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| CASE REPORT |
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| Year : 2019 | Volume
: 40
| Issue : 4 | Page : 242-246 |
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Panchakarma in autoimmune pancreatitis: A single-case study
Rajkala P Patil1, Panchakshari D Patil2, Anup B Thakar3
1 Department of Panchakarma, Central Ayurveda Research Institute for Cardiovascular Diseases, Punjabi Bagh, New Delhi, India
2 Publication Section, Central Council for Research in Ayurvedic Sciences, Janakpuri, New Delhi, India
3 Department of Panchakarma, Institute of Teaching and Research in Ayurveda, Jamnagar, Gujarat, India
| Date of Submission | 23-Jan-2020 |
| Date of Decision | 05-Mar-2020 |
| Date of Acceptance | 20-Jul-2020 |
| Date of Web Publication | 14-Jan-2021 |
Correspondence Address:
Rajkala P Patil
Central Ayurveda Research Institute for Cardiovascular Diseases (Central Council for Research in Ayurvedic Sciences, Ministry of AYUSH), Road No. 66, Punjabi Bagh (W), New Delhi - 110 026
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ayu.AYU_15_20
 Abstract | | |
Autoimmune pancreatitis (AIP) is the pancreatic manifestation of a systemic fibro-inflammatory disorder. AIP is a unique form of pancreatitis in which autoimmune mechanisms are suspected to be involved in the pathogenesis. AIP is a rare disorder, its exact cause is unknown, but it is thought to be caused by the body's immune system attacking the pancreas and it responds to steroid therapy only. In Ayurveda, although there is no synonym for AIP, but has a resemblance in clinical features of Grahani Dosha (derangement of duodenum and intestine). The cause of Grahani Dosha is Mandagni (hypofunctioning of Agni) and Panchakarma therapy increases Agni. As per Charaka Samhita, treatment for Grahani Dosha amongst the Panchakarma therapy is Virechana (therapeutic purgation) and Basti (medicated enema). The present case report is of a 30-year-old female, diagnosed as case of AIP with multisystem involvement with increased level of immunoglobulin G (IgG), glycosylated heamoglobin (HbA1c), cholesterol, triglycerides, low-density lipoprotein (LDL) and body mass index (BMI). The patient was on anticholinergic agents, antacids, levothyroxine, multivitamin along with iron and antihistamine drugs since 1 year, but with not much relief. Patient was treated with classical Virechana and Madhutailika Basti. It was observed after the completion of therapy, that there was decrease in IgG, HbA1c, S. cholesterol, S. triglyceride, low density lipoprotein (LDL) and body mass index (BMI). This shows that Virechana and Basti play a significant role in patient with AIP associated with other disorders.
Keywords: Autoimmune pancreatitis, Grahani Dosha, Madhutailika Basti, Panchakarma, Virechana
How to cite this article:
Patil RP, Patil PD, Thakar AB. Panchakarma in autoimmune pancreatitis: A single-case study. AYU 2019;40:242-6 |
| Introduction | |  |
Autoimmune pancreatitis (AIP) is a rare form of chronic pancreatitis that has only recently been recognized as a separate type of pancreatitis in the last two decades. The histopathological features of this distinct form of pancreatitis was first described as early as 1961 when Sarles et al.[1] described a type of sclerosing pancreatitis associated with hypergammaglobulinemia. Subsequently, most of the early literature about AIP came from Japan where the concept of AIP was first proposed in 1995.[2] Thereafter, many authors had reported a form of chronic pancreatitis associated with Sjögren's-like syndrome. The definition of AIP was widely accepted and AIP was differentiated from other types of chronic pancreatitis. An increasing awareness and further research of AIP have indicated that it is a heterogeneous disorder with variations in pathophysiology, genetic predisposition, and extra-pancreatic manifestations compared to chronic pancreatitis.[3],[4] In 2001, scientist reported increased serum levels of immunoglobulin G (IgG4) in patients with AIP.[5] Subsequently, in 2004, a critical milestone was reached when the researcher found intensely positive IgG4 cells in extrapancreatic organ systems in AIP patients.[6] Thus, the concept of IgG4-related systemic disease emerged. Type 1 AIP is now considered to be a pancreatic manifestation of IgG4-related disease whereas Type 2 AIP appears to be a pancreas specific disorder. The estimated prevalence in Japan, where AIP was first described, is 0.82/100,000 persons.[7] Japanese series have estimated the prevalence of AIP in patients with chronic pancreatitis to be between 5% and 6%. Several series in the United States have reported that 2%–3% of pancreatic resections had evidence of AIP at pathologic analysis.[8] Type 1 AIP is the most common form worldwide, accounting for almost all cases in Japan and Korea and more than 80% of cases in Europe and the United States.[9] Diabetes mellitus (DM), usually Type 2, is often (41% or 76% of cases) associated with it.[10],[11] In many cases, the diagnoses of DM and AIP are made simultaneously; some patients show exacerbation of pre existing DM with the onset of AIP.
