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INTERNATIONAL JOURNAL
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Bi-Monthly Peer Reviewed Indexed International Journal
VOL 4
ISSUE 2 (2016)
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CASE REPORT
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EFFECT OF JALAUKAVACHARAN (BLOOD-LETTING BY LEECHES) IN
ACUTE APPENDICITIS: A CASE STUDY
Sarvesh Chikte 1*, Piyush Gandhi 2, Shailesh Deshpande 3, Jayant Phadke 4,
Yogini Kulkarni 5
1.
PG Scholar, Dept. of Agadatantra, College of Ayurved and Research Centre, Akurdi, Pune, Contact
No. +918855828326, [email protected]
2.
Reader, Dept. of Rasashastra, College of Ayurved and Research Centre, Akurdi, Pune, Contact No.
+919860202543, [email protected]
3.
Reader, Dept. of Kayachikitsa, College of Ayurved and Research Centre, Akurdi, Pune, Contact No.
+919763104451, [email protected]
4.
Professor & H.O.D. Dept. of Agadatantra, College of Ayurved and Research Centre, Akurdi, Pune,
Contact No. +919822615265, [email protected]
5.
Professor H.O.D. Dept. of Research and Methodology, College of Ayurved and Research Centre,
Akurdi, Pune, Contact No. +919822419089, [email protected]
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Article Received on - 11th March 2016
- 31st May 2016
Article Revised on
Article Accepted on - 1st June 2016
© 2013 IJAAM
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Sarvesh Chikte et.al., Effect of Jalaukavacharan (Blood-Letting by Leeches) in Acute Appendicitis: A Case Study, Int. J. Ayu. Alt. Med.,
2016; 4(2):111-114
VOL 4
ISSUE 2 (2016)
INTERNATIONAL JOURNAL OF AYURVEDA & ALTERNATIVE MEDICINE
eISSN-2348-0173
pISSN-2395-3985
CASE REPORT
EFFECT OF JALAUKAVACHARAN (BLOOD-LETTING BY LEECHES) IN ACUTE
APPENDICITIS: A CASE STUDY
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Conservative management of acute appendicitis using Ayurvedic treatment is a
challenging task. A patient with vomiting, severe abdominal pain and mild fever
came to the outpatient department along with sonological findings suggestive of
acute appendicitis. Patient had rebound tenderness at Mc Burney point along with
tachycardia. Considering differential diagnoses mentioned in classical Ayurvedic
literature it was diagnosed as a case of Amaavastha of Antarvidradhi. As classical
treatment of Antarvidradhi suggests raktamokshana (blood –letting by leeches) it
was decided to do Jalaukavacharan (blood –letting by leeches) along with
Shankhavati (500 mg bid) and Avipattikar Choorna (5 gm HS).After
Jalaukavacharan (blood –letting by leeches) significant reliefwas seen in agony of
pain, fever and tachycardia. After subsequent settings of Jalaukavacharan (blood –
letting by leeches) it was found that patient was not only free from symptoms but
also significant remission was seen in size, inflammation and diameter of internal
lumen of appendix. Hence conservative management of acute appendicitis is
possible using classical Ayurvedic treatment. However efficacy of such treatment
must be further explored to find precise indications and contraindications for such
treatment.
Words: Acute Appendicitis,
Conservative Management.
Key
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INTRODUCTION
The vermiform appendix though considered as
vestigial part has got its importance due a
condition known as acute appendicitis which
occurs due to its inflammation.[1]In teenagers and
young adults, the male female ratio increases to
3:2 at age 25; thereafter, the incidence in male
declines.[1] Low dietary fiber and increased refined
carbohydrate may increase incidence of acute
appendicitis.[1] Obstruction of appendicular lumen
either by faecolith or stricture, that happens in
majority cases, leads to enhance the inflammation
inside the lumen. Yet in few cases of early acute
appendicitis lumen remain intact despite the
presence of mucosal inflammation and lymphoid
hyperplasia.[1] A faecolith is composed of
inspissated faecal material, calcium phosphates,
bacteria and epithelial debris. There may be an
incidental finding of a faecolith. [1]
Appendicitis occurs when mucus, stool or a
combination of the two, blocks the opening of the
appendix that leads to the inflammation. Bacteria
proliferate in the trapped space and infect the
lining of the appendix which results in to
Appendicitis.[1] Acute appendicitis presents with
symptoms like vomiting, acute severe or mild
abdominal pain, nausea and low grade fever.
Rebound tenderness is seen at Mc Burney
point.[1]The diagnosis of acute appendicitis is
essentially clinical that is confirmed by using ultrasonography where signs of inflammation are seen.
