A STUDY ON THE EFFECTIVENESS OF HOMOEOPATHIC CONSTITUTIONAL MEDICINE IN THE MANAGEMENT OF NON-ALCOHOLIC FATTY LIVER DISEASE

 Abstract

 NAFLD is an important cause of liver disease in India. During the past century, dramatic modifications in lifestyle have radically changed the health priorities in most areas of the world, owing to a growing incidence of non-communicable disease. Fatty liver has earlier often been related with excessive alcohol consumption. During the past 20 years, the interest in fatty liver occurring in non-drinkers i.e. non-alcoholic fatty liver disease (NAFLD) has raised quickly.

Methods A prospective experimental study design without control group.Patients will be collected from the In-patient and Out-patient Departments, Peripheral Centres, Rural Health Camps and Medical Camps conducted by Vinayaka Mission’s Homoeopathic Medical College and Hospital

Result This study provides evidence to say that, there is significant reduction in the Non-alcoholic fatty liver disease after giving homoeopathic constitutional medicine

Keywords: Homeopathy, liver, NAFLD, constitutional medicine, life style disorder.

ABBREVIATIONS: NAFLD- Non-alcoholic fatty liver disease, NASH- non-alcoholic steatohepatitis

Introduction

 The spectrum of NAFLD includes: simple fatty liver without necro inflammatory activity; non-alcoholic steatohepatitis (NASH), a condition characterised by hepatocellular injury, inflammation, and fibrosis; cirrhosis; and in some individuals hepatocellular carcinoma.⁽¹⁾ The prevalence of NAFLD is affected by many factors, including genetics and environment and is therefore difficult to define.⁽²⁾

CAUSES

Primary causes

Obesity, Glucose intolerance, Hypertension, Hypertriglyceridemia, Low HDL cholesterol,

Type 2 diabetes. ⁽³⁾

 

Secondary causes

Disorders of lipid metabolism- Abetalipoproteinemia (Bassen–Kornzweig syndrome), Hypobetalipoproteinemia,Familial combined hyperlipidemia, Glycogen storage disease, Weber–Christian disease, Lipodystrophy.

Nutritional causes- Total parenteral nutrition, Severe surgical weight loss, Starvation

Medications-HAART, Oestrogen, Glucocorticoids, amiodarone, tamoxifen, diltiazem, methotrexate, zidovudine, cocaine, valproate, aspirin tetracycline.

Other causes- Celiac Disease, Wilson disease, Toxicity/environmental

Infections- Hepatitis C virus, small bowel diverticulosis with bacterial overgrowth, Human immunodeficiency virus.^{(4),(5), (6)}

GENETIC BACKGROUND OF NAFLD

PNPLA3 and TM6SF2 have been identified as potential genetic modifiers.⁽⁷⁾

PATHOPHYSIOLOGY

Several mechanisms have been postulated to explain the pathogenesis of NASH.The current two-hit hypothesis explains why not everyone with fatty liver disease develops hepatic fibrosis

The “firsthit” is development of hepatic macro-steatosis as a result of increased lipolysis and free fatty acids. Postulated mechanisms leading to hepatic steatosis include increased lipogenesis, decreased lipid export, and a reduction of free fatty acid oxidation with insulin resistance leading to fatty acid dysregulation.Several potential “second hits” include oxidative stress from reactive oxygen species in the mitochondria and cytochrome P450 enzymes. Further second hits include the presence of endotoxins, cytokines, adipokines, and environmental factors. These complex interactions of the various factors lead to insulin resistance, and serum & liver iron overload and oxidative stress that lead to necro inflammation and fibrosis.^{(8), (9)}

CLINICAL FEATURES

Most patients with NAFLD are asymptomatic.

When patients are symptomatic, symptoms include:

§ Fatigue ⁽¹⁰⁾

§ Up to 40 per cent have persistent right upper abdominal pain and may complain of lethargy and malaise. ⁽¹¹⁾ The upper abdominal pain may have sharp or dull quality.

§ Thirst, and anxiety, feeling of changing temperature, and bloating were the most common complaints.

