Part V: Etiology, Pathology and Treatment of Hepatobiliary ... · Corydalis (Yan Hu Suo), Paeonia (Bai Shao); tropane-alkaloid containing plants, e.g., Belladonna, Hyocyamus 3. Dissolve

Applied Phytotherapeutics I The Inner Alchemist: Liver By Terry Willard ClH, PhD, Todd Caldecott ClH Session Two

©2019 Wild Rose College of Natural Healing All Rights Reserved. 1

Part V: Etiology, Pathology and Treatment of Hepatobiliary Disorders

Bilious dyspepsia The term bilious dyspepsia is associated with a disorder of bile secretion. It is not a diagnostic classification per se, but a range of symptoms that often exist for some time before a well-defined pathology, such as cholangitis (infection of the common bile duct) or cholecystitis (acute inflammation of the gallbladder, usually with severe pain) begin to manifest. In the approach of the herbalist, it is important to recognize these pre-conditions to avoid the possibility of medical interventions to treat a full-blown pathology sometime in the future. Bilious dyspepsia can be identified by symptoms such as nausea and vomiting, anorexia, bloating and a feeling of fullness. There is an aversion to fatty foods, and what appear to be manifestations of liver congestion, including mild hepatic tenderness upon palpation, chronic skin conditions, and in the mental and emotional realm, a depressive or morose condition. Very often, the condition is chronic, experienced after meals, and thus treatment addresses the nature of the diet as well as attempting to correct disturbances in digestive secretion, particularly those of the liver. In the older medical texts, bilious dyspepsia was correlated with “bilious fever,” which is an acute manifestation of bilious dyspepsia. Symptoms include those of a normal fever, along with the vomiting of bile, yellowish skin, constipation, muscular spasm, dry skin, dark yellowish urine, a bitter taste in the mouth and a tongue with a dark yellow coating, generalized body pain with, in particular, pain in the head around the temples and eyes. It is important, however, to ascertain the cause of such conditions, which could range from cholangitis to yellow fever.

Holistic treatment The treatment of bilious dyspepsia is comprised of both temporary and permanent changes in diet, and the correction of liver and gastric secretion using cholagogues, carminatives, and stimulants. For acute problems, the Wonder Bitters or Stomach Tonic, listed in The Fire Within: Digestion, can be used. 1. Bland diet: The diet should be simple and relatively bland,

comprised mostly of steamed vegetables, soupy, partially milled grains (e.g., basmati rice, pot barley) and legumes (e.g.,

Cholangitis symptoms



mung, adzuki, etc.), or steamed vegetables with small amounts of animal protein such as soft boiled or poached eggs or poached fish. The amount of fat in the diet should be limited, with only a small amount of oils like olive or hemp that have not been heated (i.e., no fried foods). Deep-fried foods, fatty animal meats, alcohol, as well as heavy, sticky and congesting foods such as flour and dairy should also be avoided. One useful food is the Ayurvedic recipe for kicharee, consumed for a few days at every meal:

1 cup basmati rice 1/4 cup washed mung beans 4 cups water 2 inches fresh ginger root, coarsely sliced 1/2 tsp turmeric 1/2 tsp salt Bring rice, mung beans, ginger root, and spices to boil in water, reduce to simmer and cook for an hour or more, stirring frequently to ensure beans don’t stick to the bottom of the pot. The length of cooking time is dependent upon the desired consistency.

As the patient improves, the dietary restrictions can be reduced, but the patient should continue to avoid alcohol, deep-fried foods, fatty meats, and flour products.

2. Enhance digestion: There are several poly-herbal approaches that can help with restoring the digestive capacity. One that has been used quite successfully is a Wild Rose formula called Biliherb. We rely upon botanicals that are considered cholagogues, stimulants, and carminatives in the Western tradition, but we can as well use dipana-pachana and anulomana remedies in Ayurvedic medicine, as well as herbs that strengthen the Spleen Qi, relieve Food Stagnation and Disperse Liver Qi in Chinese medicine. The following is a tincture formula has been used at Wild Rose Clinic with many patients, with success, marrying herbs from all three herbal traditions

Codonopsis (Dang Shen) 15 % Astragalus (Huang Qi) 15 Berberis 15 Gentiana 15 Crataegus pinatifida (Shan Za) 10 Citrus reticulata (Chen Pi) 10 Elettaria (Ela) 10 Piper longum (Pippali) 5

Biliherb Black Radish root

109mg Barberry root bark

72.7mg Wood Bentony herb

36.4mg, Dandelion root

36.4mg. Dosage: 2 – 3 tablets, with each meal

Wonder Bitters 20 – 40 drop in water 3 times a day; or Curcuma, often in the form of Golden Milk can help here. 1 – 3 cups a day

Stomach Tonic 2 parts Meadowsweet Spirea ulmaria 1 part Gentian Gentiana lutea 1 part Goldenseal Hydrastis canadensis 1 part Fennel Seed Anethum foeniculum 1 part Fenugreek Seed Trigonella foenum-graecum 1 part Lobelia Lobelia inflate Dosage: 1 - 2 capsule or 15 drop of tincture at the beginning of the meal



Glycyrrhiza 5 Rx: 5 mL before meals thrice daily, with water. This is a “warming” remedy, unsuitable for acute cholelithiasis or cholangitis, which represent congestion and heat in the body.

