Cirrhosis of Liver: miasmatic assessment

March 4, 2012 admin Practice of Medicine 2

Dr Ajit Kulkarni

Introduction
Cirrhosis of liver is the twelfth leading cause of death in the world, killing thousands of people every year.

Basic pathology in the cirrhosis is the scarring of the liver tissue which is followed by fibrosis [formation of scar tissue] and destruction of the normal architecture of the liver. Cirrhosis is a complex process where inflammation, destruction (necrosis), fibrosis and regeneration are going on simultaneously. The liver cells that are functionally intact undergo hypertrophy to compensate the process of destruction. New hepatocytes are also formed in clusters that give rise to regenerative nodules within the scar tissue. This scar tissue is unable to carry out normal metabolic functions of liver which ultimately leads to the development of systemic manifestations. Loss of normal architecture also leads to abnormal communications between the portal and systemic vasculature within the liver.

Pattern of response
The evolution of cirrhosis is gradual & progressive. Cirrhosis is a serious, chronic condition.

Causes of cirrhosis
The treatment modalities and miasmatic assessment depend upon the causes, clinical features and the extent of hepatic pathology.

  • Alcohol (50 %)
  • Viral infection (20 % )
  • Hepatitis B, C, D.
  • Non A-E viral hepatitis
  • Drugs, Toxins etc. (10 %)
  • Others(10%)
  • Primary biliary cirrhosis
  • Sclerosing  cholangitis
  • Blocked bile ducts
  • Veno-occlusive diseases
  • Budd-chiari syndrome
  • Nonalcoholic Steatohepatitis( NASH)
  • Inherited diseases

Clinical features
In early stages, hepatic cirrhosis may be asymptomatic. Even 10% of the healthy liver tissue is adequate to carry out the normal metabolic functions. Cirrhosis may take years to manifest itself clinically or before any clinical suspicion is aroused. Most common clinical features of cirrhosis are enlisted below.

  1. Ascites and oedema of the legs
  2. Hematemesis due to rupture of oesophageal varices
  3. Malnutrition and weight loss
  4. Hepatomegaly initially followed by atrophy in advanced stages
  5. Jaundice
  6. Circulatory changes: spider telangiectasia, palmer erythema, cyanosis
  7. Endocrine changes: loss of libido, hair loss
  8. Male: gynecomastia, testicular atrophy, impotency
  9. Female: breast atrophy, irregular menses, amenorrhoea
  10. Hemorrhagic tendency: easy bruising, purpura, epistaxis, menorrhagia
  11. Portal hypertension: splenomegaly, prominent collaterals on the abdomen, variceal bleeding, fetor hepaticus
  12. Hepatic encephalopathy
  13. Other features: pigmentation, digital clubbing, low grade fever,

Miasmatic Representation

Chief characters

  1. SYCOTIC
  • Chronic Hepatitis
  • Hepatomegaly
  1. TUBERCULAR
  • Oesophageal varices
  1. SYPHILITIC
  • Atrophy of liver
  • Metabolic failure

Interplay of stages OR Mixed manifestations

  • Cirrhosis of liver + Portal Hypertension (TUBERCULAR)
  • Cirrhosis of liver + Endocrine changes (SYPHILITIC)
  • Cirrhosis of liver + Ascites (TUBERCULAR)
  • Cirrhosis of liver + Haemorrhagic tendency (TUBERCULAR)
  • Cirrhosis of liver + Renal failure (SYPHILITIC)
  • Cirrhosis of liver + Oesophageal varices (TUBERCULAR)
  • Cirrhosis of liver + Hepatic Encephalopathy (SYPHILITIC) 

Stage 1

  1. Hepatomegaly
  2. Malnutrition/weight loss
  3. Splenomegaly
  4. Prominent abdominal veins
  5. Spider naevi on the upper part of body
  6. Palmar erythema
  7. Opacity of nail bed

Miasms: Sycotic3, Tubercular2

Reasons:

  1. Return to base line is slow (Syc)
  2. Symptoms: Characteristics2  Patho1 (Syc)
  3. Emaciation (Loss) (Tub)
  4. Structural2 but hepatic function not affected much (Syc)
  5. Destructive (Tub)

Rubrics:

1. Liver, enlarged:

3 marks: Chin, Lyc, Mag-m, Nat-s, Nux-v

2 marks: Ars, Aur-m, Bry, Calc, Calc-ars, Carb-v, Card-m, Chel, Chion, Cocc, Con, Dig, Ferr, Fl-ac, Hep, Hippoz, Iod, Kali-c, Laur, Merc, Merc-d, Nat-m, Nit-ac, Nux-m, Phos, Podo, Stel, Sulph, Sul-ac, Sul-I, Tarax, Tarn, Tub, Tephrosia-pur, Vip, Zinc, Zinc-p