§ Sleep disorder and late onset of sleeping were noticeable. ⁽¹²⁾

§ A smaller fraction of patients experiences symptoms indicative of more serious liver disease and may develop pruritus, anorexia, and nausea. ⁽¹³⁾

MATERIALS AND METHODS

Source of Data:

Patients will be collected from the In-patient and Out-patient Departments, Peripheral Centres, Rural Health Camps and Medical Camps conducted by Vinayaka Mission’s Homoeopathic Medical College and Hospital.

Method of Collection of the Data:

Research design:

A prospective experimental study design without control group.

Sample design:

Purposive sampling done according to inclusion and exclusion criteria.

Data collection:

Primary and secondary data collected through a predesigned case sheet.

 

Statistical analysis:

Paired t- test

Inclusion criteria fixed for the study:

§ Age group of 20 to 65 years

§ Both male and female has been included.

§ Persons with clinical symptomatic presentation of NAFLD.

§ Diagnosed cases of NAFLD

§ Subjects who have given consent for the study

Medication will be on the basis of constitutional homeopathic totality.

Exclusion Criteria fixed for the study:

§ Persons with history of chronic alcohol intake

§ Cases with established complications and advanced stage of liver disease.

§ Cases associated with other severe systemic illness.

§ Age group below 20 and above 65 years.

Prognostic criteria:

It is based on the symptomatic improvement and investigatory findings (was evaluated according to the Non-Alcoholic Fatty Liver Disease- US-FLI score) after the treatment.

Ultra-Sonographic Score for Evaluation of Presence and Severity of Non-Alcoholic Fatty Liver Disease- US-FLI (Ultra Sonographic Fatty Liver Indicator)

The severity of NAFLD was evaluated according to a semi quantitative US-FLI ranging from 0 to 8 and composing following indicators:

§ Presence or absence of liver-kidney contrast, graded as absent (score of 0), mild or moderate (score of 2), or severe (score of 3)

§ Presence or absence of posterior attenuation of the ultrasound beam (score of 1 or 0)

§ Presence or absence of vessel blurring (score of 1 or 0),

§ Difficulty visualizing the gallbladder wall (score of 1)

§ difficulty visualizing the diaphragm (score of 1)

§ Area of focal sparing (score of 1)

 

The subjects were divided into three groups of NAFLD severity according to the

US-FLI:

§ Normal liver (US-FLI = 0 or 1)

§ Mild NAFLD (US-FLI = 2 or 3)

§ Severe NAFLD (US-FLI ≥ 4)

Methodology

The patients will be investigated to confirm the diagnosis before starting the study. Detailed case history by interview as per the proforma prepared for the topic Medication will be on the basis of constitutional homeopathic totality. Cases will be followed for a period of 1 year, with a fortnightly O.P.D visits.

Result

The test statistic “t” follows patient’s t distribution with n- 1 (29) degrees of freedom. Here, tabled value of „t‟ at 5% level of significance is 2.045 for 29 degrees of freedom. Since the calculated value is 7.423 which are greater than the table at 5%, we reject null hypothesis.

Inference

This study provides evidence to say that, there is significant reduction in the Non-alcoholic fatty liver disease after giving homoeopathic constitutional medicine.

Therefore, Homoeopathic constitutional medicine is effective in cases of Non-alcoholic fatty liver disease.

Discussion

NAFLD, the commonest liver disorder in the world, is closely associated with metabolic syndrome, particularly obesity and insulin resistance. Sedentary lifestyle and poor dietary choices are leading to obesity, subsequently increasing risk for developing metabolic syndrome and NAFLD. It can progress to cirrhosis, hepatocellular carcinoma, and liver failure.

The development and progression of NAFLD are also affected by diet and genetic factors. Over the last decade, it has been shown that the clinical burden of NAFLD is not only confined to liver-related morbidity and mortality, but there is now growing evidence that NAFLD is a multisystem disease, affecting extra-hepatic organs and regulatory pathways.

Thirty clinically and ultrasonographic diagnosed cases of Non-alcoholic fatty liver patients were taken into consideration for the study.