3. Assist digestion: In older patients especially, it is usually wise

to include a full spectrum digestive enzyme with ox bile with each meal.

Cholelithiasis and cholecystitis Cholelithiasis refers to the formation or presence of calculi (gallstones) in the gallbladder and accounts for most clinical disorders of the extrahepatic biliary tract. Factors that increase the probability of (cholesterol) gallstones include: being female, obesity, increased age, being a North American First Nations, a Western diet, and a positive family history. Often associated with this condition are the five “Fs”: Fair, Female, Fertile, Fat, and Forty. As mentioned above, people with many other body types can get this, but this is the largest group. Facts to remember: § gallstones consist of cholesterol (75%), the remainder

consisting of calcium bilirubinate or other calcium salts; they result from supersaturation of bile, precipitated in the gall bladder as solid cholesterol crystals (and are caused by a deficiency of 7-hydroxylase)

§ herbal perspective: this enzyme deficiency occurs in poor liver function, i.e., ‘hepatic torpor,’ caused by dietary factors, xenobiotic insult, excess liver burden, and a lack of bitter foods (which stimulate bile excretion and synthesis)

§ pigment stones appear to be unrelated to the risk factors, related specifically to unconjugated bilirubin in the bile.

§ Symptoms are: nausea, vomiting and epigastric or right upper quadrant pain that often radiates to the lower right scapula

§ inflammation, resulting in acute cholecystitis and when the obstruction promotes the reflux of pancreatic juices acute pancreatitis.



If the pain is only intermittent and correlated with eating fatty foods, the issue is less serious, even though it could be quite painful. Biliary colic is secondary to transient obstruction of the cystic ducts by a stone. You will know it is true cholecystitis if you see the three symptoms of the Charcot’s triad – fever, jaundice and right upper quadrant pain. The situation is worsening when you observe ascending cholangitis, which indicates a bacterial infection superimposed on the obstruction to bile flow, progressing into Reynold’s pentad with the addition of altered mental status and septic shock.

Medical treatment

Where gallstones have been detected and are asymptomatic there is a debate as to the correct medical procedure, which is largely based upon the personal biases of the attending physicians. Although surgeons invariably recommend a cholecystectomy (gallbladder removal), they base this recommendation upon a cumulative risk of symptoms developing (about 2% per year).i

Medical treatment for gallstones typically consists of a cholecystectomy, at one time performed by removing the gallbladder through a right subcostal or midline incision. Laparoscopic cholecystectomy, however, has replaced this technique, consisting of the insertion of surgical instruments and a



video camera into the peritoneal cavity through multiple small incisions in the abdominal wall. The relative frequency of cholecystectomy is reflected in the belief that it does not result in nutritional problems, and has no side effects. This claim is the subject of some debate. German physician Rudolf Weiss discusses what has been long recognized in Europe as post-cholecystectomy syndrome, which he describes as a “…heterogenous condition,” which can be as diverse as the formation of new stones, duodenal ulcers or the “…regulatory failure in the whole complex of biliary system, pancreas, duodenum and jejunum.”ii In many cases, the underlying condition of gallstones, what Weiss terms biliary dyskinesia, continues untreated, providing the patient with continued symptoms such as poor digestion and fat malabsorption (including fat soluble vitamins and essential fatty acids) and no reduction in the risk of liver disease.

Holistic treatment The holistic treatment of cholelithiasis is another example of the benefit of natural holistic methods that are orientated to correcting the underlying problems of bile synthesis and excretion, and which, over a relatively short period of time, can provide enormous relief to the patient and essentially result in a cure. The primary issue of concern is the presence of very large stones, which if induced to leave the gall bladder, can pass into the common bile duct and become lodged in the hepatopancreatic ampulla, causing a reflux of pancreatic juice into the pancreas, and resulting in acute pancreatitis. Thus, gallstones should be identified and their size should be determined before recommending treatment. Weiss states that the key to treating gallstones is to observe three basic components: the usage of cholagogues, antispasmodics and carminatives. Weiss notes that cholagogues are never used in active inflammation, only when the condition has achieved a latent state. Antispasmodics and carminatives are the mainstay of treatment in acute conditions. 1. Dietary modifications.

§ Dietary fiber: Among the dietary strategies to inhibit stone formation is to increase the consumption of dietary fiber, which reduces the bile acid concentration in the bile by inhibiting the bacterial activity that causes secondary and tertiary bile salt to be absorbed. Not all sources of fiber, however, should be considered equal: a diet rich in legume fiber is associated with a higher incidence of cholelithiasis. Fiber can thus be included from above ground vegetables, vegetable peels (on underground vegetables) and to a lesser



extent, whole grains. Decrease low fiber foods, especially refined carbohydrates including flour and potatoes, as they are associated with increasing the cholesterol saturation of bile.iii

§ Food allergens: Food allergens are theorized to play a role in cholelithiasis, and restrictions of such foods, including eggs, pork and milk should be determined through an elimination-challenge diet; refer to Lesson 1: The Fire Within: Digestive Function and Botanical Medicine.

