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CASE REPORT
Year : 2018 | Volume
: 37
| Issue : 3 | Page : 162-167
A case report on ayurvedic management of acute renal colic
Amit Nakanekar1, Pallavi Thote2, Niharika Palan2, Prashant Deshmukh3, Jayant Gulhane1, Amrut Salunke4
1 Department of Kayachikitsa, GAC, Nagpur, India
2 UG Student, GAC, Nagpur, Maharashtra, India
3 Department of Rognidan, NIA, Jaipur, India
4 Department of Shalakyatantra, GAC, Nagpur, India
Correspondence Address:
Dr. Amit Nakanekar
Government Ayurved College, Nagpur, Maharashtra
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/asl.ASL_7_18
Background: Acute renal calculus is a common recurrent and emergency condition with an annual incidence of one to two cases per 1000. Lifetime risk of its recurrence is 10–20% in men and 3–5% in women. It is an important cause of acute renal failure. About 12% of the population of India is reported to have urinary stones. Acute attacks are managed by analgesics, antispasmodics and use of Non-steroidal anti-inflammatory drugs (NSAIDs). In this case report we report an acute renal colic case managed by Ayurveda treatment without using any modern analgesics.
Case Summary: A 34 year old male patient presented with severe pain in abdomen radiating from lower back to pubic symphysis, vomiting and nausea. Diagnosis of ureteric stone was confirmed by Ultrasonography (USG) of abdomen. We gave him local snehana (~local massage with sesame oil), nāḍi svedana (~fomentation), basti (~medicated enema) and oral Ayurveda medicines. Reduction in acute pain was achieved in three hours. Painless removal of stone was also achieved in seven days.
Conclusion: This case study provides an example of successful management of acute renal colic with Ayurveda treatment alone and without using any modern analgesics. This case study also gives leads for the experiments on role of gut in the management of pain. Clinical trials on Ayurveda management of acute renal colic are warranted.
Keywords: Acute renal colic, basti, case report, pain
Acute renal calculus is a common emergency condition. It has an annual incidence of 1–2 cases per 1000. It can have recurrence with the risk of its recurrence being greater in men than women.[1] It is proven to be an important cause of renal failure. More than 10% of the population in industrialized parts of the world is affected by urinary stone tract disease.[2],[3] About 12% of the population of India is reported to have urinary stones.[4]
Although urinary stones are seen in all age groups, the age of peak incidence for urinary stone is around 20–40 years.[5] It is caused due to various factors such as hot climate, diet, metabolic disorders, immobilization, decreased urinary citrate, inadequate urinary drainage and infectious bacteria such as proteus, Randall's plaque etc.[6] Majority of patients of acute renal colic suffer from complaints of sudden onset of pain. This pain radiates from the flank to the lower extremities. Pain may occur along with hematuria, nausea, vomiting and costo-vertebral tenderness. Sometimes hypertension, swollen abdomen and fever with chills can occur.[7] Generally acute renal colic is managed by NSAIDS, antiemetics and antispasmodics by allopathic doctors. Sometimes the severity of pain is so high that the physician may use strong pain relievers such as morphine.[8] Although analgesics are considered as one of the best options for pain reduction; yet they tend to develop various adverse reactions such as gastritis. The recurrent use of analgesics is also associated with adverse reactions such as liver damage, thrombocytopenia, renal impairment, gastrointestinal bleeding, ulceration and perforation.[9] Some of the Ayurveda vaidyas claim that they manage these acute conditions effectively through Ayurveda. Even then, there is a lack of scientific documentation of such interventions on PubMed. Here we have successfully managed a patient of acute renal colic by using Ayurveda only [Graph 1].
A 34-year-old male presented with chief complaints of severe pain and tenderness in the abdomen in the left iliac region for three days along with four to five episodes of vomiting in the same period. He was admitted in Male Indoor Patient Department (IPD-May 2015) of Government Ayurveda Hospital, Nagpur (GACN). We advised him Ultra Sonography (USG) of abdomen and pelvis. USG Report showed two calculi: first was on the left and was a lower ureteric calculus causing mild hydroureteronephrosis and the other was a left renal calculus [Figure 1] and [Figure 2]. According to Ayurveda the condition was diagnosed as Mūtrāśmarī.