The patients were between the age group of 20- 65 years. Patients of both sexes were treated. A detailed case history with the proper clinical examination was done in all the patients.

The protocol for the study was cases are followed for a period of 1 year and investigations will be done before and after treatment.

The treatment result has shown that maximum number of patients (12) were under Mild Improvement which is 40%, while Moderate Improvement was seen in 33.3% of patients (10), and 13.3% of patients (04) got recovered and no improvement is seen in 13.3% of patients (04) in this study.As per the study 36.7% were male and 63.3% were female patients. The male female ratio is 1:2.In total number of patients, 40% (12) patients got variationin liver function test and 60% (18) have no variation in their liver function test.In total number of patients 13.3% (4) patients are vegetarian and 86.7% (26) are non-vegetarian.In total number of patients 76.6% (23) patients were clinically presented symptomatic and 23.3% (7) patients were presented as asymptomatic.The remedies that are used most frequently for managing the patients was Phosphorous, Lycopodium, Nuxvomica in 5 (16.60%) cases each. The next were Calcarea carb and Sulphur in 3 (10%) cases each and Chelidonium, Arsenicum and Pulsatilla in 2 (6.70%) cases each and the least used were Bryonia, Lachesis, and Mercurius Solubilis each in 1 (3.33%) case. The commonly affected age group according to my study was 45-49 years (20%), and 60-65 years (16.6%)

The fundamental miasm which covered mostly was psora which is seen in 80% of patient.

Dominant miasm which covered mostly was sycosis (56.7%).

This study provides evidence to say that, there is significant reduction of Non-alcoholic fatty liver disease after giving Homoeopathic constitutional medicine.

The Homoeopathic system of medicine, patient is considered as unique, requiring individual assessment and treatment. As an integrated entity, including the physical, mental, emotional, spiritual, social and any other aspects of the total person. Homeopathy looks beyond the labels of disease to cure their causes rather than merely their symptoms and it stimulates the body’s own natural healing powers to bring health, vitality and well-being. It does not treat superficially by just driving away the symptoms but heals the patient from within.

 

CONCLUSION

Thirty clinically diagnosed cases of NAFLD were taken into consideration for the study. The patients were between the age group of 20-65 years. Patients of both sexes were treated. A detailed case history with the proper clinical examination with ultrasonography of abdomen and Liver Function Test was done in all the patients.

 In total number of patients 76.6% (23) patients were clinically presented symptomatic and 23.3% (7) patients were presented as asymptomatic.The remedies that are used most frequently for managing the patients was Phosphorous, Lycopodium, and Nuxvomica in 5 (16.60%) case each.

Along with constitutional treatment, general management in the form of diet and exercise guidelines was given to the patients. According to need of the cases some acute remedies were prescribed in between.

My study shows that NAFLD can be effectively treated with Homoeopathic constitutional medicines.the Homoeopathic treatment based on Holistic approach is having a good scope in treating non-alcoholic fatty liver disease patients, as most of the sample patients got relief, both symptomatically and diagnostically.

RECOMMENDATIONS

§ A Similar study should be done under large sample.

§ Proper advertisement should be given patients regarding the treatment of NAFLD in Homoeopathy and it has no side effects in treatment.

§ It will be always scientific if control (placebo) group would have been kept simultaneously to verify the effectiveness of treatment.

§ Study can be done with fibrosis score.

§ Comparative study with specific liver remedies and constitutional treatment can be done.

§ Study can be done to find the incidence of Non-Alcoholic Fatty Liver Disease and its association with cardiac Risk Factors in Patients with type 2 Diabetes and obesity.

§ Patient should be counsel for the disease condition and regarding regular follow up.

 

 

LIMITATIONS

§ There is a common misunderstanding in public that in Homeopathy treatment is long standing.

§ The effectiveness of Homoeopathic treatment in case of NAFLD is less aware in public.

§ People will not follow regular follow up, so we have to counsel them regarding treatment and the importance of regular follow up in homoeopathy.

§ Mental symptoms have a significant role in selection of medicine; it is difficult to elicit the mental symptoms in the first visit.

