This case demonstrates the methodology of deriving the case history in acute abdominal diseases of Acalculous Cholecystitis and homeopathic processing while stabilization of the vital parameters in an emergency situation. Deriving the homeopathic totality during acute distress is the bigger challenge which can be learned from proper clinical and homeopathic training. Step wise clinical assessment of the case under homeopathic intervention helps to witness the process of cure.
Name of the Patient: Mrs S.K.
Age: 28 years, Sex: Female
Date of arrival in casualty: 15-11-2010 at 7 pm.
28-year-old female came to the casualty with complaints of recurrent episodes of vomiting since 1 1/2 weeks. Complaints increased since yesterday. Since today morning there is h/o 4 to 6 episodes of vomiting.
Detail ODP of the complaints:
|Gastrointestinal Tract Gall bladder Since 1 ½ week Today F: 4-6 episodes since morning Abdomen right hypochondrium Radiating to back.||Low grade fever bodyache3+ with chilliness. Backache fever during. She had repeated episodes of bilious vomiting, Vomitus was of bitter character. Vomits eatables and plain water. Vomiting Nausea Dull aching pain O/E: T-98.F, P -80/min, R.R -16/min, B.P – 130/90 mmhg, Pallor+ R.S – NAD C.V.S-NAD C.N.S – NAD P/A –RHC and epigastric tenderness. USG – Right pleural effusion with GB wall 2mm normal thickness. Cholecystitis, pancreas normal, spleen normal. Ascites++||>partial with allopathic medicine. < allopathic medicine 3+ Not better with Allopathic treatment < After eating and drinking3+. >cold drinks like fruit juices and effervescent drinks 3+ >lying down < Smell 3+ and sight2+ of food. < Jarring2+||Thirstlessness3+ fever during. Restlessness with vomiting|
Patient was apparently well before the onset of the complaints. Clinical approach towards this case are as follows:
- If we consider the symptom complex in evolution
C. Abdominal pain localised to right hypochondrium radiating to back.
D. Examination finding is suggestive of Right hypochondrium tenderness.
It points toward liver and biliary system as the seat of disease.
- Severe gastritis v/s duodenitis as one of the likely possibility since vomiting had started after the start of medicine, ie. drug induced gastritis.
But if we consider treatment history, she was already treated at 4 places with different antacids like H2 receptor antagonist and proton pump inhibitor without significant improvement
- USG is suggestive of Cholecystitis.
- S. Amylase and S. Lipase which are within normal limit to rule out pancreatic cause.
- Contingency plan; in case patient fails to respond to cholecystitis line of treatment is to go for OGD scopy to see the intra luminal pathologies or go for endoscopic USG to look for any GB calculus or cystic duct sludge or common bile duct stones.
- In spite of this if vomiting persists then will suspect extra intestinal cause which presses on the pylorus and leads to vomiting. In that case CT scan abdomen is advisable.
- In case of persistent vomiting superior mesenteric artery syndrome which is one of the rare causes should be thought of.
INDICATION FOR ADMISSION:
- Fluid and electrolyte correction: Continuous vomiting which lead to fluid loss.
- Hydration maintenance since patient is not tolerating orally. To avoid renal hypo-perfusion leading to ARF.
- Failure to respond to conventional line of treatment (since patient had taken treatment from 4 different doctors) so case requires more definite work up and detailed investigation and symptom observation. This can be done best after admitting the patient.
- Admission will help to monitor the patient better and make quick RREF. It will enable to assess whether patient is getting better or not.
- Parental fluid therapy and nutrition till the time Gall bladder inflammation settles down.
STRUCTURE FORM FUNCTION
It is the method of understanding the pathophysiological processes (Functions) with anatomical changes (Structure) during the disease phenomenon with its corresponding expressions (Form).
Gall Bladder inflammation involving the mucosa of the gall bladder à inflamed Gall bladder leading to extravasation of fluid in the pleural cavity and Peritoneal cavity.
USG – Right pleural effusion with GB wall 2mm normal thickness. Cholecystitis, pancreas normal, spleen normal. Ascites++
|Altered Gall bladder contractibility. Bile ejection is altered Leading to inability to digest fat. Reflux symptoms due to inflammation|
Low grade fever bodyache3+ with chilliness.
