Effect of yoga and naturopathy on liver, renal and cardiorespiratory functions of a patient with hepatic cirrhosis with portal hypertension and ascites: a case report

Introduction

Alcohol consumption accounts for approximately 3.8% of all global deaths and 4.6% of global disability-adjusted life years [1]. Alcohol abuse is one of the most common cause of hepatic cirrhosis. The 5- and 10-year survival rates of compensated hepatic cirrhosis patients are 84% and 68%, respectively. According to the World Health Organization, about 800,000 patients die of hepatic cirrhosis each year worldwide [2]. Since the use of conventional medicine alone has its own adverse effects, this case study was performed to evaluate the feasibility and effect of integrated naturopathy and yoga therapies (INYTs) on liver, renal and cardiorespiratory functions of a patient with hepatic cirrhosis with portal hypertension and ascites.

Case description

A 39-year-old, married man was diagnosed with liver cirrhosis with portal hypertension and ascites in February 2016. His symptoms as described by him began with generalized body weakness, breathlessness, inability to walk due to exertional dyspnea and sudden weight gain of 16 kg within a period of 3 weeks. The patient was admitted to a private hospital and underwent routine physical and biochemical examinations. In the examination, the patient was known to have icteric eyes, protruded abdomen, bilateral pitting edema in the legs, history of regular intake of alcohol since 7 years and tremendous family stress. His vitals like systolic blood pressure (SBP) and diastolic blood pressure (DBP) were 140 mmHg and 86 mmHg, respectively. Investigations including complete blood count, liver function tests (LFT), urine analysis and abdomino-pelvic ultrasonography reports were suggesting the presence of hepatic cirrhosis with portal hypertension and ascites. Then, the patient was put on allopathic medications such as acetaminophen, prednisolone, ceftriaxone, isordil and furosemide for the period of 6 months. After 6 months, the patient was undergoing ayurvedic medicines such as Kumaryasava and Goutheertha ark for a period of 4 months due to economic constrains to purchase those allopathic medications. Since the patient did not find much improvement after the ayurvedic medications, he was looking for some other alternative. In January 2017, he visited our hospital with the same complaints. We suggested the patient to undergo INYT and continue the ayurvedic medications that he was taking before coming to our hospital along with an ayurvedic herbal syrup “Liv-52” and an allopathic medication “Furosemide.”

Intervention

The patient was admitted to our hospital as an inpatient and underwent INYT for a period of 4 weeks. INYT includes naturopathic treatments like hydrotherapy, mud therapy, massage therapy and diet therapy and yoga practices like simple breathing exercises, pranayama and cyclic meditation. The details of treatments given for the patient have been provided in Table 1.

Outcome measures

Height: It was measured in centimeter using a standard measuring tape.

Weight: It was measured in kilogram using a standard weighing machine.

Body mass index (BMI): It was calculated using a formula, i. e. weight in kg/height in m².

Blood pressure (BP): Both SBP and DBP were assessed using a sphygmomanometer (Diamond BPMR-120 Mercurial BP Delux, Pune, India).

Breath holding time (BHT): The patient was asked to hold his breath voluntarily as long as possible and the duration of the breath holding was noted in seconds using a stopwatch.

Abdominal girth measurement: It was measured in inches using a standard measuring tape at the level of umbilicus.

Blood Analysis: Hemoglobin was estimated using an auto-hematology analyzer (BC-300 plus mindray, China). LFT and renal function test (RFT) were performed using a biochemistry analyzer (CKK-24 Biochemistry analyzer, Medsource Ozone Biomedicals Pvt. Ltd, Haryana, India).

Results and discussion

The results of this study showed a better reduction in body weight, BMI, abdominal girth, SBP and DBP along with improvement in BHT, hemoglobin level, LFT and RFT (Table 2).

According to yoga, imbalanced state of mind is the origin of various psychosomatic diseases, and by treating the mind, we can treat the psychosomatic diseases [3]. Stress is one of the most important factors that precipitate alcohol relapse, through constellation of interrelated cognitive, emotional, physiological and behavioral mechanisms. Evidence suggests that yoga is useful for prevention, treatment and recovery from addiction by regulating stress and unhooking substance use impulses [4]. According to naturopathy, there is only one cause of disease and only one way to cure the diseases, i. e. violation of nature (physical or mental or behavioral) is the cause of disease and returning to the nature is the only way to cure the disease. A basic principle of naturopathy is “body heals itself” when you support and provide an opportunity by means of treating the patients as a whole using natural elements like water (hydrotherapy), mud (mud therapy), sun-cooked foods (fruits and vegetables), etc. [5].