Raktamokshana,
Abhyantar
Vidradhi,
Treatment of choice for acute appendicitis is
surgical removal of appendix.
CASE REPORT
A 24 years old female patient came in outpatient
department with complaints of vomiting, fever and
pain in abdomen since four hours. Patient had four
episodes of vomiting after lunch at four in
afternoon along with mild fever (axillary
temperature 1000 F). After two hours after
vomiting, patient started to suffer from severe pain
in abdomen. Hence patient went for ultrasonography of abdomen and pelvis that
significantly dilated and inflamed appendix. It
shows maximum calibre up to 15mm and length
up to 6 cm along with a 10 mm faecolith is seen at
the proximal end, which were consistent with
acute appendicitis. When thoroughly examined,
patient had tachycardia (radial pulse rate -98 per
minute). Patient was normotensive (blood
pressure 110 /70 millimetres of Hg.) Patient had
rebound tenderness at right iliac fossa. These all
finding along with findings in ultra-sonography
confirmed the diagnosis.
Ayurvedic Diagnosis
According to classical Ayurvedic texts the
differential diagnoses considered were Gulma,
Shula and Abhyantar Vidradhi which have
Udarashula (abdominal pain) as common finding.
Also in all above diseases site of pathology is in the
organs in Mahastroras (Gastrointestinal tract)
Sarvesh Chikte et.al., Effect of Jalaukavacharan (Blood-Letting by Leeches) in Acute Appendicitis: A Case Study, Int. J. Ayu. Alt. Med.,
2016; 4(2):111-114
112
Sarvesh Chikte
PG Scholar,
Dept. of Agadatantra,
College of Ayurved and
Research Centre, Akurdi, Pune,
Contact No. +918855828326,
[email protected]
ABSTRACT:
Page
*Corresponding Author
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which have Koshtha (lumen).[2],[3],[4]Faulty dietary
habits, food at improper times leads to
accumulation of mala and dosha in the small parts
of Koshtha (lumen)that leads to obstruction. But
patient of gulma is usually emaciated and
pathology of Gulma is relatively chronic.[2]
Generally Gulma is not converted into pakavastha
(formation of pooya (pus) or vrana).[5]In shula
though the pain is acute but it is related with
ingestion, digestion of food. Pain is relieved
intermittently in vataj shula for short duration.
Also pain in the abdomen is generalised and
without tenderness at specific site. But in view
severe pain and its ability to get converted into
pakavastha in short duration of time it was clearly
a case of Abhyantar Vidradhi precisely Ama
Avastha of Abhyantar Vidradhi.[4]
Management Protocol
Patient underwent Jalaukavacharan (blood –
letting by leeches) at the point of maximum pain
immediately. Total five leeches were used for
Jalaukavacharan (blood –letting by leeches). All
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due care as mentioned by classical texts was taken
during the procedure.[6] Patient also received
Shankha vati 500 mg twice a day with luke- warm
water and Avipattikar Choorna 5 grams at night
along with warm water. Jalaukavacharan (blood –
letting by leeches) was repeated on 10th day, 24th
day, 30th day and 35th day.
Treatment outcome [Table No: - 1]
Patient showed significant relief. Immediately after
first setting of Jalaukavacharan (blood –letting by
leeches) complete remission was seen in intensity
of pain and fever. Pulse was normal and patient
was very much comfortable. Hence it was decided
to continue the treatment. Ultra-sonography after
two days showed slight reduction in inflammation.
Further follow up showed minimal dilatation and
inflammation while ultra-sonography done after
35 days showed normal findings. Patient continued
regular follow up and other oral medications
throughout the period and was absolutely
symptom free.
16.09.2013
After 1st setting of
(blood –letting by
leeches)
24.09.2103
2nd and 3rd setting
of
(blood –letting by
leeches)
19.10.2013
4th and 5th setting of
(blood –letting by
leeches)
Treatment Outcome
Right iliac fossa shows significantly dilated and inflamed appendix. It shows maximum calibre up to
15mm and length up to 6 cm. The blind end is directed inferolaterally. A 10 mm faecolith is seen at the
proximal end. No obvious free fluid is seen. Surrounding mesentery and bowel loops also shows
significant inflammation without obvious mass formation at this stage. Findings are consistent with
Acute Appendicitis.
Abdominal pain was relieved.
Pulse is decreased to
Body temperature was normal
USG findings
16.09.2013 Follow up case of acute appendicitis. A persistently dilated and inflamed appendix is seen
in RIF. The inflammation slightly reduced as compared to last USG. It shows maximum calibre up to 13
mm. and length up to 5 cm. The blind end is directed inferolaterally. No obvious free fluid/ nodes /
bowel mass are seen.