In Ayurveda, Agni (factors for digestion and metabolism) is given prime importance in pathogenesis of the disease. Grahani (small intestine) is an anatomical structure situated between Amashaya (stomach) and Pakwashaya (large intestine). Its physiological importance is due to its interdependence on Agni.[12] Grahani Dosha refers to Grahanyashrita Agnidosha (mal functioning of Agni at intestine level). In Grahanyashrita Dosha indigestion of food occurs and symptoms like Vishtamba (improper defecation), Praseka (nausea), Arti (pain), Vidaha (burning sensation) and Aruchi (dyspepsia) and Gaurava (heaviness) develops.[13]
In light of the Ayurvedic principles, the present case was treated for the management of AIP with multisystem disorder not responding to conventional therapy by utilizing the two arms of Panchakarma, i.e., Virechana (therapeutic purgation) and Basti (therapeutic enema). In diseases of the gastrointestinal tract, Virechana is reported to be more effective, as it eliminates aggravated Pitta and Kapha Dosha from the body. Basti is being used to pacify Vata, it also impart mild cleansing effect on the gastrointestinal tract.
| Patient Information | | |
A 30-year-old female, a home maker of Indian origin residing in America approached Panchakarma OPD of Institute for Post Graduate Teaching and Research in Ayurveda, Gujarat Ayurved University, Jamnagar, Gujarat, India, on December 30, 2015 with the episodes of recurrent abdominal pain. The pain increased after taking fatty meal that would persist for at least 5–6 h, usually at night, and usually preceding with episodes of vomiting and 5–7 loose stools. The pain was so severe that patient was unable to take a sip of water and would just sit in the bending position for several hours. There was difficulty in carrying out the daily chores due to weakness and fatigue. Also, she had anorexia and fear of taking fatty food. On physical examination, the patient was obese, anxious, pale with dry skin, had coated tongue and pedal edema. On abdomen examination, there was mild tenderness over the umbilical region. The patient had Pitta predominant Kapha Prakriti and had a past one year history of chronic cholecystitis with cholelithiasis, for this cholecystectomy was done. Subsequently, she was diagnosed for type 2 diabetes, metabolic syndrome and hypothyroidism with Vitamin B12 and iron deficiency. The patient was nonalcoholic and nonsmoker. There was no significant family history. When the patient came for consultation, the patient was on anticholinergic agents, antacids, levothyroxine, multivitamin along with iron, and antihistamine medicines since 1 year, but with not much relief [Table 1].
