Liver is considered to be the key organ of the body as it is concerned with filtration, metabolism, detoxification and other vital functions. Non Alcoholic Steatohepatitis (NASH) represents a part of a wide spectrum of Non Alcoholic Fatty Liver Disease (NAFLD). NASH is typically associated with Obesity, Type II Diabetes, Dyslipidemia and the Metabolic Syndrome. Epidemiological studies suggest the prevalence of NAFLD is around 9% to 32% of general population in India with a higher prevalence in those with Obesity and Diabetes. It can be understood that the Nidana and Samprapti of Yakritodara is similar to the etiopathogenesis of Non-alcoholic Steatohepatitis (NASH). Ayurveda known for its safe and cost effective medication has a great potential in treating NASH. Virechana being the most suitable Shodhana Karma is indicated in liver disorders in Bahu Doshavastha and Srotorodha. Hence, it is the need of the hour to search an effective and safe Hepatoprotective ideal remedy from the Ayurvedic treasure of therapeutics for the welfare of mankind

Dr. Prashanth A. S.

Dr. S. G. Chavan

Dr. Shirvadkar Divyashree M

English

Journal of Ayurveda and Integrated Medical Sciences (JAIMS)

                                                      REVIEW ARTICLE July-Aug 2019  Journal of Ayurveda and Integrated Medical Sciences | July - Aug  2019 | Vol. 4 | Issue 4 328  An Ayurvedic pragmatic approach to Non-alcoholic Steatohepatitis vis-à-vis Yakritodara Dr. Shirvadkar Divyashree M1, Dr. Prashanth A. S.,2 Dr. S. G. Chavan3  1Post Graduate Scholar, 2Professor & Head, 3Professor, Department of Kayachikitsa, Ayurveda Mahavidyalaya, Hubballi, Karnataka, INDIA.                     INTRODUCTION The liver is the most massive organ of the viscera occupying a substantial portion of the abdominal cavity. It is wedge shaped weighing about 1.2-1.5kg and is divided into largest right and much smaller left lobe. It is the only organ of the viscera that can regenerate.The liver is the key organ which regulates the homeostasis in the body responsible for the production and excretion of bile, metabolism of proteins, carbohydrates, lipids, storage of vitamins and  detoxification  of  the  toxic  substances  such   as  Address for correspondence:  Dr. Shirvadkar Divyashree M  Post Graduate Scholar, Department of Kayachikitsa, Ayurveda Mahavidyalaya, Hubballi, Karnataka, INDIA. E-mail: divyashirvadkar3@gmail.com  Submission Date: 10/07/2019 Accepted Date: 19/08/2019 Access this article online Quick Response Code Website: www.jaims.in  Published by Maharshi Charaka Ayurveda Organization, Vijayapur, Karnataka (Regd) under the license CC-by-NC-SA alcohol, drugs etc. Due to the advanced technology and the busy schedule, the lifestyle of an individual has become sedentary along with lack of exercise and there is increased popularity of fast foods leading to the impairment of metabolism in an individual making him prone to a series of disorders called as ‘lifestyle disorders’ which has a direct impact on the liver and its functions. Non Alcoholic Steatohepatitis (NASH) represents a part of a wide spectrum of Non Alcoholic Fatty Liver Disease (NAFLD) which ranges from simple Steatosis and Steatohepatitis to advanced Fibrosis and Cirrhosis.[1]The occurrence of Non Alcoholic Steatohepatitis in Type 2 Diabetics, Obese and Hypertriglyceridemics is exceedingly high. Also, the risk of severe liver disease goes up with the increasing features of ‘Metabolic Syndrome’.[2] Global prevelance of NAFLD is estimated at 24% with highest rates in the Middle East and South America and lowest inAfrica.