§ Saturated fat: Fatty meats should be avoided in favor of lean meats (e.g., venison, buffalo), poultry, and fish.

§ Water: Water consumption should be increased to maintain the water content of the bile.

§ Terpene-containing foods, e.g., citrus fruits, culinary mints, etc. can help to break down stones.iv

2. Ease spasm and colic.

§ Antispasmodics, to ease pain and spasm associated with acute cholelithiasis: e.g., Dioscorea, Piper methysticum, Viburnum, Carum, Foeniculum, Brickellia, Picraena, Piscidia, Valeriana, Cannabis, Asparagus (Shatavari), Corydalis (Yan Hu Suo), Paeonia (Bai Shao); tropane-alkaloid containing plants, e.g., Belladonna, Hyocyamus

3. Dissolve the gallstones and thin the bile.

§ Cholagogues and hepatics, used in smaller dosages initially, gradually increasing dose: e.g., Raphnus, Leptandra, Beberis, Coptic, Mahonia, Silybum, Cynara, Taraxacum, Peumus boldo, Curcuma, Artemisia, Fumaria officinalis, Agrimonia

§ Choleretics, to be used with caution only where no obstruction exists (i.e., better for catarrhal conditions or prevention), e.g., Chelidonium (has traditionally been used with stones), Chionathus

§ “Jin Qian Cao” herbs, referring to herbs with capability to break down stones, e.g., Lysimachia (Jin Qian Cao) and Desmodium (Guang Jin Qian)

4. Chinese formulae: § Chai Hu Kuei Chioh Tang (Buplerum and Cinnamon

combination); Rx: decoction (1:4), one cup thrice dailyv § Xiao Chai Hu Tang (Major Buplerum combination); Rx:

decoction (1:4), one cup thrice dailyvi

Cholecytitis Dioscorea 2 prts Chionanthus 2 prts Valeriana 2 pts Taraxacum 1 prt Leptandra 1 prt Dosage: 3 – 5 ml TID Best if consumed with carminative such as infusion of Matricaria

Gallstones Dioscorea 2 prts Chionanthus 2 prts Valeriana 2 pts Leptandra 1 prt Chelone 1 prt Dosage: 3 – 5 ml TID. Take with carminative tea



§ Xiao Chai Hu Tang (Minor Buplerum combination); Rx: decoction (1:4), one cup thrice dailyvii

§ Hao Qin Qing Dan Tang (Artemisa and Scutellaria Decoction to Clear Gall Bladder); Rx: decoction (1:4), one cup twice daily

§ Li Gan Pian (Benefit Liver tablets), contains 30% pig bile, Rx: 2-3 tabs thrice daily.viii

6. Ayurvedic formulae: In Ayurvedic medicine, biliary dyskinesia

with attendant colic pains is called Parinamasula. § Narikela lavanam § one part Samudradi churna combined with five parts

Amalakyadi churna (Chakradatta, 1:106)

7. Lithotriptic supplements. § Vitamin C, 1-3 g daily § Vitamin E, 400-800 IU daily § Phosphatidylcholine, 500-1000 mg daily § Choline, 1 g daily § Vitamin B complex (with B12), 100 mg daily § Bile acids: Ox bile, ursodeoxycholic acid § Lecithin, improves the solubility of cholesterol, 2-3 g daily § Peppermint EO (terpenes), enteric coated, 1-2 capsules

thrice daily, between meals 8. Additional considerations.

§ Obesity is associated with a higher incidence of gallstones. § Regular exercise can inhibit gallstone formation. § Diets that promote quick weight loss by drastic caloric

restriction can promote gallstones.ix

The liver-gallbladder flush is a folk technique for removing stones from the gall bladder. A variety of techniques are utilized, all of which focus on the internal usage of relatively large amounts of an oil such as olive oil, along with terpene-rich fruit juices such as lemon or grapefruit, to dissolve the stones and induce bile synthesis and ejection. While many who perform this technique feel that what they have eliminated are gall stones, others suggest that what appear to be “stones” are really just a soft saponified complex of minerals, olive oil, and lemon juice formed in the lumen of the bowel. Thus, it is difficult to gauge the success of such treatments, and debate will continue until practitioners publish their clinical results in a peer-reviewed journal, complete with an analysis of the “stones” eliminated. The primary concern over the usage of the liver-gallbladder flush is that the great volume of fat consumed during the course of



treatment can cause a large stone to be thrown from the gall bladder and lodge somewhere in the biliary tree or in the hepatopancreatic ampulla, promoting a life-threatening emergency. Suffice it to say that the liver-gallbladder flush should never be used in acute conditions. The most common liver-gallbladder flush method consists of consuming 250 mL of olive oil with the juice of two lemons before bed, in small amounts (2 tablespoon) every 15 minutes until finished. If the patient desires to use this method, it is best used after at least one month (but up to 12 months) of using lithotriptic botanicals (such as Biliherb; 2 tablet, twice daily) and supplements to dissolve the stones first. An additional approach is to consume large volumes of organic, cold-pressed unpasteurized apple juice several days before doing the flush, which is also thought to help dissolve the stones. It should be remembered that on the day of the flush the patient should eat no solid food, only drinking apple juice until about 6 pm. An additional technique requires the administration of a tepid coffee enema, administered first thing in the morning on an empty stomach. The oil should be shortly eliminated via the feces, and a sieve can be used to collect the stones, which can then be analyzed.