Backache fever during.
bilious vomiting, Vomitus was of bitter character.
Vomits eatables and plain water.
< After eating and drinking3+.
>cold drinks like fruit juices
and effervescent drinks 3+
Nausea < Smell 3+ and sight2+ of food.
Dull aching pain < Jarring2
|Hb -11.1||WBC -5400, E3,L45,M2|
|Plt count- 1,60,000||S. Bilirubin – 0.77|
|BUN -9.1||SGOT -58.6|
|S. Na -133.3 Cl -95.8 K -3.4||SGPT -125.3|
|S. Amylase and Lipase – normal. Urine ® -ALB –trace pus cells – 1to 2||ALK PHOS- 37.3|
|S. Creat- 1.0||USG – Right pleural effusion with GB wall 2mm normal thickness. Cholecystitis, pancreas normal, spleen normal. Ascites++|
CASE DEFINED IN IPD
LIFE SPACE: An obese fair complexioned female was admitted in IPD for c/o cholecystitis. Patient was freely expressive about her sufferings and chief complaint. Patient hails from neighboring village. She has two daughters. Her husband is working in a company and financially stable. Patient hails from a small village in U.P.
She has 3 brothers and 2 sisters. She has been eldest in the family. She has completed her education from Urdu medium school. She was staying with one of her aunts who didn’t have any children. She grew up at her aunt’s place. Memories of her childhood were good and were the best days of her life. She was pampered a lot being the only child at aunt’s place.
She was fond of wearing beautiful dresses and matching accessories, which her parents would send her from Mumbai. If she had to go out, she would wear costlier dresses. She is obstinate, wants her demands to be fulfilled. She wants things to be kept at proper place. She is very conscious about her looks, dresses and jewelries.
She was very fearful and would never stay alone. She has fear of darkness. Once at night she was alone at home, and there was sudden electricity failure. She tried lighting a lamp, but unfortunately, she spilled the oil on herself and sustained severe burn injuries over her neck, chest and left hand.
Her parents took her to Mumbai, and got her treated at good hospitals. She underwent a cosmetic plastic surgery. All these days were the worst days of her life. She cried a lot and prayed to God to make her alright. After a period of 2 to 3 days of treatment she improved, though she has burn scar marks.
During her bad days her fiancé was very supportive. When patient recovered, her in laws were not ready to accept her with the scar marks, but the fiancé took a firm decision and married her. Her husband is very caring in nature. She cannot stay alone even now. Whenever she is alone at home, she will either visit her neighbors or relatives or her mother’s house.
She desires company. Even her cousins tease her saying that if any thief enters her home, she herself will give him everything and will request not to harm her. She laughs at this and says that it’s true. She shares a good relation with her neighbors, would easily get along with anyone.
This patient is anxious regarding her daughter’s future. She likes helping people who are in trouble and can’t tolerate their pain. Dreams of snakes+, fish+ and death of people+. On observation: patient was very childish in her conduct. She was very communicative. Vivacious while she was talking.
Perspiration scanty more on face+, offensive ++
Cravings- Cold drinks+3, ice cream+3, meat+3, pungent+3, sour++2
Aversion –sweets+2, Milk aggravation à Nausea.
Menses- Regular, moderate flow, painless, offensive+2, clots occasionally.
OBS/H- G3P2A1L2, H/O morning sickness throughout pregnancy
Fan: Summer: full, Monsoon: slow, Winter: slow
Covering: Summer: nil, Monsoon: covering2+, Winter: covering2+
Requires to keep legs uncovered 3+ all throughout the seasons
Bathing: Cold: summer, Tepid: Winter, Monsoon
1. Thirstlessness fever during
2. Sensitive to allopathic medicines
3. Nausea < smell of the food
4. Vomiting amelioration by cold drinks
5. Vomiting < eating after
6. Vomiting < drinking after
7. Abdominal Pain < Jarring
8. Extremity pain fever during
9. Backache fever during
10. Headache fever during
11. Abdominal pain extending to back.
|REPERTORIAL CHRONIC TOTALITY OF CASE|
|Company desiresFear of darkFear of being aloneFear of thunderstormVivaciousSympatheticChillyMilk aggravationDesires spices, condimentsDesires cold drinksHeat-general foot soles uncovers it.||ChillyDesires cold drinksMilk aggravationHeat uncover foot, soles must.|
Dreams are not considered since they are very infrequent 1+ intensity.