Past HistoryPatient did not have any history of hypertension, diabetes mellitus, typhoid, jaundice, malaria, trauma or any other major surgical or medical illness. He used to occasionally consume alcohol for the past five years. His diet was of mixed type (Non vegetarian food twice a week). He did not have any family history of major illnesses.
He had history of renal calculi four years ago and he was hospitalized for the same; but reports were missing.
He was suffering from abdominal pain, vomiting and nausea since three days and treated by a local general physician for the same, but there was no relief in symptoms. Oligo urea was also noted and he had not passed urine since 7 hours at the time of presentation. He had not passed stools for three days prior to presentation. Looking at the severity of symptoms he was admitted in Male Indoor Department of Government Ayurvedahospital, Nagpur for further management.
Examination on AdmissionPatient presented with severe abdominal pain. Severity of pain was very intense and he was unable to maintain any position due to pain. Visual Analogue Scale for pain was 10+. He was observed sitting in forward bending position by keeping his left hand on left lumbar region.
Basic parameters such as Blood Pressure (110/70), pulse (92/min), temperature (98.6 F), respiratory rate (22/min) were within normal limits. No abnormality was detected in cardiovascular, respiratory and central nervous systems.
His jihvā (tongue) was mild sāma (~coated). Severe abdominal pain originating in flank and radiating inferiorly was present. His abdominal muscles were rigid and his sleep cycle was also disturbed.
During Daśavidha parīkṣā bhāva (~ten types of examination) we observed that doṣas involved were vāta kapha, and dūṣyas were mūtra and purīṣa. Agni of patient was manda with mūtravāha, purīṣavāha and rasavāha srotoduṣṭi. Avasthā was nūtana (~acute) and ātyayika. Ṛtu was grīṣma (summer). His sattva, sātmya and saṃhanana were madhyama.
Diagnostic AssessmentInvestigations on admission [Figure 1] and [Figure 2]
USG-Abdomen and Pelvis at 9/5/2015 showed left ureteric calculus causing mild hydroureteronephrosis. Mild dilatation of left pelvi-calyceal system and ureter was seen with calculus size 5 mm in left lower ureter. Two small calculi were seen on left side of average size 4 mm [Figure 1] and [Figure 2].
Fasting blood sugar level was 84 mg/dl, urine routine and microscopic was also within normal limits along with Hemogram.
InterventionsTreatment was planned after considering clinical condition and investigations. Apāna vāyu gati avarodha (~obstruction to normal functions of Apāna) due to As'mari was considered while planning the treatment. Treatment was planned to relive avarodha (~obstruction) caused due to Aśmarī by treating apāna vāyu and aśmarī. In particular, treatment was planned on the principles of (i) anulomana of apāna (~ normalization of movements and direction of apāna), (ii) bhedana of aśmarī (~breaking of stone) and (iii) application of cikitsā sūtra of mūtravāha srotas (~ treatment principles of urinary system mentioned in Ayurved a). Details of the treatment are given in [Table 1].
Follow-Up and OutcomesPain along with tenderness, nausea and vomiting subsided within three hours and induction of sound sleep along with increased food intake was also achieved on the first day. The assessment of pain was done using Visual analogue scale [Table 2] and [Graph 1]. From the next day there was absence of pain; urine output was also increased and soft stools were passedPain was observed before giving basti and after basti pratyāgama.(~ Evacuation of enema). Pain reduced rapidly after pratyāgama of first anuvāsana. [Graph 2] shows details of basti pratyāgama. Significant decrease in pain intensity after initial basti pratyāgama and complete regression of pain was observed after third basti pratyāgama [Graph 1].