Cholangitis

Cholangitis refers to the acute inflammation of the biliary tree and the subsequent obstruction of bile flow. Pathologists recognize two forms: pyogenic cholangitis, caused by a bacterial infection, and sclerosing cholangitis, which is thought to be an autoimmune disorder.

§ usually precipitated by an obstruction of the common bile duct, which develops a secondary infection (stones are the common cause), other factors could include strictures, stenosis, tumors, parasites, or endoscopic procedures of the common bile duct.

§ most important clinical signs of cholangitis include the Charcot triad, including: ˉ right upper quadrant (RUQ) pain ˉ fever ˉ jaundice

§ Common bacterial: Escherichia coli (39%), Klebsiella (54%), Enterobacter (34%) species, enterococci (34%), and group D streptococci,

§ relatively uncommon in North America but very common in South East Asia,



§ Primary infectious causes include intestinal parasites (e.g., Ascaris lumbricoides) and yeast (Candida spp.)

§ mortality of cholangitis is up to 40%, more common in elderly patients and/or those suffering from renal failure, liver disease, inflammatory bowel disease, and tumors.

§ primary sclerosing cholangitis (PSC) is a chronic liver disease characterized by inflammation, destruction and fibrosis of the bile ducts, eventually leading to cirrhosis of the liver.

§ PSC patients have an increased risk of cancer of the bile duct.

§ most researchers suspect PSC to be an autoimmune disease § Symptoms and signs of PSC include pruritus, jaundice,

fatigue, fever, weight loss and signs of advanced liver disease.

Medical treatment

The medical treatment of pyogenic cholangitis consists of an intravenous combination of broad-spectrum antibiotics, including penicillin (e.g., piperacillin, ampicillin, penicillin) and metronidazole; penicillin and metronidazole plus an aminoglycoside (e.g., gentamicin, tobramycin); an aminoglycoside and third-generation cephalosporin; piperacillin and tazobactam; mezlocillin; imipenem; meropenem; ticarcillin and clavulanate; or ampicillin and sulbactam. In very ill patients the infected regions of the biliary tree are drained percutaneously or endoscopically.x In contrast, the medical treatment of primary sclerosing cholangitis is limited to purely symptomatic measures. The bile acid ursodeoxycholic acid is used to improve disturbed laboratory parameters, and cholestyramine and opioid antagonists are given to control itching. Deficiencies in fat-soluble vitamins and essential fatty acids are very common, and should be treated with supplementation. Aggressive antibiotic therapy is used to treat episodes of bacterial cholangitis. xi

Holistic treatment Acute bacterial cholangitis is a life-threatening condition and patients presenting with Charcot’s triad should be immediately referred to emergency care. Thus, the kind of patient with cholangitis that is likely to be seen by a herbalist will be those in which the symptoms are relatively mild, or in the case of PSC, chronic. Given this caveat, several remedies and interventions are helpful in cholangitis. 1. Dietary modifications. For acute scenarios refer to the dietary strategies mentioned under “bilious dyspepsia,” with an observance of the rule “light, little, and liquid”, with a preference



to fresh vegetable juices and vegetable broths to avoid stimulating too much in the way of digestive activity. Given that PSC is likely an autoimmune disorder, the Paleolithic diet discussed in The Fire Within: Digestive Function and Botanical Medicine should be resorted to, to control or halt the progression of the disease. For cholangitis associated with gallstones refer to the section under cholelithiasis. 2. Cholagogues and choleretics. In his text, Herbal Repertory in Clinical Practice (1990) Michael Moore differentiates among the most potent cholagogues in the Western materia medica, used in small drop doses.

§ For acute pain: Leptandra § Pale stools, cloudy or dark urine, pain in right

hypochondrium to shoulder: Chelidonium § Pale stools, cloudy or dark urine, pain in right

hypochondrium to navel: Chionanthus § Sharp cutting pains, increased by motion: Chionanthus

3. Antispasmodics. To relieve pain, e.g., Dioscorea, Piper methysticum, Viburnum, Carum, Foeniculum, Brickellia, Picraena, Piscidia, Valeriana, Cannabis, Asparagus (Shatavari), Corydalis (Yan Hu Suo), Paeonia (Bai Shao); tropane-alkaloid containing plants, e.g., Belladonna, Hyocyamus

4. Antimicrobials, to relieve heat (Pitta): Including Echinacea, Allium; avoid using with bitter antimicrobials e.g., Hydrastis, Berberis, Coptis, Scutellaria baicalensis, Azadirachta 5. Chinese formulae: from a Chinese perspective, cholangitis is a damp heat condition. The following formula is a base formula to which are made slight modifications depending upon the signs and symptoms.