Ayurvedic management
The patient was assessed as per Dashavidha Parikshya Bhava (ten examination tools) before planning the Panchakarma treatment. No concurrent conventional medication was administered during this period except for hypothyroid. Ayurvedic management started with Deepana-Pachana (carminative and digestive) for 3 days with Phaltrikadi decoction,[14] Shivakshara Pachana powder,[15] and Dhanyaka Siddha Jala (medicated water prepared with coriander). On 4th day Snehapana (internal oleation) with Tiktaka Ghrita[16] in increasing dose was administered for 4 days. After assessing Samyaka Snigdha Lakhsna (signs of proper oleation), 3 days gap was given. In gap days, Sarvanga Abhyanga (external oleation) with Kshirabala Taila[17] and Swedana (fomentation) was done. On the 11th day, Virechana was administered with Avipattikara powder[18] after performing the ritual of prayer. The patient reported total 14 Vegas (stool frequency) along with Samyaka Virechana Lakshana (signs of proper purgation). Samsarjana (special light diet) was advised for 5 days according to type of Shuddhi (purification). After Samsarjana, Madhutailika Basti[19] was administered with classical Putaka (a brass nozzle attached to polythene bag) method for 5 days [Table 2].
Outcome
The patient was followed up telephonically for a period of 6 months. Effect of therapy was assessed based on physical symptoms, laboratory parameters, and quality of life (QoL) parameters. After therapy, the patient did not report the recurrence of pain till 6 months. Overall condition of the patient improved as there was weight loss, improvement in digestion, no pedal edema, and skin became radiant. The patient became self-dependent in carrying out routine of daily work without any lethargy. Body mass index decreased from 32.8 to 31.22 kg/m2. Laboratory investigations showed significant changes like decrease of glycosylated hemoglobin from 6.4 to 5.98 within 3 weeks. IgG4 also showed slight decrease in level which was 4.65 before the treatment and 4.19 after the treatment. Lipid levels also showed a significant decrease within 3 weeks of Ayurveda treatment. QoL parameters[20] showed improvement after Panchakarma therapy as per SF-12 scale [Table 3].
| Discussion | | |
AIP with hypothyroidism, dyslipidemia, type 2 diabetes, fatty liver and obesity can be considered as multisystem involvement. In Ayurveda, it can be considered under umbrella cover of Grahani Dosha.
Agni has an important role in the physiological functioning of body. Agni by the virtue of Sukshma Guna (subtle in nature) converts Ahara Dravya (food particles) into Ahara-Rasa (essence of food) and with the help of Dhatvagni (tissue metabolism), the Poshakansha (nourishing part) is made available to body and thus digestion, absorption and assimilation is maintained which is important for the maintenance of life.[21]
Grahani[12] is an anatomical structure situated above Nabhi (naval) and the physiological importance is due to its interdependence on Agni. Among various causes, improper lifestyle is the prime factor leading to impairment of Agni causing Mandagni (weak digestive power) which is the main pathology involved in Grahani Dosha.[22] Agnimandya, Ama (improperly processed food substance), and Srotorodha (obstruction in channels) are the basic events responsible for outbreak of any disease.[23] Grahani Dosha is the disease related with gastrointestinal disorder. This condition usually develops due to irregular dietary habit such as over-eating; more ingestion of cold, heavy, dry, fried and dehydrated food. A wide variety of gastrointestinal symptoms such as loss of appetite, abdominal pain, nausea, vomiting, and constipation is reported in Grahani Dosha.[24] When digested or indigested food is invariably voided. Through stool, the condition is described as Grahani Roga.[25] Grahani Roga is considered as the advanced stage of Grahani Dosha.
In treatment of Grahani, if Pakwashayasth Doshas remain in Leenavastha (the deep seated Doshas) then Sramsana (mild laxative) should be adopted with Deepana Dravya (carminative drugs). If Sama Rasa Lakshanas are produced, then Langhana (reducing therapy), Deepana-Pachana, and Virechana should to be adopted. After ascertaining symptoms of Nirama Lakshana (without association of Ama), Agni is stimulated with Snehana (oleation) therapy and Niruha Basti (type of medicated enema) can be administered.[26]
Due to unhealthy eating habits, Agni present in the body is unable to properly digest the food. This undigested food may convert to Ama which when combines with Dosha (Vata, Pitta and Kapha) leads to Grahani Dosha. Prolonged faulty eating habits can lead to the recurrent episodes of abdominal pain leading to chronicity of the condition. In AIP, Dosha (Vikriti) may stay in Leenavastha (inactive state) during non-acute condition.[26] To break the Samprapti (pathology) of the disease, the drugs must have Deepana-Pachana properties predominantly. Due to accumulation of Dosha in the Grahani in Leenavastha, it may not be treated by Shamana (medicines) only. The Vikriti Doshas are to be expelled from the body which may be achieved by Virechana[26] as the main stay of the Panchakarma therapy. In the present case study, Virechana was planned as the initial mode of the treatment.