1 mark: acon, aesc, am-m arg-n, aur-a, aur-I, aur-s, baj, bell, boerh, calc-sil, can-s, chin-s, corn-c, cupr, cur, doli, eel’s serum, form, gins, glyc, grap, hell-f, Ins, kali-i, lac-d, lept, mang, myr, nat-p, nyct, ol-i,    pin-s, pul, pyro, querc, senna, sep, staph.

  1. Emaciation, body, liver affection: 2 marks: Hydr, mag-m
  1. Emaciation body, liver hypertrophied: 2 marks: Chen-v
  1. Enlarged spleen: 3 marks: Cean, chin
  1. Abdominal veins, distended portal system:

2 marks: Abs, agar, anthr, apis, arn, ars, ars-I, ars-s-f, asaf, aur-m, bar-c, bell, bels, brom, bry, calc-I, carb-ac, card, cedr, caps, chin-s, chion, cit-v, cocc, con, corn-c, corn-f, ferr, ferr-m, helia, hell, hippoz, ign, kali-I, kali-m, lach, linar, luffa-a, mez, nat-m, nat-s, nit-ac, nux-v, ph-ac, phos, pin-s, pod, poly m, polyp, puls, querc, ran-s, sec, sulph, sul-ac, sul-I, thuj, urt-u, xanthor-ap

  1. White, nails: 1 mark: Cupr, nit-ac

Totality: Chin: 6/2, Lyc: 5/3, Mag-m: 6/3, Nux-v: 7/3, Sulph: 6/3

Stage 2

  1. Atrophy of liver
  2. Mild jaundice
  3. Malnutrition/weight loss
  4. Persistent splenomegaly
  1. Persistent spider naevi on the upper part of body
  2. Persistent palmar erythema
  3. Persistent opacity of nail bed
  4. Nausea and vomiting

Miasm: Syphilis3 Tubercular2 

Reasons:

  1. Atrophy of liver (Syph)
  2. Mild jaundice (Syph)
  3. Malnourished/weight loss (Tub)
  4. Nausea/vomiting (Tub)
  5. Return to base line impossible (Syph)
  6. Pathology3 (Syph)
  7. Structural3 Functional (Tub)
  8. Degenerating (Syph)
  9. Emaciation (Tub) 

Rubrics:

1. Atrophy of liver: 3 marks: Aur, calc, card-m, iod, phos

2 marks: Agar, arg-n, ars-I, aur-m, aur-m-n, bry, cal-a, carb-v, chel, chin, chion, choles, cupr, cur, hydr, lach, lyc, merc, myr, mur-ac, nastur, nat-chl, nat-m, nat-p, nit-ac, nit-m-ac, nux-v, plb, sulph.

  1. Atrophy, of chronic with emaciation and dessication of body: 2 marks: Merc 1 mark: Card-m
  1. Atrophy, hepatitis during: 2marks: Card-m, hep
  1. Atrophy of, nodulated in marasmus: 2 marks: Hydr
  1. Atrophy of, nutmeg or alcoholic variety: 3 marks: Lach, lyc, nux-m, 2 marks: Carb-v, nat-m, nux-v, phos
  1. Cirrhosis, liver, atrophy with: 3 marks: Lach, lyc, nux-m, sul-ac, 2 marks: Carb-v, nat-m, nux-v, phos
  1. Jaundice: 3 marks: Lach, lyc, nux-v, phos, 2 marks: Carb-v, nat-m, 1 mark: Sul-ac

Totality: Lyc: 8/4, Lach: 8/3, Phos: 7/3, Sul-ac: 5/3

COMPLICATIONS:

Cirrhosis of liver + Portal hypertension:

  1. Cirrhosis
  2. Atrophy of liver
  3. Portal hypertension
  4. Jaundice
  5. Splenomegaly
  6. Bleeding from oesophageal varices
  7. Malnutrition/weight loss

Miasms: Tub3    Syph2

Reasons: (HELLO SIR, THE REASONS MENTIONED UNDER THIS HEAD NEEDS EVALUATION AS IT SEEMS TO BE REPETITION OF WHAT HAS BEEN STATED ABOVE. THE POINTS IN BOLD ITALICS ARE ONLY NEEDED)

  • Return to base line impossible (Syph)
  • Return to base line difficult (P.H.T.) (Tub)
  • Characteristic2 Patho3 (Tub)
  • Emaciation + Feebleness (Syph + Tub)
  • Structural3 +Functional1 (Tub)
  • Not manageable (Tub)
  • Destructive (Tub)

Rubrics:

1. Cirrhosis, liver: 3 marks: Sul-ac. 2 marks: Ars-iod.,aur-m.,card-m.,chin.,cupr.,hep.,hydr.,iod.,lyc.,merc.,mur-ac.,phos.,sulph.