§ Da Chai Hu Wang (Major Buplerum combination), alternating fever and chills, nausea and vomiting, epigastric pain and distension, with burning diarrhea or constipation, a bitter taste in the mouth, a yellow tongue coating, and a forceful pulse; Rx: decoction (1:4), one cup thrice daily.xii

§ Xiao Chai Hu Tang (Minor Buplerum combination), for alternating fever with chills, a dry throat, a sour taste in the mouth, dizziness, irritability, sensation of fullness, gastric reflux, nausea, anorexia, a thin white coating on tongue, a wiry pulse; Rx: decoction (1:4), one cup thrice daily.xiii

The following are useful Chinese patent remedies: § Li Dan Pian (Benefit Gall Bladder pills), resolves damp-

heat and toxic heat in the Liver and Gall Bladder; Rx: 6 tablets thrice daily.xiv



§ Li Dan Pai Shi Pian (Benefit Gall Bladder Discharge Stone tablet), resolves damp-heat and toxic heat in the Liver and Gall Bladder, useful in Ascaris infection; Rx: 4-10 tabs twice daily.xv

Cholangitis and PSC are difficult conditions to treat and, where possible, herbal treatment should be undertaken in conjunction with the patient’s medical doctor. Where gall stones can be seen to be the underlying cause of cholangitis, therapy can be undertaken to dissolve and eliminate the stones, only as long as the stones aren’t too large to be passed, and thus must first be assessed by radiological or ultrasonic methods.

Jaundice

Jaundice is a term that refers to a yellowing of the skin, sclera (whites of the eyes) and other tissues, caused by an excess of circulating bilirubin.

§ Bilirubin is a water-insoluble waste product derived mostly from the heme portion of degenerating RBCs

§ mild jaundice has the absence of a dark-coloured urine, which would tend to indicate an unconjugated hyperbilirubinemia, caused by either hemolysis or Gilbert's syndrome

§ more severe indications of jaundice, and/or a very dark urine is a definite indication of an overt liver or biliary disorder

§ other symptoms including poor appetite, weight loss and fatigue, suggest alcoholic liver disease or chronic hepatitis

§ unconjugated hyperbilirubinemia is the result of a hemolytic anemia, a premature destruction of the RBCs

§ Gilbert's syndrome is an inherited autosomal dominant, mild and chronic, unconjugated hyperbilirubinemia, often misdiagnosed as chronic hepatitis

§ obstructive jaundice, or cholestasis, results from impaired bile flow, from any point between the liver cell canaliculi and the ampulla of vater

§ neonatal jaundice is in most cases a normal event experienced by up to 70% of newborns, called “physiologic jaundice,” the cause of which is poorly understood.

Medical treatment of jaundice As jaundice is often a symptom of an underlying liver pathology (except for inherited disorders of bilirubin metabolism), the treatment is orientated towards resolving the underlying condition. Intrahepatic cholestasis is often treated with the drugs cholestyramine or ursodeoxycholic, which combine with the bile

Beta Carotene Don’t mistake heavy use of beta-carotene or other carotinoids with jaundice. You have to observe the whites of the eyes, if they are yellow then jaundice is suspected.



acids in the intestine to form an insoluble complex that is excreted by the feces. This allows excess bile acids to be properly eliminated, and thus can help with systemic symptoms such as itching. Extrahepatic biliary obstruction is usually treated by surgical intervention, including stone extraction, and/or the insertion of stents and catheters. In some patients, benefit is to be had by undergoing biliary lithotripsy through endoscopic methods, or shockwave therapy.xvi

Holistic treatment of jaundice

A careful assessment should be made to determine the origin of the jaundiced state before undertaking any kind of therapy. These origins could range from cholangitis (inflammation and infection), cholecystitis (gall stones), a malignancy, hepatitis or cirrhosis, infection with parasites such as liver flukes (e.g., Clonochoris sinensis) or intestinal parasites (e.g., Ascaris). Caution should be taken whenever there is any kind of abdominal pain. Nonetheless, herbal treatment should be considered as a beneficial, non-invasive method to enhance the metabolism of bilirubin, to ease the itching and aesthetic problems associated with jaundice, while determining the underlying cause. In Therapeutic Herbalism, David Hoffman recommends, among other things, the usage of cholagogues and hepatics, lymphagogues and anti-pruritics, e.g.,

§ cholagogues and hepatics, to improve liver catabolism, e.g., Taraxacum, Silybum, Berberis, Peumus, Chionanthus, Leptandra, Chelidonium

§ lymphagogues, to mobilize and discharge cellular wastes, e.g., Galium, Chimaphila, Echinacea, Calendula, Urtica, Phytolacca

§ anti-pruritics, used topically as a bath to ease itching, e.g., Stellaria, Avena, Plantago

Alcoholic liver disease

Alcoholic liver disease (ALD) is the name for degenerative changes in the liver, which progresses from fatty liver, to alcoholic hepatitis and finally cirrhosis. Only about 15% of people with alcoholism, however, will go on to experience cirrhosis of the liver.