[3] Epidemiological studies suggest the prevalence of NAFLD is around 9% to 32% of general population in India with a higher prevalence in those with Obesity and Diabetes.[4] A B S T R A C T  Liver is considered to be the key organ of the body as it is concerned with filtration, metabolism, detoxification and other vital functions. Non Alcoholic Steatohepatitis (NASH) represents a part of a wide spectrum of Non Alcoholic Fatty Liver Disease (NAFLD). NASH is typically associated with Obesity, Type II Diabetes, Dyslipidemia and the Metabolic Syndrome. Epidemiological studies suggest the prevalence of NAFLD is around 9% to 32% of general population in India with a higher prevalence in those with Obesity and Diabetes. It can be understood that the Nidana and Samprapti of Yakritodara is similar to the etiopathogenesis of Non-alcoholic Steatohepatitis (NASH). Ayurveda known for its safe and cost effective medication has a great potential in treating NASH. Virechana being the most suitable Shodhana Karma is indicated in liver disorders in Bahu Doshavastha and Srotorodha. Hence, it is the need of the hour to search an effective and safe Hepatoprotective ideal remedy from the Ayurvedic treasure of therapeutics for the welfare of mankind. Key words: Non Alcoholic Steatohepatitis, Yakritodara, Virechana. Dr. Shirvadkar Divyashree M. et al.  An Ayurvedic pragmatic approach to Non-alcoholic Steatohepatitis. ISSN: 2456-3110                                                       REVIEW ARTICLE July-Aug 2019  Journal of Ayurveda and Integrated Medical Sciences | July - Aug  2019 | Vol. 4 | Issue 4 329  Liver is compared with Yakrit mentioned in Ayurvedic classics. Acharya Bhavamishra was the first to introduce the term ‘Yakrit Vikara’ with its classification in his treatise Bhavaprakasha.[5] There is no direct reference available in the Ayurvedic classics correlating to Non Alcoholic Steatohepatitis (NASH). Non Alcoholic Fatty Liver disease (NAFLD) is a Santarpanajanya Vyadhi and based on the Nidana, Samprapti and Lakshanas, we can correlate it with Kaphaja Yakritodara.[6] Non Alcoholic Steatohepatitis (NASH) is a large, untapped market with no FDA (Food and Drug Administrative agency) approved therapeutics. In spite of the tremendous advances made in modern medicine, still there is a need of effective and safe Hepatoprotective medicines. Hence, it is the need of the hour to search an effective and safe Hepatoprotective ideal remedy from Ayurvedic treasure of therapeutics for the welfare of mankind.  Embryological origin and physiological perspective of Yakrit  During Garbhavastha, Yakrit is formed from Rakta Dhatu itself during the 3rd to 7th month.[7] Acharya Bhavamishra explained, Yakrit is situated on the right side below the Hridaya, it is formed from Shonita and is the seat of Ranjaka Pitta.[8] Yakrit is derived from the Matruja bhava[9] and is the Mulasthana of Raktavaha srotas.[10] Samana Vayu brings the Aahara Rasa into the Hridaya where it is converted into the Rasa Dhatu which when reaches the Yakrit and Pleeha gets converted into Rakta Dhatu due to the Ushnata of Ranjaka pitta.[11] Etio-Pathogenesis : Modern and Ayurvedic Perspective Heavy fat rich diet, junk foods, soft drinks sedentary lifestyle, Metabolic syndrome (Obesity, Diabetes Mellitus, Dyslipidemia, Hypertension), drugs like (eg: Corticosteroids, Aspirin, Tetracycline) etc. are considered tobe the major etiological factors of Non Alcoholic Steatohepatitis.