§ Patient will not follow the advised diet and regimen during the treatment.

§ After getting slight improvement in the condition they will leave the treatment

§ There was no control group since the sample size was small. 

MULTIDIMENSIONAL APPROACH TO CONQUER PILES WITH HOMOEOPATHY & NO SURGERY

 ABSTRACT 

Piles are another term for haemorrhoids. Haemorrhoids are collections of inflamed tissue in the anal canal. They contain blood vessels, support tissue, muscle, and elastic fibers. Piles are certainly one of the commonest ailments that afflict mankind. This article provides an overview of the aetiology, diagnosis, and appropriate general & homoeopathic management of this disorder.

INTRODUCTION

Haemorrhoids are dilated veins occurring in relation to the anus, and originating in the sub epithelial plexus formed by radicals of the superior, middle, and inferior rectal veins. Haemorrhoids may be external or internal to the anal orifice. The external varieties are covered by skin, while the internal varieties lie beneath the mucous membrane. It is difficult to obtain any accurate idea of their incidence, but clinical experience suggests that very many people of both the sexes suffer from haemorrhoids, and that even more perhaps have piles in the symptom less form. It is frequent experiences to find haemorrhoids at routine rectal examination in patients who never had any complaints referable to them. The incidence of piles apparently increases with age, and it seems likely that at least 50% of people over the age of 50 years having some form of haemorrhoidal formation

 

AETIOLOGY

The veins around anus tend to stretch under pressure and may bulge or swell. Swollen veins (haemorrhoids) can develop from an increase in pressure in the lower rectum.

Factors that might cause increased pressure include:

· Straining during bowel movements  

· Sitting for long periods of time on the toilet.

· Chronic diarrhea or constipation

· Obesity

· Pregnancy

· Anal intercourse

· Diet is also a major factor; people who eat foods low in fiber are prone to constipation and hemorrhoid symptoms. Also, people who eat spicy foods may have exacerbation of their symptoms. Some people who simply do not drink enough fluid may suffer from constipation and haemorrhoid symptoms

· Haemorrhoids are more likely as get older because the tissues that support the veins in rectum and anus can weaken and stretch with aging.

· Other diseases like carcinoma of Rectum, cirrhosis of liver, portal hypertension

 

CLINICAL MANIFESTATIONS

Haemorrhoids are usually not painful, but if a blood clot forms, they can be very painful.

Common symptoms include:

· Painless bright red blood from the rectum

· Anal itching

· Anal ache or pain, especially while sitting

· Pain during bowel movements

· One or more hard tender lumps near the anus

· Prolapse of the haemorrhoids is a later development.  It occurs initially at defecation, the piles appearing at the anal orifice at the height of the expulsive effort, and slipping back immediately afterwards. Later the piles tend to remain in a prolapsed condition after the motion has been passed and the patient finds it necessary to replace them digitally into the anal canal. At this stage they are also liable to come down on any exertion such as sneezing, coughing, lifting, walking or on passing flatus, so that the patient may find himself frequently inconvenienced by the piles prolapsing at the various time during the day. Finally a stage is reached when the piles are more or less permanently prolapsed, with anal mucosa exposed and in contact with the under clothing

 

 

 

Grades of internal haemorrhoids

Internal haemorrhoids are classified by the degree of tissue prolapse into the anal canal.

· Grade I (First degree) - haemorrhoids project into the anal canal with minimal bleeding or may be asymptomatic but do not prolapse.

· Grade II (Second degree) - haemorrhoids protrude beyond the anal verge with straining or defecating and reduce spontaneously when straining ceases.

· Grade III (Third degree) - haemorrhoids protrude spontaneously or with straining and require manual reduction.

· Grade IV (Fourth degree) - haemorrhoids chronically prolapse and, if reducible, fall out again. Others prolapse out of the anus and are irreducible (strangulated), creating a surgical emergency

Complications of Haemorrhoids are rare but include:

· Anemia. Chronic blood loss from Haemorrhoids may cause anemia, in which you don't have enough healthy red blood cells to carry oxygen to your cells. This may result in fatigue and weakness.