§ consuming as little as 20 grams of ethanol, equal to 60 mL of 40% whiskey, 200 mL of 12% wine, or 500 mL of 5% beer can produce liver injury when consumed daily over a period of years

Jaundice Taraxacum root 2 prts Verbena 1prt Silybum 1 prt Chionanthus 1 prt Peumus 1 prt Dosage 1.5 – 5 ml TID, building up over 3 – 5 days



§ alcoholic hepatitis results from consuming up to 80 grams of alcohol daily for almost a decade

§ cirrhosis is typically seen with the consumption of 160-200g daily over the same period

§ alcohol and its metabolites are toxic to the liver and other organs, increasing the redox state of the liver, inhibiting gluconeogenesis and protein synthesis, as well as increasing fatty acid synthesis and lipid peroxidation (seen in fatty liver). It promotes hypoxic damage, as well as inducing microsomal P-450, which is involved in drug metabolism

§ fatty liver or steatosis is the initial manifestation of acute or chronic excess alcohol consumption

§ alcoholic hepatitis, is usually superimposed upon the fatty changes

§ in severe cases, the liver can be totally obliterated, surrounded by dense fibrous tissue called central hyaline sclerosis

§ cirrhosis represents the end-stage disease of ALD, with hepatocellular necrosis and generalized fibrosis that surrounds the few remaining hepatocellular nodules. Essentially, the liver becomes shrunken and fibrotic, and patients will often die from esophageal hemorrhage (secondary to portal hypertension) or from complete hepatic failure.

Treatment of alcoholism There are a variety of approaches undertaken in the treatment of alcoholism, but none are effective until the patient is faced with the realization of the impact of the disease and fortified with the resolve to make healthy changes. This process is greatly assisted by a loving, compassionate and respectful group of peers that the patient can turn to for advice, reassurance, and encouragement. In many cases, the 12-Step program initiated by Alcoholics Anonymous is undertaken: Step 1. We admitted we were powerless over alcohol - that our lives had become unmanageable. Step 2: We came to believe that a Power greater than ourselves could restore us to sanity. Step 3: We made a decision to turn our will and our lives over to the care of God, as we understand him. Step 4: We made a searching and fearless moral inventory of ourselves. Step 5: We admitted to God, to ourselves and to another human being the exact nature of our wrongs. Step 6: We were entirely ready to have God remove all these defects of character.



Step 7: We humbly asked Him to remove these shortcomings. Step 8: We made a list of all the persons we had harmed, and became willing to make amends to them all. Step 9: We made direct amends to such people wherever possible, except when to do so would injure them or others. Step 10: We continued to take personal inventory, and when we were wrong, promptly admitted it. Step 11: We sought through prayer and meditation to improve our conscious contact with God as we understand him, praying only for knowledge of his will and the power to carry that out. Step 12: Having had a spiritual awakening as a result of these steps, we tried to carry this message to others, and to practice these principles in all our affairs. The 12-Step program promulgated by Alcoholics Anonymous (AA) is supported by a large community that maintains regular meetings in almost every city and town. While many have benefitted from the program, not all people find the 12-Steps outlined to be necessarily helpful. The 12-Step program has a strong Judeo-Christian ethic, and thus may discourage participation by people of other faiths, rationalists, and agnostics. Many have found success with the 12 steps by adjusting some of the wording to their own belief system. Some people can give up alcohol simply through the act of gumption, others with intensive psychotherapy, or some with the help of family and friends. Former alcoholics often believe that alcoholism is a disease -a perspective which is fostered by AA and has now more or less become enshrined as truth. Some critics perceive that this notion has divested alcoholics of personal responsibility, and therefore the need for balance and moderation in all activities. For example, many former alcoholics continue to abuse their bodies, such as by smoking or drinking large volumes of coffee: in such cases, the addictive response has not been addressed. Some former alcoholics who have learned to control their desires find that they can continue to drink in small amounts on special occasions, after a period of abstinence and self-reflection, without guilt or depression. In large part, the success of either method depends upon the patient. It is important when initiating a program for an alcoholic patient to ensure that alcohol consumption is tapered off slowly, over a period of a week. Quitting alcohol “cold turkey” may give rise to delirium tremens (DTs), a potentially fatal form of ethanol (alcohol) withdrawal. Symptoms include tremors, irritability, insomnia, nausea/vomiting (frequently secondary to gastritis or pancreatitis) hallucinations (auditory, visual, or olfactory), confusion delusions, severe agitation, and seizures, which can



begin between 6 to 48 hours after the last drink. The condition appears to be caused by the direct effect that ethanol has on the benzodiazepine-GABAa-chloride receptor complex, leading to the down-regulation of GABA and an unopposed increase in sympathetic activity. Ethanol also acts as an N-methyl D-aspartate receptor antagonist. Beyond specific treatments to the hepatobiliary system, the treatment of alcoholism in herbal medicine consists of: 1. Restoring proper nutrition. The high carbohydrate, high