P.D.F (Potential Differential Field) It is a specific set of symptoms which indicates towards remedy confirmation. P.D.F includes:
a. Acute and chronic dimensions of the drug pathogensis and of the patient.
b. Thermal clevage including the differential thermal modalities and the thermal centering wherein the precise differential vasomotor effects are taken careful note of.
c. Miasmatic cleavage with adequate attention to the dominant miasm at the moment in time when the patient confronts us.
d. Characteristic particulars (The so called keynotes)
i) Characteristic discharges from skin and mucous membranes.
ii) Sensation as if
iii) Differential Modalities / Contradictory Modalities – thermal, positional, etc.
e. Natural lines/ planes of cleavage in the patients symptomatic expression and the identification of the remedy blocks.
f. Mental state and not merely the mental symptoms in the repertories.
(Dr K. N. Kasad, Repertotial Syndrome Concept, Recognition, Representation and Differentiation, ICR Symposium Volume on Hahnemannian Totality, Dr. M.L.Dhawale Memorial Trust, 3rd 2003, Part II, Area D,D.99,D.100).
ACUTE REMEDY DIFFERENTIATION
|CAUSATION||ILL EFFECTS OF JARRING, WET GETTING. BOILED MILK, PORK, TOBACCO.||MILK, ICE-CREAMS, PORK, FAT, PASTRY, IRON, QUININE||TOBACCO,|
|THIRST||THIRSTLESSNESS DESIRES ACIDS||THIRSTLESSNESS CRAVES ACIDS REFRESHING THINGS OR WHAT DISAGREES||DESIRES COLD DRINKS WHICH > POST OPERATIVE VOMITING AFTER CHLOROFORM|
|MODALITIES||NAUSEA < SMELL OF FOOD 3+ >COLD DRINKS GALL BLADDER PAIN < STOOPING||STITCHING PAINS < WALKING OR MIS STEPS < BEGINNING MOTION < EATING LONG AFTER > GENTAL MOTION||> COLD FOOD AND DRINK > RUBBING|
|NAUSEA||NAUSEA AT THE THOUGHT, SMELL OF FOOD IN MORNING, AT THOUGHT OF COITION||NAUSEA ON PUTTING HANDS IN COLD WATER|
|VOMITTING||VOMITS SOLID ONLY. MILKY VOMITING IN MORNING ON RINSING MOUTH.||VOMITING OF FOOD LONG EATEN||OF BILE, BLOOD, COFEE-GROUND VOMITING FROM SLIGHTEST WATER CLOSES HER EYES WHILE BATHING|
|ABDOMINAL PAIN||GRIPING IN GALLBLADDER < STOOPING||STITCHING PAINS < WALKING OR MIS STEPS||SORE SPOT AT PIT OF STOMACH > RUBBING. FLATULENT COLIC < HOT DRINKS|
|TISSUE AFFINITY||VENOUS CIRCULATION – DIGESTIVE TRACT, PORTAL SYSTEM. Gall Bladder||MUCOUS MEMBRANES- STOMACH, BOWELS||MUCOUS MEMBRANES PF STOMACH AND BOWELS|
|CONSTITUTION||DRAGGY RELAXED FEMALES – LITHAEMIC, PLETHORIC.||TALL, GRACILE, NERVOUS AND DELICATE.|
It has to be done at different levels
- General causation and modalities level
- Physical general: THIRSTLESSNESS
- Physical general sensation: In our case ACHES – PAIN all over the body and abdominal pain.
- Physical Particulars
- Nausea: Smell of the food 3+
- Vomiting > Cold drinks
Remedies coming for differentiation after repertorisation:
Pulsatilla, Sepia, Phosphorus
Thirstlessness as the general trend in the totality is better covered by Sepia.