· Strangulated hemorrhoid. If blood supply to an internal hemorrhoid is cut off, the hemorrhoid may be "strangulated," which can cause extreme pain and lead to tissue death (gangrene).

 

Test and Examination

Tests and procedures to diagnose internal haemorrhoids may include:

· Examination of anal canal and rectum for abnormalities. During a digital rectal exam, physician inserts a gloved, lubricated finger into rectum. He or she feels for anything unusual, such as growths.

· Visual inspection of anal canal and rectum. Because internal Haemorrhoids are often too soft to be felt during a rectal examination, doctor may also examine the lower portion of colon and rectum with an anoscope, proctoscope or sigmoidoscope. These are scopes that allow seeing into anus and rectum.

· Physician may want to do a more extensive examination of entire colon using colonoscopy. This might be recommended if: signs and symptoms suggest might have another digestive system disease, if have risk factors for colorectal cancer, you’re older than age 50 and haven't had a recent colonoscopy.

 

Prevention of Haemorrohids

The best way to prevent Haemorrhoids is to keep your stools soft, so they pass easily. To prevent Haemorrhoids and reduce symptoms of Haemorrhoids, follow these tips:

1. Eat high-fiber foods. Eat more fruits, vegetables and wholegrains. Doing so softens the stool and increases its bulk, which will help you avoid the straining that can cause Haemorrhoids or worsen symptoms from existing Haemorrhoids. Add fiber to your diet slowly to avoid problems with gas.

2. Drink plenty of fluids. Drink six to eight glasses of water and other liquids (not alcohol) each day to help keep stools soft. Consider fiber supplements. Most people don't get enough of the recommended amount of fiber — 25 grams a day for women and 38 grams a day for men — in their diet. Studies have shown that over-the-counter fiber supplements, such as Metamucil and Citrucel, improve overall symptoms and bleeding from Haemorrhoids. These products help keep stools soft and regular. If you use fiber supplements, be sure to drink at least eight glasses of water or other fluids every day. Otherwise, the supplements can cause constipation or make constipation worse.

3. Don't strain. Straining and holding your breath when trying to pass a stool creates greater pressure in the veins in the lower rectum.

4. Go as soon as you feel the urge. If you wait to pass a bowel movement and the urge goes away, your stool could become dry and be harder to pass.

5. Exercise. Stay active to help prevent constipation and to reduce pressure on veins, which can occur with long periods of standing or sitting. Exercise can also help you lose excess weight that may be contributing to your Haemorrhoids.

6. Avoid long periods of sitting. Sitting too long, particularly on the toilet, can increase the pressure on the veins in the anus.

 

GENERAL MANAGEMENT

· Soak regularly in a warm bath or sitz bath. Soak your anal area in plain warm water 10 to 15 minutes two to three times a day. A sitz bath fits over the toilet.

· Keep the anal area clean. Bathe (preferably) or shower daily to cleanse the skin around your anus gently with warm water. Soap isn't necessary and may aggravate the problem. Avoid alcohol based or perfumed wipes. Gently dry the area with a hair dryer after bathing.

· Don't use dry toilet paper. To help keep the anal area clean after a bowel movement, use moist towelettes or wet toilet paper that doesn't contain perfume or alcohol.

· Apply cold. Apply ice packs or cold compresses on your anus to relieve swelling.

 

HOMOEOPATHIC MANAGEMENT

The medicines given below indicate the therapeutic affinity but this is not a complete and definite guide to the treatment of this condition. Homoeopathy medicines are effective in treating. It is true that this method takes a longer time, but it is also the best one because not only the haemorroids are cured but also the patient.