calorie nature of regular alcohol consumption can have a major effect upon metabolic and cardiovascular health. (Refer to Dwelling in the Heart: Cardiovascular Function and Botanical Medicine.) Furthermore, an assessment of hepatic detoxification should also be undertaken at some point to establish guidelines for hepatotrophorestoration or, at least, the usage of hepatorestorative botanicals. A variety of nutrients in supplemental form can be seen to be helpful, including: § Vitamin A, 25,000 IU daily § Vitamin B complex, 100 mg daily § Vitamin C, 2-3 g daily § Vitamin E, 400 IU daily § Magnesium, 250 mg twice daily § Selenium, 200 mcg daily § Zinc, 30 mg daily § EFAs, EPA/DHA, 1000 mg each daily § Glutamine, 1 g daily § MSM, 2-3 g daily § Probiotics

2. Addressing symptoms of withdrawal. § Oral rehydration § Antispasmodics, e.g., Cimicifuga, Dioscorea, Viburnum,

Ferula § Relaxing nervines, e.g., Avena, Valeriana, Scutellaria,

Passiflora § Trophorestoratives, e.g., Turnena, Panax quinquefolium,

Panax ginseng leaf (Ren Shen Ye), Paeonia (Bai Shao), Withania (Ashvagandha), Emblica (Amalaki), Vitis (Draksha), Boerhavia (Punarnava)

§ Sedatives, e.g., Eschscholzia, Meconopsis, Corydalis (Yan Hu Suo)

§ Aromatherapy, e.g., EO of lavender, rose, geranium, neroli, vetivert, rosemary, lemon balm, peppermint, basil, sweet marjoram, bergamont, hyssop, lemon, clary sage, myrrh, frankincense, sandalwood

§ Massage

Milk Thistle (Silybum marianum) One of the best herbs to protect and re-build the liver from alcohol toxicity



§ Steam bath, sweat lodge, after weaning and no indication of delirium tremens

Acute viral hepatitis

Acute viral hepatitis refers to liver inflammation caused by certain viruses, including the hepatitis A, B, C, D, and E viruses. Other viruses that affect the liver include EBV, herpes simplex, yellow fever and cytomegalovirus are usually considered as separate disorders. Hepatitis A virus (HAV) is a single-stranded RNA picornavirus. Upon investigation the viral antigens may be found in the blood, stool, and liver but only during acute infection.

Hepatitis B virus (HBV) is a liver-specific DNA virus that causes both acute and chronic liver disease. The virus is comprised of an inner core and a surface coating.

Hepatitis D virus (HDV) is a defective RNA virus that can replicate only in the presence of either acute or chronic HBV infection, and usually increases the severity of existing chronic hepatitis. Hepatitis C virus (HCV) is considered to be quite a different pathogen from the family known as Flaviviridae, and is a close cousin to the viruses that cause bovine diarrhea, hog cholera, and yellow fever. Researchers have identified more than 100 strains of the virus and grouped them into six major "genotypes," which tend to be in specific regions around the world.

Medical treatment There are no satisfactory treatments for viral hepatitis, and thus much of the focus is upon prophylaxis, including personal hygiene, blood-screening, drug and alcohol counseling, and safe injection sites for drug users. Medical prevention includes the use of globulin preparations or the newly developed vaccines for HAV and HBV. The development of a vaccine for HCV has thus far eluded researchers. Current medical treatment for HCV consists of various anti-viral agents including interferon, serine protease inhibitors, inosine monophosphate dehydrogenase inhibitors, nucleoside analogues, protease inhibitors, RNS inhibitors and monoclonal antibodies, all of which are still in the early phases of clinical trials.



Many patients will experience a sudden onset or worsening of symptoms with medical treatment, including fatigue, joint pain, memory loss, mental confusion, skin problems, depression, irritability, anxiety, nausea, sleep disturbances, chills, fever, eyesight changes, flu-like symptoms, headaches, weight loss, anorexia, hemolytic anemia, hair loss, dental problems, diarrhea, hearing problems, mouth sores, excessive bleeding, heat/cold sensitivity, shortness of breath, thoughts of suicide, social isolation and RUQ pain.

Holistic treatment The holistic treatment of viral hepatitis is to support liver function through the usage of nutrient trophorestoratives, hepatics and liver trophorestoratives and antiviral botanicals. For HCV in particular, the orientation is that HCV is less an actual disease with a specific etiology, than it is a kind of hepatitis that appears to be directly related to the chronic exposure to liver toxins derived from industry, the environment, drugs, and alcohol. The basic treatment consists of trophorestorative nutrients and botanicals, liver trophorestoratives, gentle cholagogues and hepatics, and lifestyle counseling and harm reduction. Antiviral botanicals are often used as well, based on the hypothesis that HCV is in fact caused by a virus. 1. Trophorestorative nutrients:

§ Vitamin A, 25,000 IU daily § Vitamin B complex, 100 mg daily § Vitamin C, 2-3 g daily § Vitamin E, 400 IU daily § Magnesium, 250 mg twice daily § Selenium, 200 mcg daily § Zinc, 30 mg daily § EFAs, EPA/DHA, 1000 mg each daily § Glutamine, 1 g daily § MSM, 2-3 g daily § Probiotics