Stress and inflammation play a role in the pathogenesis of hepatic cirrhosis [2], whereas yoga practice [6] and the naturopathic treatments like massage and mud therapies were reported to reduces stress [7] and inflammation [6, 7]. Similarly, in a hydrotherapy textbook, hip bath is reported to be effective in improving the functions of abdominal organs, while kidney pack is reported to be effective improving kidney functions (i. e. diuretic action that helps in reducing excessive fluid accumulation) [8], and both are commonly being employed in various naturopathic hospital in India. Hence, considering both traditional and clinical concepts, the treatments have been provided to the patient in order to support the body and mind to heal itself.

Stress is the subjective experience of negative emotional states coupled with physiological activation that often produces uncomfortable physical sensations, including muscle tension, elevated heart rate and blood pressure and gastrointestinal distress [4]. A marked cardiorespiratory impairment is known to develop in patient with hepatic cirrhosis [9]. As described by the patient, he was having a tremendous family stress and was consuming alcohol regularly for the past 7 years. In the baseline assessment, both SBP and DBP were also found to be higher, while BHT (one of the variable used to measure the pulmonary function) was very lower in the patient. The results of this study showed a better reduction in both SBP and DBP along with a better increase in BHT. It suggests that the INYT is effective in improving cardiorespiratory functions of patients with hepatic cirrhosis with portal hypertension and ascites. It might attribute to the practice of yoga that is known to reduce stress and improve respiratory muscles [6].

Endothelial injury/dysfunction, hepatocyte degeneration and necrosis and inflammatory cell infiltration are observed in the pathogenesis or development of hepatic cirrhosis [2] that leads to the impairment of liver functions and serum protein levels. The results of this study showed a better improvement in LFT and serum protein levels after INYT. It suggests that 4 weeks of INYT is effective not only in improving liver functions but also in restoring the serum protein levels in patient with hepatic cirrhosis. And, it indicates that INYT might play a role in controlling the development of hepatic cirrhosis. Because, practice of yoga was reported to improve endothelial dysfunctions and reduce the inflammation [6], and the naturopathic treatments like massage and mud therapies were also reported to reduce stress and inflammation in inflammatory diseases [7]. Diet that was provided to this patient was in combination of various fruits, diuretic juices, low fat and low protein which might have played a vital role in reducing the workload of the liver and in providing the micronutrients that were depleted by chronic alcohol consumption [1].

In this case, the patient reported a sudden increase of 16 kg body weight and protrusion of abdomen within 3 weeks. During the examination and investigation, the presence of ascites (accumulation of fluid in the peritoneal cavity) was ruled out. Ascites is more commonly coexist with hepatic cirrhosis that increases body weight and intra-abdominal pressure, leading to hemodynamic abnormalities of the myocardium and impairing renal function [10]. Result of this study showed a marked reduction in body weight, BMI and abdominal girth along with improvement in RFT. It suggests that 4 weeks of INYT is effective in improving renal function and reducing ascites of patient with hepatic cirrhosis. It might attribute to the effect of low fat, low protein vegetarian diet, diuretic juice and the hydrotherapeutic procedures like kidney pack, hip bath and mud applications to abdomen.

The backbone of the treatment of patients with alcoholic liver diseases (ALDs) is the achievement and maintenance of alcohol abstinence since the efficacy of medical treatments for ALD is limited in those who continue to drink [1]. Before visiting our hospital, the patient could not be completely away from alcohol consumption due to family stress and that might have reduced the efficacy of medicines (either conventional or ayurvedic or both). This could be one of the reasons for the deterioration of the patient’s health even though he was under conventional and ayurvedic medications.

In our hospital, the patient was able to be completely away from alcohol consumption without any adverse effect. It could be due to the reduction of stress (one of the most important factors for alcohol relapse) [4] by inclusion of INYT in addition to ayurveda and conventional medicines. The support provided to the body by means of INYT along with control over alcohol consumption might have enhanced the efficacy of the ayurvedic and conventional medicines too. This could be the reasons for the better improvement in many aspects of hepatic cirrhosis like body weight, BMI, abdominal girth, liver and renal functions. Hence, the overall improvement in this patient might attribute to the synergetic effect of INYT, ayurveda and conventional medicines. However, INYT might play a very vital role in improving the health status of this patient since there were no improvements noted when the patient was under ayurveda and conventional medicines without INYT.

Strengths of this study: This is the first case study reporting the effects of INYT in patients with hepatic cirrhosis with portal hypertension and ascites. Intervention was safe, feasible and well tolerated and no side effects were reported by the patient throughout the study period. It showed more effectiveness especially in reducing the abdominal girth, body weight, BMI and blood pressure that is very much needed for this particular case. Limitations of this study: Ultrasonography (abdomen), changes in major inflammatory markers and stress level were not assessed; validity and reliability of this result may vary because of single case. Hence, further well-planned clinical observational studies with the above-mentioned variables are required with large sample size to validate our results.

Conclusions

The results of this study suggest that INYT in combination with ayurveda and conventional medications were safe, feasible, well tolerated and effective in patients with hepatic cirrhosis with portal hypertension and ascites.