  1. Portal system, general congestion: 2 marks: Aesc., carb-v., card-m., nux-v., polyp-p.
  1. Spleen, enlarged: 3 marks: Cean.,Chin.,Iod.

2 marks: Anth.,arn., ars., ars-i., aur-m., calc., calc-s.,caps.,chin-s., cocc., con.,ferr., ferr-m., helia., hippoz., lach., net-m., nit-ac., nux-v., phos-ac., phos., ran-s., sul., sul-pac., urt-u.

  1. Varices, of oesophagus 3 marks: Ham.

Totality: Nux-v. – 5/3, Sulph – 6/3, Card-m – 4/2

Cirrhosis of liver + Ascites:

Miasms: Tub3 Syph2

Reasons:

  1. Return to baseline difficult (Tub)
  2. Characteristic2 Patho3 (Tub)
  3. Emaciation + Feebleness (Tub + Syph)
  4. Structural3 + Functional1 (Tub)
  5. Not manageable (Tub)
  6. Hopeful (Tub)
  7. Destructive (Tub)

Rubrics:

  1. Cirrhosis, liver: 3 marks: Sul-ac, 2 marks: Ars-iod, aur-m, card-m, chin, cupr, hep, hydr, iod, lyc, merc, mur-ac, phos, sulph
  1. Ascites: 3 marks: Apis, apoc, ars, lyc, ter, 2 marks: Abro, acet-ac, adon, agar, agn, am-c, anac, arg-n, ars-s-f, aur, aur-m, aur-p, bell,

Blatta-a, boerh, bry, cahim, calc, cal-sil, calot, canth, carb-an, (carb-v), carc, card-m, chel, cocc-c, coll, con, cop, crot-t, chim, chin, china-a, colch, dig, digin, dios, dulc, fel, fl-ac, graph, hell, hydr, ign, iod, ip, jug-c, kali-c, kali-chl, lac-d, lach, led, mag-c, merc, mur-ac, myrc, nat-chl, nat-m, oxyd, paeon, par, penic, phos, phyt, plb, prun, pyro, quas, raph, rhus-t, sac-o, samb, seneg, senec, sec, slag, sol-n, sulph, sul-ac, syph, stry, tenc, trill, uran, xan, zinc 

Totality: Merc – 4/2, Aur-m – 4/2

Cirrhosis of liver + Oesophageal varices:
Mortality rate: 30 to 60 % in each bleeding episode

Symptoms:

  • Hematemesis
  • Massive with rapid development of shock or the bleeding may stop spontaneously only to recur later
  • Occasionally hematochezia or melena
  • Hepatomegaly (may or may not present)
  • Ascites (may or may not be present)
  • Jaundice (may or may not present)

Miasms: Tub3 Syph2

Reasons:

  1. Return to baseline difficult/impossible (Tub + Syph)
  2. Pathology3 (Syph)
  3. Emaciation + Feebleness (Tub + Syph)
  4. Structural3 Functional1 (Tub)
  5. Not manageable + out of control (Tub + Syph)
  6. Destructive (Tub)

Rubrics:

  1. Oesophageal varices: 3 marks: Ham
  1. Vomiting, blood: 3 marks: Arn, cact, carb-v, chin, crot-h, ferr, ham, ip, phos, sabin

2 marks: Acon, am-c, ars, bry, calc, canth, caust, chin-a, cic, cupr, cycl, erig, ferr-ar, ferr-phos, hyos, kreos, lach, merc-c, mill, nat-a, nit-ac, nux-v, petr, phyto, plb, podo, puls, sang, sec, sep, sil, stann, sulph, ter, verat, verat-v, zinc

  1. Cirrhosis, Liver: 3 marks: Sul-ac

2 marks: Ars-I, aur-m, card-m, chin, cupr, hep, hydr, iod, lyc, merc, mur-ac, phos, sulph

  1. Portal system, general, congestion: 2 marks: Aesc, carb-v, card-m, nux-v, polyp-p

Totality: Ham- 6/2, Phos- 5/2, Carb-v- 5/2

Cirrhosis of liver + Renal failure:

  1. Liver cirrhosis
  2. Jaundice
  3. Ascites
  4. Oliguria
  5. Acute renal failure (urine sodium low)

Miasms: Syph3 Tub1

Reasons:

  1. Returns to baseline difficult (ARF) + Impossible (Cirrhosis)
  2. Pathology3
  3. Emaciation + Feebleness
  4. Structural3 (Cirrhosis) + Functional1 (ARF)
  5. Degenerating (Cirrhosis)
  6. Not manageable (ARF)
  7. Hopeful (ARF) + Despair (Cirrhosis)

Rubrics:

  1. Cirrhosis of liver: 3 marks: Sul-ac

2 marks: Ars-iod, aur-m, card-m, chin, cupr, hepr, hydr, iod, lyc, merc, mur-ac, phos, sulph

  1. Ascites: 3 marks: Apis, apoc, ars, lyc, ter

2 marks: Acet-ac, adon, agn, arg-n, aur, aur-m, blatta-a, bry, calc, canth, card-m, chel, chim, chin, chin-a, dig, dul, fl-ac, graph, hell, kali-c, kali-chl, led, merc, phos, prun, senec, sulph

  1. Renal failure, acute: 2 marks: Lyc, mag-m, mag-s, phos, ser-ang, sulph, urea

1 mark: Aesc-c, allox, am-c, apis, apoc, arg-n, ars, aur, aur-m-n, aur-s, benz-ac, crot-h, kali-c, kreos, lach, mag-c, nat-c, nat-m, op, ph-ac, pip-m, plb, sep, ter, urt-u

  1. Jaundice: 3 marks: Lach, lyco, nux-v, phos, 2 marks: Carb-v, nat-m, 1 mark: Sul-ac

 Totality: Lyco – 10/4, Phos – 9/4, Sulph – 6/3

Cirrhosis of liver + Hepatic encephalopathy:

Stage I: Varied manifestations, including apathy, lack of awareness, euphoria, anxiety, restlessness, shortened attention span

Stage II: lethargy, drowsiness, disorientation

Stage III: Deep somnolence, (but patient can at least transiently be aroused)

Stage IV: Coma (Absent verbal response)

Miasms: Syph4

Reasons:

  1. Return to baseline à Impossible
  2. Pathology3
  3. Feebleness
  4. No activity
  5. Condition out of control
  6. Despair3
  7. Degeneration
  8. Disorganized, perverted metabolism

Rubrics:

  1. Coma, liver with c/o: 1 mark: Arg-n, Crot-h
  1. Cirrhosis of liver: 3 marks: Sul-ac, 2 marks: Ars-iod, aur-m, card-m, chin, cupr, hep, hydr, iod, lyco, merc, mur-ac, phos, sulph

1 mark: Abies-c., apoc., ars., aur., calc-ar., casc., crot-h., fel., fl-ac., graph., kali-bi., kali-i., mec-d., nat-c., nit-ac., nux-v., plb., podo., ques., senec., urea.

  1. Coma, jaundice in: 3 marks: Chel
  1. Liver with brain complications: Crot-h, phos, pyro, Tub.

Totality: Crot-h-3/3, Phos-3/2

Conclusion:
The correlation between stages of cirrhosis and repertorial rubrics has been presented for the sake of clarity of miasmatic assessment. Although the person diagnosis and individualization are the central tenets of prescribing, the stages of cirrhosis and the therapeutical application of homoeopathic remedies should not be underestimated. It is important to make the totality of a case, a comprehensive diagnosis – person diagnosis + disease diagnosis for rational management of a serious condition like cirrhosis of liver.

References:

  1. Davidson’s Text book of Medicine, 19th edition
  2. A Select Homoeopathic Materia Medica by Dr. P.I. Tarkas and Dr. Ajit Kulkarni
  3. Homoeopathic Medical Repertory by Murphy, 2nd edition
  4. Synthesis by Frederik Schroyens, edition 9.1
  5. A Select Homoeopathic Repertory by Dr. P.I. Tarkas and Dr. Ajit Kulkarni, unpublished 

(The gradation given to miasms – 3, 2, and 1 indicates the preponderance of miasmatic influence over the system. The gradation given to remedies concerning the rubrics is as per the intensity of remedies.)

Author: Dr. Ajit Kulkarni  M.D. (Hom.)
Prestige chambers, Powai naka, Satara- 415001
dr_ajitkulkarni@rediffmail.com
www.ajitkulkarni

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