2. Trophorestorative botanicals, e.g., Coriolus, Ganoderma, Lentinula, Grifolia, Cordyceps, Astragalus, Panax quinquefolium, Avena, centella (mandukaparni), Bacopa (Brahmi), Withania (Ashvagandha), Paeonia (Bai Shao), rehmannia (Shu Di Huang), Polygonum (He Shou Wu), Lycium (Gou Qi Zi) 3. Liver trophorestoratives, e.g., Silybum, Cynara, Emblica (Amalaki), Taraxacum, Tinospora (Guduchi), Picrorrhiza (Katuka), Andrographis (Bhunimba), Schizandra (Wu Wei Zi)

Hep- Mushroom Blend Maitake (4:1) 100 mg Shiatake LEM 75 mg Coriolus (8:1) 50 mg Dandelion Root 75 mg Milk Thistle extract 75 mg Black Radish 50 mg Burdock root 50 mg Dosage: 2 – 3 cap; 2 – 3 x daily

Coriolus versicolor One of the best anti-viral agents, especially good for HCB. Dosage: (8:1) 3 cap tid



4. Antiviral botanicals, e.g., Coriolus, Allium, Ligusticum, Lomatium, Hypericum, Echinacea, Isatis (Ban Lan Gen), Ganoderma, Lentinus, Grifolia, Cordyceps

Chronic hepatitis and cirrhosis Chronic hepatitis refers to the presence of inflammation and necrosis in the liver for more than six months, although pathologists admit this is a somewhat arbitrary designation. Rather than defining hepatitis as chronic, the medical emphasis is to note the specific etiological and pathological factors involved in the disease such as chronic HCV with periportal inflammation, autoimmune hepatitis with cirrhosis, etc.

Holistic treatment The holistic treatment of chronic hepatitis is essentially the same as that for viral hepatitis, without necessarily using herbs that have antiviral activities. In end-stage conditions, the treatment is more or less symptomatic. Decoction for Acute or Chronic Hepatitis Silybum powder 120 g (4 oz) Taraxacum 120 g (4 oz) Glycyrrhiza 60 g (2 oz) Arcticum 60 g (2 oz) Foeniculum 60 g (2 oz) Citrus auran peel 60 g (2 oz) Simmer 2 Tbsp. of mixture in 6 cups water for 25 minutes. Remove from heat, steep 25 min, strain and drink entire amount each day.



References

i Berkow, Robert ed. et al. 1992. The Merck Manual of Diagnosis and Therapy. 17th ed. Rahway, NJ: Merck and Co ii Weiss, Rudolf. 1988. Herbal Medicine. Trans. By A.R. Meuss. Beaconsfield, England: Beaconsfield Publishers, p 77 iii Pizzorno, Joseph and Michael Murray, eds. 1999. Textbook of Natural Medicine. 2nd ed. Vol. 1-2. London: Churchill Livingstone, p 1244 iv Tillotson, Alan. 2001. The One Earth Herbal Sourcebook. New York: Twin Streams (Kensington), p323 v Hsu, Hong-Yen, Ph.D., and Peacher, William G., M.D. Chinese Herb Medicine and Therapy. New Canaan, Conn.: Keats Publishing, 1994. vi Bensky, Dan and Randall Barolet. 1990. Chinese Herbal Medicine: Formulae and Strategies. Seattle, WA: Eastland Press

vii Bensky, Dan and Randall Barolet. 1990. Chinese Herbal Medicine: Formulae and Strategies. Seattle, WA: Eastland Press viii Fratkin, Jake. 1986. Chinese Patent Formulas: A Practical Guide. Boulder, CO: Shya Publications

ix Tillotson, Alan. 2001. The One Earth Herbal Sourcebook. New York: Twin Streams (Kensington)

x Santen, Sally. 2003. Cholangitis. Available from: http://www.emedicine.com/EMERG/topic96.htm



xi Berkow, Robert ed. et al. 1992. The Merck Manual of Diagnosis and Therapy. 17th ed. Rahway, NJ: Merck and Co xii Bensky, Dan and Randall Barolet. 1990. Chinese Herbal Medicine: Formulae and Strategies. Seattle, WA: Eastland Press xiii Bensky, Dan and Randall Barolet. 1990. Chinese Herbal Medicine: Formulae and Strategies. Seattle, WA: Eastland Press xiv Fratkin, Jake. 1986. Chinese Patent Formulas: A Practical Guide. Boulder, CO: Shya Publications xv Fratkin, Jake. 1986. Chinese Patent Formulas: A Practical Guide. Boulder, CO: Shya Publications xvi Berkow, Robert ed. et al. 1992. The Merck Manual of Diagnosis and Therapy

Documents

Part V: Etiology, Pathology and Treatment of Hepatobiliary ... · Corydalis (Yan Hu Suo), Paeonia (Bai Shao); tropane-alkaloid containing plants, e.g., Belladonna, Hyocyamus 3. Dissolve