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p-ISSN - 2395 - 3985 e-ISSN - 2348 - 0173 Vol - 4 / Issue - 2 / March - April - 2016 Free Full Text @ www.ijaam.org www.ijaam.org IJA A M INTERNATIONAL JOURNAL OF AYURVEDA & ALTERNATIVE MEDICINE Bi-Monthly Peer Reviewed Indexed International Journal VOL 4 ISSUE 2 (2016) INTERNATIONAL JOURNAL OF AYURVEDA & ALTERNATIVE MEDICINE eISSN-2348-0173 pISSN-2395-3985 CASE REPORT Scientific Journal Impact Factor 5.733 (2015) by InnoSpace Sci. Res., Morocco 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] All articles published in IJAAM are peer-reviewed and can be downloaded, printed and distributed freely for non commercial purpose (see copyright notice below). Page (Full Text Available @ www.ijaam.org) 111 Article Received on - 11th March 2016 - 31st May 2016 Article Revised on Article Accepted on - 1st June 2016 © 2013 IJAAM This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by-nc-nd/3.0/deed.en_US), which permits unrestricted non commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 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 QR Code IJAAM 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 www.ijaam.org 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 VOL 4 ISSUE 2 (2016) INTERNATIONAL JOURNAL OF AYURVEDA & ALTERNATIVE MEDICINE 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 eISSN-2348-0173 pISSN-2395-3985 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 VOL 4 ISSUE 2 (2016) INTERNATIONAL JOURNAL OF AYURVEDA & ALTERNATIVE MEDICINE 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. eISSN-2348-0173 pISSN-2395-3985 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. REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. Williams NS, Christopher JK, Bulstrode, O’ Connell PR, editors. Bailey and Love’s Short practice of Surgery. 25th ed. London, Hodder Education; 2008. p. 1204 - 1218. Acharya YT, editor. Charak Samhita of Agnivesha. Reprint 1984. Varanasi, Chaukhamba Sanskrit Sansthan; 1984.p. 436 Acharya YT, editor. Charak Samhita of Agnivesha. Reprint 1984. Varanasi, Chaukhamba Sanskrit Sansthan; 1984.p. 617. Acharya YT, editor. Charak Samhita of Agnivesha. Reprint 1984. Varanasi, Chaukhamba Sanskrit Sansthan; 1984.p. 104. Upadhyay Y, editor. Madhav Nidan. Reprint 2009. Varanasi, ChaukhambaPrakashan; 2009.p. 544. Kasture HS. Ayurvediya PanchakarmaVidnyan. Nagpur, ShriBaidyanath Ayurved Bhawan Ltd; 2008. p. 511. Acharya YT, editor. Sushruta Samhita of Sushruta. 12th ed. Varanasi, Chaukhamba Sanskrit Sansthan; 2001. P.32. Acharya YT, editor. Charak Samhita of Agnivesha. Reprint 1984. Varanasi, Chaukhamba Sanskrit Sansthan; 1984.p. 104. Paradkar HS, editor. Astangahrudayam of Vagbhata. Reprint 2000. Varanasi, Chaukhamba Sanskrit Sansthan; 2000. p.681. 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 Page 114 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 INTERNATIONAL JOURNAL OF AYURVEDA & ALTERNATIVE MEDICINE #401/8-A, 4th Floor, Shiv Shrishti Apt. 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