Considering the Dashavidha Pariksha Bhavas, the combination of drugs for Deepana-Pachana was taken so that Agni may get stimulated on one hand with Shivakshara Pachana powder as it is having digestive and carminative property and has Tridosha Shamaka (pacification) effect.[15] On the other hand to remove the accumulated Kleda, Phalatrikadi decoction was administered as it is having Kledahara (removes impurities) property.[14] Medicated coriander water was advised during Deepana-Pachana as coriander is having Pitta Shamaka (alleviating Pitta) and Deepana-Pachana properties to prevent any acute attack of pancreatitis.[27] Primary goal to stimulate the Agni was achieved with Deepana-Pachana therapy due to which patient felt lightness in the body and had increased hunger.
Tiktaka Ghrita was selected for the Snehapana due to its virtue of alleviating Pitta and Kleda.[16] For Abhyanga, Kshirabala Taila was applied for proper oleation of the skin. Avipatikara powder was administered for Virechana as it is a mild, safe purgative, alleviating Pitta and has no reported adverse effect.[28] As the patient reported 14 Vegas during the Virechana, assessing Shuddhi, on the same day, Peya (rice gruel) was advised as first diet. On next day, two diets of Vilepi (thick rice gruel) were advised. On the 3rd day Akrit Mudgayusha (plain green gram gruel) twice a day was advised. On the 4th day, Krit Mudgayusha (green gram gruel simmered with Ghrita, cumin and salt) was advised as a diet. On the 5th day, Khichadi (thick gruel prepared with rice and green gram simmered with Ghrita, cumin and salt) was given. This procedure was followed to gradually increase Agni to bring the digestive system in a normal state.
Madhutailika Basti is a type of Niruha Basti and as per text can be given at any time to the persons with delicate physique, to remove Dosha as it has no complications, increases the strength and improves the complexion. Further no definite regimen needs to be followed during this course of Basti.[29] Shatapushpa (Anethum sowa Roxb. ex Fleming) Kalka (paste) in Madhutailika Basti was replaced with Guduchi (Tinospora cordifolia.(Thunb.) Miers.) Kalka to make the Basti milder so that the purpose of mild Shodhana (purification) with Pitta Shamana can be achieved, as Guduchi is having Snigdha Guna (unctuous property), Ushna Virya (hot potency), and Shamshamaniya properties.[30] Dhanwantaram oil used in Madhutailika Basti has Kapha-Pitta Shamaka and Kledahara properties.[31]
As a result of all these, there was weight loss, improvement in digestion, and complexion of skin with feeling of lightness in the body. It is also worth mentioning that during the 21 days of Panchakarma therapy, the patient did not complain of any symptoms and tolerated the therapy without any adverse events.
| Conclusion | | |
The case report demonstrates clinical improvement in autoimmune pancreatitis (AIP) with Panchakarma therapy. As this is the single-case study, it may open a new path to the clinicians and researchers for exploring the Panchakarma option for the treatment of autoimmune pancreatitis(AIP).
Limitations
To establish the procedure as mode of treatment, large sample size should be taken. The procedure cannot be adopted in all patients as some patients may be averse to take Ghrita. This is an IPD procedure for which the patient needs to be admitted for 3 weeks which may not be feasible for all the patients. These therapies cannot be performed in acute conditions and Basti cannot be performed in patients with anal diseases.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for images and other clinical information to be reported in the journal. The patient understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]
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