Ultrasonography (USG) was done before treatment and after seven days of treatment. There was absence of clinical symptoms at the end of seven days. Urine output was increased from 250ml (first day of admission) to 500, 1200, 1700 ml and maintained thereafter. After treatment, USG showed absence of one ureteric calculus, [Figure 3] and [Figure 4] and decrease in the size of the other stone. Patient was also willing for discharge and hence we stopped treatment after seven days. All the findings were suggestive of effectiveness of the therapy.
DiscussionRenal stones are assumed in this study to be Mūtrāśmarī. It is caused due to vitiation specifically of vāta and kapha doṣa.[10]Suśruta has mentioned aśmarī as one of the mahāgadas (diseases that are difficult to treat).[11]Ayurveda recommends several treatment modalities in the form of various basti (~medicated enema) procedures, life style changes and various medicinal preparations for the treatment of aśmarī.[12],[13],[14]
The concept behind the use of snehana, svedana and mātrā basti (~ medicated enema of oil) was to retain the normal functioning of the apāna vāyu and to lubricate stool in the intestine. It is clearly mentioned that without vāta doṣa there is no pain, Caraka has mentioned aśmarī as one of the symptoms of gudagata vāta.[15] The basic treatment of vāta is basti.[16] Pathogenesis of the renal colic (~mūtrāśmarī) in Ayurveda, involves the drying of kapha or śukra due to raukṣya (~dry nature of vāta doṣa) and auṣṇya of pitta doṣa (~hot nature of pitta).[17]Caraka says that the mātrā basti completely resolves the conditions due to vitiated vāta doṣa and nirūha basti works by resolving the pathogenesis due to vāta, pitta, kapha, purīṣa and Mūtra.[18]Pañcāsava used in this treatment contains the Pañcakolas which are said to be śūlanāśaka and kaphaghna. Aśmarī formation is mainly due to kaphadoṣa.[19]Śaṅkhavaṭi contains many kṣāra dravyas.[20]Kṣāra is also responsible for bhedana (~breaking) action. Aśmarī is also a bhedya disease (~disease that can be treated by breaking it internally).[21]Śaṅkhavaṭi and Basti both are responsible for anulomana of Vāta and removal of Mala.
Removal of stool and gases from intestines reduces external pressure on ureters. This facilitates removal of Aśmarī (~calculus). Varuṇādi Kvātha (~decoction) was used for Aśmarī Bhedana (~ breaking the calculus). This decoction is Aśmarīhara.[22]
However, this is only a single case study showing efficacy of Ayurveda treatment for acute renal colic. There are many other clinical trials demonstrating efficacy of various Ayurvedatreatments using Śvadaṃṣṭrādi Kvātha in the Management of mūtra aśmarī[23] and also the use of Tilādi Kṣāra and Varuṇādi ghṛta but they have not discussed acute management of these patients.[24]
The present case study is important because it demonstrates the acute management of Mūtrāśmarī by Ayurveda. Patient had taken analgesics some days ago before coming to Ayurveda treatment but there was a relapse of clinical symptoms. Lithotripsy was already tried by him earlier for a similar condition four years prior to the present case and he was unwilling to undergo it again. Analgesics and other treatment options such as hydrotherapy do not act on route causes of mūtra aśmarī (urinary calculi) such as constipation, improper metabolism leading to stone formation and later renal impairment.[24]
This case report can be replicated in remote areas where higher medical facilities are unavailable as oil is easily available in households. More importantly we do not observe recurrence of renal colic in this patient since last four years. Considering all these points we opine that this case report will serve as an important evidence to demonstrate efficacy of Ayurveda treatment in acute renal colic conditions.
Patient PerspectivePatient had severe pain at the time of admission while he was free from symptoms at the time of discharge.
Informed Consent – Informed consent was taken from the patient and has been uploaded to the journal portal.
ConclusionThis case study provides an example of successful acute renal colic management with Ayurveda treatment. This case study also gives leads for the experiments on role of gut in the management of pain. Future clinical trials on management of acute renal colic using Ayurveda management are necessary.
Acknowledgement
Authors are thankful to Dr Sonkul for providing his expertise during Ultrasonography.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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