19973081}.

It refers to the situation that causes excessive bile pigmentation to discolour the body's lustre and enhances the skin's complexion, ensuing in yellowish staining of the bile (Pitta) into the blood \unskip~\citep{848730:19973070}. Thus, hepatoprotective drug treatment is given along with NityaVirechana with mild virechaka drug treatment.

The basic idea is that there is no load on the liver, so nityavirechana therapy is suggested for that. Excessive bilirubin in the process of developing jaundice contributes to increased development of stercobilin. The Nitya virechana procedure helps eliminate excess stercobilinogen and helps reduce hyperbilirubinemia and ultimately hepatocellular jaundice.

`Virechana is seen as the most appropriate practice for Kamala's management. In Jalodar, Charaka had explained, "DoshatimatropchayatStotomarganirodhanat ... tasmatnityamevaVirechayet II" Nitya Virechana (daily purgation treatment) Jalodara's Chikitsa Sutra is "Nitya Virechana." Virechana is essential to break down all Dosha's Sanga and keep it smooth and separate it. Mula Sthana (main site) is Rakta's Liver (Yakrita). Ashraya and Ashrayi Sambandha (mutual interdependence) are present in Rakta-Pitta, thus purging is the best treatment for removal of vitiated Pitta Dosha' \unskip~\citep{848730:19973069}. Bearing this principle in mind, we rewarded the patient with Nityavirechana with the drug Yakritapliaharilauha which is shown as a gentle laxative. 

\textbf{Probable mode of action of Drugs}

\textbf{YakritaplihariLauha}

Composition of Yakrit Plihari lauha, which is used for Nitya virechana in Table~\ref{tw-24a29b839b95}.

There are seven Dravya which is used as Bhavana for Yakrita plihari lauha  in Table~\ref{tw-9cdbad7f88ff}.

  ``Yakrit Pilhari Lauh is referenced from Bhaishajya Ratnavali, Pliha-Yakrit Rogadhikaar.  It is useful in the treatment of Udararoga, Anaha, Jvara, Pandu, Kamala, Shotha, Halimaka, Mandagni, Aruchi and Yakrit-pliharoga'' \unskip~\citep{848730:19973075}. ``It is used in the Ayurvedic treatment of all types of, fever, oedema, jaundice, bloating, anaemia, anorexia, indigestion'' \unskip~\citep{848730:19973073}. `It acts as a mild purgative.

\textbf{Arogyavardhini vati}

It is a traditional plan of polyherbal-minerals recorded in the Ayurvedic model. It has been utilised for a considerable length of time in the treatment of jaundice, hepatic issue and different skin issue with phenomenal viability and security. It is made out of Terminalia chebula (Haritaki) Terminalia bellerica (Bibitaka), Emblicaoficinalis (Amalaki), Aspalitum (ShilajatuSuddha), Commiporawightill (GugguluShuddha), Ricinus Communis (Eranda), Picrorrhiza kurroa (Katuka) Azadiracta indica (Nimba) leaf squeeze and metals like Shuddha Rasa (filtered mercury), Shuddha Gandhaka (sanitised sulfur), Laua Bhasma (debris formed iron compound), Abhraka Bhasma (debris moulded mica), and Tamra Bhasma (debris moulded copper mixes). A trial concentrate settled the defensive impact of notable Arogyavardhini vati on CCI4-incited hepatotoxicity in rodents that it has demonstrated cell reinforcement properties. It is protected to utilise; however, it contains mercury and copper. Arogyavardini vati and Bhumyamlaki 's left squeeze (Phyllanthus frataruns L.) and Triphlachurna assume a crucial job in HBsAg freedom and regularisation of the liver \unskip~\citep{848730:19973080}.

\textbf{Syrup Livomyn}

\unskip~\citep{848730:19973074} has purgative activity and it was improving the recovery and utilitarian recuperation of beta cells; demonstrating stifling activity on hepatic medication utilising chemicals; hindering the carcinogenesis procedure. It has a property to bringing down the serum levels of hepatic chemicals and diminishing the blood glucose levels and delivering the antimicrobial action. 

\textbf{Capsule Amlicure D.S.}

Fixings are Each container contains Bhringaraja Dhana satva, Bhumyamalaki, Kalamegha conc. 50 mg each, Mandoorabhasma 40 mg, Kasni, Haritaki, Punarnavaghanasatva, Guduchi, Chitraka, Rohitaka 30 mg every, Arjuna twak, Amalaki, Vidanga, Tulasi, Kunvarpathi 20 mg each, Sharapunkha moola 15 mg, Pitpapra, Shweta parpati, Shankhabhasma, Kalipath, Kachora, Nishothar, Moolishan, Yasthimadhu 10 mg each, Pravala Pisthi, Than, Kasondimakoi 5 mg each. Signs Acute or Chronic hepatitis with or without jaundice, Hepatic or biliary issue, Colics and fits, Fatty penetration of the liver, Alcoholism and other inebriation of liver. It fills in as liver restorative in conditions like Elevated degree of bilirubin (jaundice), Enlarged liver, Pre-cirrhotic condition, modified lipid digestion including greasy invasion. It helps in recovery and fix of hepatocytes by expanding the nucleic corrosive substance {\textendash} RNA, DNA and Protein. It speeds up repair \&Regeneration of liver cells. It is acting as an antioxidant, accelerates the repair and regeneration to alcoholic liver cells. It protects against liver Toxins, enhances immunity, promotes and enriches hepato-biliary secretions, thus speeding up the digestion of fat and delays the deposition of fat in liver tissue, fights fatty liver condition \unskip~\citep{848730:19973078}.
    
\section{Conclusions}
Based on clinical and biochemical findings, it is concluded that Yakritpliharilauha's Nitya Virechana is successful in treating Hepatic Cellular Jaundice. It significantly relieved all symptoms of Hepatic Cellular Jaundice. And so, the level of bilirubin also reduced substantially by Nitya virechana. Upon fifteen days, the patient was relaxed, and his appetite increased, and Nitya virechana increased his weight too. So Nitya virechana is the most exceptional treatment for Kamala, this study has proved very well.
\section*{Acknowledgement}We are thankful to postgraduate students of Panchakarma department MGACH \& RC. 

\textbf{Funding Support}

The authors declare that they have no funding support for this study.

\textbf{Conflict of Interest}

The authors declare that they have no conflict of interest for this study.
    

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