Indicated Remedies	Indications
Aesculus hippocastanum	When this remedy is needed, Haemorrhoids are sore and aching, with a swollen feeling. Pain may last for hours after the bowels have moved. People who need this remedy often have the sensation of a lump, or a feeling that a lot of small sharp sticks are inside the rectum, poking them. Sharp and shooting pains may be felt in the rectum and back. A person who needs this remedy may also have low back problems.
Aloe	Haemorrhoids that are swollen and protrude “like a bunch of grapes” and are soothed by cold soaks or compresses may be helped with this remedy. Haemorrhoids may alternate with diarrhea, and the person may have a lot of flatulence.
Arnica montana	Sore, bruised-feeling Haemorrhoids may be relieved with this remedy, especially when straining or over-exertion (for instance, childbirth or heavy lifting) has brought on the Haemorrhoids.
Calcarea fluorica:	This remedy may be indicated for Haemorrhoids with bleeding and itching in the anal region, or internal Haemorrhoids causing soreness in the very low back and sacrum. The person may also have problems with flatulence and constipation.
Collinsonia canadensis	Sensation of sharp sticks in rectum. Sense of constriction. Vascular engorgement of rectum. Dry feces. Most obstinate constipation, with protruding hæmorrhoids. Aching in anus and hypogastrium. Constipation during pregnancy; with membranous dysmenorrhœa, following labor Painful bleeding piles. Dysentery, with tenesmus. Alternate constipation and diarrhœa, and great flatulence. Itching of anus
Graphites:	Burning Haemorrhoids with soreness, cracks, and itching in the anal region suggest a need for this remedy. A person who needs Graphites is often overweight, has difficulty concentrating, and tends toward skin eruptions.
Hamamelis:	A raw, sore feeling in the anus, with bleeding Haemorrhoids, indicates a needfor this remedy. Pulsation may be felt in the rectum, and the lower back often aches.Symptoms may be worse from warmth.
Ignatia:	Haemorrhoids accompanied by spasms and stabbing pain in the rectum suggest a need for this remedy—especially if the person is sensitive and emotional. Stitching pains can be felt in the rectal area when coughing. Bleeding and pain are often worse when the stool is loose, and rectal prolapse sometimes follows bowel movements.
Nux vomica:	Itching, painful Haemorrhoids, a feeling of constriction in the rectum, and chronic constipation with ineffectual urging are indications for this remedy. People who need Nux vomica are usually impatient, tense, and irritable, and often have a tendency toward heavy use of stimulants, strong foods, and alcohol or drugs.
Paeonia officinalis	Biting, itching in anus; orifice swollen. Burning in anus after stool; then internal chilliness. Fistula ani, diarrhœa, with anal burning and internal chilliness. Painful ulcer, oozing offensive moisture on perineum. Hæmorrhoids, fissures, ulceration of anus and perineum, purple, covered with crusts. Atrocious pains with and after each stool. Sudden, pasty diarrhœa, with faintness in abdomen.
Pulsatilla:	When this remedy is indicated, Haemorrhoids are itchy and uncomfortable, with sticking pains. They are likely to protrude, with improvement after lying down. Warmth often aggravates the symptoms. This is a very helpful remedy for Haemorrhoids that appear during pregnancy or around the menstrual period.
Negundium Americana	This remedy is useful in cases of chronic painful swollen piles with the sensation of sharp sticks and constricted feeling in the anus. It also helps in case of Chronic constipation leads to hemorrhoids. There is engorgement of the rectum and great burning, smarting, and itching in the rectum after stool.
Sedum acre	It is used for the treatment of pains associated with haemorrhoids, Relieves pain related to anal fissures and reduces rectal bleeding, Improves defecation which normally can be painful during haemorrhoids
Sulphur:	Itching, burning, oozing Haemorrhoids accompanied by a feeling of fullness and pressure in the abdomen suggest a need for this remedy. The anus is inflamed and red and may protrude significantly. The person may feel worse from warmth and bathing, and have flatulence with a strong, offensive odor.

CONCLUSION

Homoeopathy treats the person as a whole. It means that homoeopathic treatment focuses on the patient as a person, as well as his pathological condition. The homoeopathic medicines are selected after a full individualizing examination and case-analysis, which includes the medical history of the patient, physical and mental constitution etc. A miasmatic tendency (predisposition/susceptibility) is also often taken into account for the treatment of chronic conditions. It is true that this method takes a longer time, but it is also the best one because not only the haemorroids are cured but also the patient.

Deep-acting medicines are required to treat the constitution and bring about lasting relief.