[12] According to Bhavaprakasha, Vidahi, Abhishyandi Ahara like Madhya, Kulatha, Masha, Mahisha Dadhi causes Rakta and Kapha Dushti[13] leading to the Dushti of Rasavaha, Raktavaha, Medovaha, Annavaha and Pureeshavaha Srotas and thereby producing “Kaphaja Yakritodara”. Ajirna (Indigestion), Sthoulya (Obesity) and Prameha (Diabetes Mellitus) which also occur due to the Dushti of Annavaha, Rasavaha and Medovaha Srotas acts as Nidanarthakara Rogas (Diseases which cause another diseases) which may result in the manifestation of Non Alcoholic Steatohepatitis. Several mechanisms have been postulated to explain the pathogenesis of Non Alcoholic Steatohepatitis. The currently favoured is ‘Two Hit Hypothesis’ which explains why not everyone with fatty liver disease develops hepatic fibrosis. The ‘first hit’ results in steatosis (fatty liver) which is only complicated by inflammation. If a ‘second hit’ occurs, Leptin, which is an appetite reducer and a fibrogenicin vitro, is probably then needed to cause hepatic fibrosis. The components of first hit includes the release of free fatty acids from central adipose tissue, along with adipokines, drain into the portal vein as well as causing insulin resistance. These processes result in reduced hepatic fatty acid oxidation and increased fatty acid synthesis. Fatty liver occurs as a result of increased fat import into hepatocytes and reduced fat export. Insulin resistance causes hepatic steatosis, which also perpetuates insulin resistance. Subsequent activation of TNF-alpha, oxidant stress through the production of reactive oxygen species and production of endotoxins thenresult in inflammation and eventually fibrosis. Factors including leptin are probably needed for fibrosis.[14] Similarly,according to Ayurvedic perspective, the Vidahi-Abhishyandi Aahara and Vihara leads to Agnivikruti and formation of Apakva Anna Rasa resulting in Kapha Dushti (Bahu Drava Sleshma) and impaired fatty acid metabolism. The improper formation and deposition of Abaddha Medas occurs in Yakrit leading to Medovriddhi. This process results in Steatosis (fat deposition in liver). The Kapha and Medo Dushti causes Srotorodha that leads to Vata Dr. Shirvadkar Divyashree M. et al.  An Ayurvedic pragmatic approach to Non-alcoholic Steatohepatitis. ISSN: 2456-3110                                                       REVIEW ARTICLE July-Aug 2019  Journal of Ayurveda and Integrated Medical Sciences | July - Aug  2019 | Vol. 4 | Issue 4 330  Prakopa and causing Agnidipti. When Pitta gets involved in the Samprapti, hepatocytes have inflammatory changes and the disease progresses to the next level i.e. Non Alcoholic Steatohepatitis (Steatosis + Inflammation). The Prakupita Vata further causes Dhatu Paaka leading to Fibrosis and the condition may progress to its drastic end stages Cirrhosis, Ascites, Hepato cellular Carcinoma and also paveway to other metabolic complications.  Lakshanas Agninasha (Loss of appetite), Avipaka (Indigestion), Arochaka (Anorexia), Udarashoola (Dull aching abdominal pain in the right hypochondriac region), Anaaha (Abdominal bloating), Chardi (Vomiting), Pandu (Anemia), Mrudu Jwara (Fever), Dourbalya (Fatigue).[15] Samprapti Ghataka ▪ Dosha  -  Tridosha - Samanavayu, Apanavayu, Pachakapitta, Ranjakapitta, Kledaka Kapha ▪ Dushya - Rasa, Rakta, Meda ▪ Agni    - Jataragni, Dhatvagni ▪ Ama - Jataragni and Dhatwagnimandhyajanya Ama ▪ Srotas - Rasavaha, Raktavaha, Medovaha, Annavaha, Pureeshavaha ▪ Sanchara - Siras ▪ Srotodushti Prakara - Sanga ▪ Udbhava Sthana - Amashaya ▪ Vyakta Sthana - Udara ▪ Adhishtana - Yakrit ▪ Vyadhi Swabhava - Chirakari ▪ Rogamarga - Abhyantara ▪ Sadhyasadhyata - Krichrasadhya Chikitsa There is no established treatment for Non Alcoholic Steatohepatitis (NASH) in conventional medical science. Initial approach involves dietary modifications based on Metabolic Profile (Obesity, Diabetes, Hyperlipidemia, Hypertension) and