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बुधवार, 5 अक्तूबर 2011

KAMALA/ Jaundice can not be a disease but a symptom

In Ayurvreda Kamala is considered as a disease, where there will be yellowish discoloration of skin, urine and mucosa. In Ayurveda Pandu and Kamala is explained in a same chapter. It is explained as, Pandu in due course if not treated will result in Kamala. This is excellent explanation available in Ayurveda. In Ayurveda mainly two types of Jaundice is explained, but in the modern science three types of Jaundice is explained.

In Ayurveda Kamala is a disease but as science advanced now Kamala is considered as just a symptom, where this condition is seen in different diseases like Malaria, Dengue fever, Leptosopirosis, Haemolytic anaemia, Amoebic liver abscess, Viral and bacterial hepatitis, Hydatid cyst, Cirrhosis of the liver, Hepatoma, Metastasis in Liver, Malignancy of head of pancreas obstructing the common bile duct, gall stone impacted in common bile duct and so on.


It is very important to understand the mode of production and function of bilirubin.

Haemoglobin when breaks down will form Haem+globin. Where haem is iron, which is partially reutilised for the production of haemoglobin, and rest is excreted. Globin is a protein, after breakdown one of the end products is biliverdin and after four levels of enzymatic action will be converted in to unconjugated bilirubin. This unconjugated bilirubin is not soluble in water and commonly known as indirect bilirubin.

The unconjugated bilirubin, in blood stream when enters liver will be converted in to conjugated bilirubin commonly known as direct bilirubin, which is water soluble and some portion of Bilirubin is destroyed in the liver. This conjugated bilirubin will be secreted into intestine through common bile duct and is called as stercobilinogen. Here this will color the stool and 95% of the same will be reabsorbed to blood stream. This in turn in circulation will enter the kidney and is called as urobilinogen and here also this will colour the urine and other 95% will be reabsorbed to blood stream and later most of it will be destroyed in the liver.

So the main function of Bilirubin is colouring the stool and urine. But this is a very good marker to identify Liver diseases, to asses over destruction of RBCs and any obstruction in common bile duct. Further to understand this it is very important to understand three types of Jaundice.

Three types of Jaundice:

Prehepatic Jaundice- Here due to over destruction of RBCs there will be excess production of unconjugated biiirubin and liver fails to convert this excess uncojugated to conjugated one, so there will be high indirect bilirubin in the blood stream. But direct bilirubin will be normal or slightly elevated. In this variety usually color of urine will be normal because unconjugated bilirubin is not water soluble.

Hepatic Jaundice- Here liver fails to completely conjugate the unconjugated bilirubin and fails to destroy the conjuagated bilirubin due to liver disorder, so both direct and indirect bilirubin will be elevated
Post hepatic jaundice- Here unconjuagated bilirubin will be normal but destruction of conjugated bilirubin will be delayed because of obstruction in common bile duct, so only direct bilirubin will be elevated. Colour of stool will be whitish, thick and sticky.

By understanding the above differences it is very easy to understand the site of pathology. After identifying the type of jaundice we have to search for the root cause of jaundice.

In diseases like Malaria, Dengue fever, the cause for jaundice is excess destruction of RBCs, but in Leptospirosis cause is hepatitis, so it is very important to identify the type of jaundice along with other criteria in patients with suspected dengue or leptospirosis. In amoebic liver abscess there will be high fever along with tenderness over liver area, fever will be usually along with rigors. In all viral hepatitis the typical onset will be with fever and vomiting followed by jaundice, fever and vomiting usually persists for 3-5 days, afterwards which subsides spontaneously and in Hepatitis A jaundice will subiside within 15-20 days, in Hep B, 50% will be subsided and cured in the same way and other 48% will continue as carriers, and 2% will die due to hepatic failure, in Hep C immediate fatal rate is low but carrier possibility is same as in Hep B, in Hep D it is same as A, and in Hep E Jaundice will usually last for 3 months and then subsides.

In our area we come across with many jaundice patients because almost all people both educated and illiterate people of this place believe that Ayurveda is the only remedy for Jaundice and I had to refer many cases of Malaria, some of dengue, one case of Leptospirosis and amoebic liver abscess to higher instituition and many other condition we could manage with Ayurveda medicines.

But in Viral hepatitis really we treat the self limiting condition with Ayurveda medicines and people believe that Jaundice is cured because of our medicine, even many Ayurvedists claim in that way. But any how even in hepatitis A 0.07% of patients die due to hepatic failure, so complete bed rest low fat, low protein and carbohydrate rich diet should be advised to the patient for fast recovery and even we many times feel that patient recovers fast when treated with Ayurveda medicines. I have treated three cases of Hepatitis E during last 12.5 years, in all the three jaundice recovered after 1.5 to 3 months period, which is really the normal course of the illness. I have treated many cases of chronic carriers of Hepatitis B, but I have not seen even single patient with negative HBsAg after Ayurveda treatment. (here we can consider only chronic carriers, not the recent below one year, because in many carriers HBsAg becomes negative after one year spontaneously)

But we have seen very good result in many cases of Cirhosis of the liver. I can give two very good eg of Cirhosis, one patient with cirrhosis of liver with portal hypertension took treatment for one year and had very good symptomatic recovery and the condition recovered after 7 years and that time his condition became worse and died after 3 months. In this case, doctors in KMC Mangalore had given 6 months deadline for his survival, but with Ayurvedic medicines he recovered miraculously and survived for the next seven years without any problem. But he was not in the state of hepatic failure during the first visit. I have also advised him to take vaso dilators for long time to prevent easophageal varices, and advised for endscopy twice during the seven years, but he has had not developed oesophageal varices even after seven years, but he died due to hepatic failure. Another important thing is he was not alcoholic nor he was obese, his lipid profile tests were normal, so the cause could be genetic.

In another case, he was alcoholic very young of about 34years of age, when he visited my clinic he was in stage of hepatic failure and was using antibiotics continuously to prevent intestinal infection and his haemoglobin level used to fall down below six once in twenty days, was regularly going for blood transfusion. After 5.5 months treatment he required no blood transfusion, he started doing his work of catering, recovered well and he could manage his work for next 6 months, but in between he started taking alcohol and once again the condition aggravated came back for treatment but this time condition became worst and died in modern hospital.

As per our record these two are the best observed result in cirrhosis of the liver. We have treated number of cases of cirrhosis, but most of the cases in end stage, but in above two cases we got very good result in end stage. In the second case he could stop blood transfusion after 5.5 months of treatment; even I could not believe that.

So we have very good scope in treating cirrhosis like organ failure illness and can improve the condition. But mere two or 3 case is not sufficient to prove the efficacy of drug, we need lot of research activities to prove the action of drug in liver diseases. There are more than 50 herbs identified as liver tonics, and we have to show the real efficacy of these herbs through evidence based analysis, which will help not only the patients but also the Ayurvedic doctors.

I remember a word of one scholar he was of the opinion that, if we conduct such research activities and prove the efficacy of such herbs then modern physicians can easily prescribe Ayurveda medicines in many diseases, but what I say is, if this really happens then we have to consider this as our victory, because our treatment should be acceptable by all and should be result oriented. Otherwise prescribing Ayurveda medicines will be difficult, not only to allopathic physicians but also for Ayurvedic doctors.

Jayagovinda Ukkinadka

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