No symptoms were present.
USG findings
5.10.2013- Follow up case of Appendicitis. Appendix shows minimal dilation and inflammation.
Maximum calibre up to 8mm. The inflammation has significantly reduced a compared to last USG. No
associated nodes/ free fluid/ obvious bowel mass is seen.
No symptoms were present.
USG findings
22.10.2013- Follow up case of Appendicitis. Appendix is still seen at right iliac fossa and shows
minimal dilatation and inflammation. It measures up to 3 cm. in length and maximum calibre up to
6mm.
There is no significant surrounding inflammation. No associated nodes/ free fluid/ obvious bowel
mass are seen.
DISCUSSION
Treatment
of
acute
appendicitis
is
appendicectomy. There is perception that urgent
operation is needed to prevent the increased
morbidity and mortality due to peritonitis.[1] As in
this case, the patient had less severity of infection
(pulse below 100 per minute and mild fever)it was
decided to give Ayurvedic treatment. Appendix is
produced from the mala of rakta-dhatu.[7] Ancient
seers discussed the concept of vidradhi which
occur both externally and internally. Internally it
occurs in the organ of gastrointestinal like heart,
Kloma (Pancreas), Liver, Spleen, Kidney and
appendix. Improper food at wrong time in large
quantity leads to the accumulation of mala part of
rakta, mansa in the lumen of ashaya (Organs with
Lumen) which cause obstruction and leads to the
growth.[4] It resembles with pathology of acute
appendicitis due to faecolith. Severe abdominal
pain, a main symptom mentioned by our Acharyas.
Sarvesh Chikte et.al., Effect of Jalaukavacharan (Blood-Letting by Leeches) in Acute Appendicitis: A Case Study, Int. J. Ayu. Alt. Med.,
2016; 4(2):111-114
Page
Date
14.09.2013
1st setting of
(blood –letting by
leeches)
113
Table 1: Timeline showing treatments outcome
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Ancient seers mentioned Jalaukavacharan (blood –
letting by leeches) and pachan treatment in the
Amaavastha of vidradhi. So patient was advised
shankh vati for pachan of Ama and also prevents
the further formation of Ama (undigested dosha)
which may aggravate the pathology by further
blocking the lumen. Raktadosha dominancy in
pathology of Abhyantar Vidradhi leads to
formation of pus which may cause life threatening
condition as there are chances of bursting of
appendix.[8] To prevent further progress
Jalaukavacharan (blood –letting by leeches) was
done using by using five leeches. After procedure
of Jalaukavacharan (blood –letting by leeches)
abdominal pain was reduced and pulse became
normal. Patient does not have episodes of
vomiting. Patient went to his home on that day
itself and was advised to take oral medicine for
further one month to prevent the indigestion of
food which may leads to the formation of mala
which may block the lumen of appendix.
Vaghabhat also recommends mild purgation which
may leads to the expulsion of accumulation of mala
(undigested food).[9] So Avipattikar Choorna was
given as mild laxative. After seeing the encouraging
results in relieving symptoms and no further
progress in the diameter of inflamed appendix in
ultra-sonography as mentioned above, further we
had done four settings of blood -letting by using
five leeches. After total five settings of
Jalaukavacharan (blood –letting by leeches), ultrasonography reports showed no signs of faecolith
and inflammation.
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CONCLUSION
Above case report emphasise the importance of
blood-letting in the disease of Abhyantar Vidradhi
like Acute Appendicitis. If principles of Ayurvedic
treatment regime are followed, many of such
conditions can be treated. But before proceeding
for the treatment of Acute Appendicitis it is always
better to assess the patient for its severity by both
clinically and by ultra-sonography. If it is a severe
case of acute appendicitis, it is always better to go
for operative procedure mentioned by modern
science.
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Acharya YT, editor. Sushruta Samhita of Sushruta. 12th ed.
Varanasi, Chaukhamba Sanskrit Sansthan; 2001. P.32.
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CITE THIS ARTICLE AS –
Sarvesh Chikte et.al., Effect of Jalaukavacharan (Blood-Letting by Leeches) in Acute Appendicitis: A Case Study, Int. J.
Ayu. Alt. Med., 2016; 4(2):111-114
Conflict of Interest – None Declared
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Source of Support – Nil
Sarvesh Chikte et.al., Effect of Jalaukavacharan (Blood-Letting by Leeches) in Acute Appendicitis: A Case Study, Int. J. Ayu. Alt. Med.,
2016; 4(2):111-114
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