getting patients to increased levels of physical activity. The stage of liver damage from healthy liver to Steatosis and Steatohepatitis is reversible. But, as the damage progresses further to Fibrosis and Cirrhosis, the condition becomes irreversible. Hence, steps should be taken to treat the disease at the initial stages and to stop it from progressing to the irreversible condition. According to Bhavaprakasha, the Hetu, Samprapti and Lakshanas mentioned for Pleehodara are similar to that of Yakritodara. The only difference is that the Sthana of Pleeha is Vaama Parshva and that of Yakrit is Dakshina Parshva.[16] The root cause of all the Udara Rogas is Prakupita Vata Dosha and Mala Sanchaya. Hence, Vatanulomana should be carried out repeatedly in all the Udara Rogas.[17] Virechana is the most suitable Shodhana Karma in liver disorders. It is the best remedy for Pittaja and Raktaja Roga[18] and is indicated in BahuDoshavastha and Srotorodha. “Natisnigdha Shariraay Dadhyat Sneha Virechanam| Sneha Utkilshta Shariraay Ruksham Dadhyat Virechanam||”[19] As Non Alcoholic Steatohepatitis is a Santarpanajanya Vyadhi, Ruksha Virechana should be given. If Snigdha Virechana is given in Atisnigdha individuals, then due to the Atisnigdhata, the Doshas will get adhered in the other Srotas. Hence, Ruksha Virechana is indicated. The management should be the breakdown of pathological factors like Agnivaigunya, Srotorodha and Kaphamedodushti. Agnideepana, Rookshana, Srotoshodhana, Kapha, Meda and Vata Dushti Chikitsa. When Fatty Liver progresses to next stage and Dhatus get involved, treatment should be directed towards Prasadana of Rasa and Rakta and also Yakritshothahara Chikitsa. Importance of Guda Ardraka Yoga in Yakritodara Charaka has explained the importance of Guda Aadraka Prayoga. Intake of Guda (Jaggery) and Aadraka starts with ½ Pala (24 ml) Pramana on the first day and there after, by increasing ½ Pala Matra Dr. Shirvadkar Divyashree M. et al.  An Ayurvedic pragmatic approach to Non-alcoholic Steatohepatitis. ISSN: 2456-3110                                                       REVIEW ARTICLE July-Aug 2019  Journal of Ayurveda and Integrated Medical Sciences | July - Aug  2019 | Vol. 4 | Issue 4 331  per day upto a maximum of 5 Pala Matra (10th day). This Matra should be kept constant and continued for a period of another 20 days. It acts as Kapha Shamaka, Deepana, Pachana, Shulahara. This Yoga can also be indicated in Avipaka, Kamala, Gulma, Arsha, Shotha, Prameha, Shwasa, Kasa and Pratishyaya.[20] Importance of Gomutra Haritaki Prayoga in Yakritodara[21] Gomutra and Haritaki both possess Kapha and Medoghna properties due to the dominance of Agni and Vayu Mahabhuta. Haritaki has Gunas like Kashaya, Ruksha, Ushna, Anulomana and Gomutra possesses Gunas like Katu, Tikshna, Ushna, Kshara. Gomutra is Kapha Shodhaka and Haritaki is Vatanulomaka. Hence, Gomutra Haritaki acts as Deepana, Kaphahara, Vatanulomaka, Srotoshodhaka, Shophahara and there by, helps in the breakdown of the pathological factors (Agnivaigunya, Srotorodha and Kaphamedodushti) responsible for Non Alcoholic Steatohepatitis. Important Yogas The drugs which possess the properties like Rechana, Vatashamaka, Agnivardhaka; Aama, Meda and Kapha Nashaka are preferable in Non Alcoholic Steatohepatitis. Various formulations of Churna, Vati, Kashaya, Asava-Arishta Kalpanas and Rasoushadhi’s arementioned in classical texts which can widely be used for this purpose.  ▪ Churna Yogas - Narayana Churna, Pippali Churna, Neelinada Churna, Hapushadya Churna, Patoladi Churna, Mahasudarshana Churna. ▪ Vati Kalpanas - Chitrakadi Vati, Rohitakadi Vati, Agnitundi Vati, Arogyavardhini Vati. ▪ Kashaya Kalpanas - Vasaguduchyadi Kashaya, Patola katurohinyadi Kashaya, Patolamooladi Kashaya, Varanadi Kashaya, Phalatrikadi Kwatha. ▪ Asava-Arishta Kalpanas - Rohitakarishta, Pippalyasava, Kumaryasava, Kalameghasava. ▪ Rasoushadhis - Yakrit-Plihari Loha, Icchabhedi Rasa, Pleehantaka Rasa, Lokanath Rasa, Plihari Rasa. All the above Yogas are well known for their hepatoprotective properties and can be effectively used in the management of Non Alcoholic Steatohepatitis. CONCLUSION Non Alcoholic Steatohepatitis (NASH) is the inflammation of liver and damage caused by the build up of fat in the liver. It can be understood that the etiopathogenesis of Non Alcoholic Steatohepatitis is similar to the Nidana and Samprapti of Yakritodara which is developed due to the vitiation of Kapha and Pitta. Virechana is the most suitable Shodhana Karma in liver disorders, being the best remedy for Pittaja and Raktaja Roga’s. The stage of liver damage from healthy liver to Steatosis and Steatohepatitis is reversible. But, as the damage progresses further to Fibrosis and Cirrhosis, the condition becomes irreversible. So, steps should be taken to treat the disease at the initial stages and to stop it from progressing to the irreversible condition. Hence, it is the need of the hour to search an effective and safe Hepatoprotective ideal remedy from Ayurvedic treasure of therapeutics for the welfare of mankind. REFERENCES 1. Loscalzo J, Fauci A S, Braunwald E, Hauser S L, Kasper D L, Longo D L,Harisson’s Principles of Internal Medicine,17th Edition,Vol 2,Part 13,Section 2,Chapter 302,Page No. 1973. 2. Harsh Mohan, Harsh Mohan Text Book Of Pathology,6th edition 2010, Chapter 21,The Liver,Biliary Tract and exocrine Pancreas, Jaypee brothers medical publishers, New Delhi, Page No. 629. 3. Global burden of NAFLD and NASH:trends, predictions, risk factors and prevention, link-        https://www.nature.com/articles/nrgastro.2017.109. 4. Study of prevalance of Nonalcoholic Fatty Liver Disease(NAFLD) in Type 2 Diabetic patients in India, Kalra S, et.al. J Assoc Physicians India. 2013 /jul;61(7):448-53.Link-https://www.ncbi.nlm.nih.gov<pubmed. 5. Bhavamishra, Bhavaprakasha with Vidyotini Hindi Commentary, Madhyama Khanda, 3rd Edition, Dr. Shirvadkar Divyashree M. et al.  An Ayurvedic pragmatic approach to Non-alcoholic Steatohepatitis. 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Harisha Chandra Singh Kushwaha, Charaka Samhita, Ayurveda Dipika’s Ayusi Hindi Commentary, Reprint Edition -2017, Chaukhambha Orientalia, Varanasi, Vol 2, Siddhisthana, Chapter 6,Verse 9, Page No.1021. 20. Vd. Harisha Chandra Singh Kushwaha, Charaka Samhita, Ayurveda Dipika’s Ayusi Hindi Commentary, Reprint Edition -2017, Chaukhambha Orientalia, Varanasi, Vol 2, Chikitsa Sthana ,Chapter 12,Verse 47-8, Page No.298. 21. Vd. Harisha Chandra Singh Kushwaha,Charaka Samhita, Ayurveda Dipika’s Ayusi Hindi Commentary, Reprint Edition -2017, Chaukhambha Orientalia, Varanasi, Vol 2,Chikitsa Sthana, 13th Chapter,Verse 151, Page No. 333.   ******************************  How to cite this article: Dr. Shirvadkar Divyashree M, Dr. Prashanth A. S., Dr. S. G. Chavan. An Ayurvedic pragmatic approach to Non-alcoholic Steatohepatitis vis-à-vis Yakritodara. J Ayurveda Integr Med Sci 2019;4:328-332.  Source of Support: Nil, Conflict of Interest: None declared. 

An Ayurvedic pragmatic approach to Non-alcoholic Steatohepatitis vis-à-vis Yakritodara

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An Ayurvedic pragmatic approach to Non-alcoholic Steatohepatitis vis-à-vis Yakritodara

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