Vomiting better by cold drinks is covered by Sepia and Phosporus. But phosphorus cannot be considered due to thirstlessness.
KEY symptoms ie. sensitive to modern medicine, thirstlessness and vomiting > cold drinks is better covered by Sepia both quantitatively and qualitatively.
CHRONIC CONSTIUTIONAL REMEDY
Patient is very communicative, expressive, childish and fearful is better covered by Phosphorus. Other remedies like Sepia and Lycop also come up in the reportorisation. But Phosphorus has better coverage both at the dispositional as well as qualified mentals like fear of thunderstorm and company desires are better covered.
Physical generals craving for cold drinks and milk aggravation are better covered by Calcarea Carb and Phosphorus.
Inclination to uncover feet is covered by Pulsatilla, Phosphorus, Calcarea Carb, Secale Cor, Flouric acid, Sulphur, Medorrhinum.
But Phosphorus suits the patient best considering the mental disposition and physical generals.
D/D- Phos, Lyco, Puls, Sep, Ars, Arg Nit, Calc, Sulp, China, Kali Carb.
ACUTE REMEDY: SEPIA 200 4 pills 4 hourly.
FINAL CONSTIUTIONAL REMEDY : PHOSPHOROUS 200 (1P) HS / 1WEEK
PLANNING AND PROGRAMMING:
|Susceptibility (Tissue):||High||Acalculous Cholecystitis (Structural reversible Disease) Pace of disease fast Characteristics general as well as particulars|
|Sensitivity: Mind/ Body||High||Characteristic expressed at the level of mental disposition, mental qualified expression, physical dispositional general and pathology level. Symptomatology expressed at the level of the diseased organ is also characteristic and sensitivity is reflected. Case is rich in physical general concomitants and modalities – causative and aggravating modalities.|
|Suppression||Nil||No evidence of any form of disappearance or change in the presentation both at the level of mind and body.|
|Correspondence||Sector TOTAL Constitutional TOTAL||Sector correspondence is total at the level of physical concomitants, causation and modalities.|
|constitutional level Total||Constitutional correspondence is total at the dispositional mental and physical level.|
|Structural||Reversible||If we consider Cholecystitis -inflammatory status of the wall of gall bladder with reactionary effusion seen in the peritoneal and pleural cavity. Inflammation is not limited to Gall bladder. It has overcome the peritoneal and diaphragmatic barrier.|
|Miasmatic||PSORIC3+ à SYCOTIC1+||Mental – Expressive, Sensitive etc.. Body – Inflammatory reversible conditions|
FOLLOW UP CRITERIA
|Date||Gen Well Being||Apt Thirst||Fever sleep||Body ache/ Head Ache||Vomiting Freq/ Intensity||Vom Charac/ quantity||Nausea/Abd Pain||Other symptoms||O/E Findings.||Action|
|15/11/10 10 pm||Sepia 200 4 pills 4 hourly|
|16/11 9am||Slightly||SQ||Nil/ N||>+||2 episodes||SQ||>+/ nil||Sepia 200 4 pills 4 hourly|
|16/11 9 pm||SQ||>+/ SQ||NIL/ N||>++||3 episodes Total 6 episodes since admission||Change to watery vomiting <sitting >lying down||Passing flatus Eructation+ Tongue thin white coated.||BP 110/70 P/A R hypochondrium min tenderness.||Sepia 200 4 pills 4hourly|
|17-11-10 9 am||Better Weakness better||Thirst Improved||No vomiting since yest night||BP 150/90 Afeb P/A min tenderness R hypochondrium|
|17-11-10 5 pm||Over all feeling better Weakness >2+||Appetite feeling hungry Thirst improved||Vomiting 3 episodes of watery||Abdominal pain > 2+||Afeb BP 140/100 P/A soft non tender||Sepia 200 4pills 4 hourly|
|Date||Gen Well Being||Apt Thirst||Fever sleep||Body ache/ Head Ache||Vomiting Freq/ Intensity||Vom Charac/ quantity||Nausea/ Abd Pain||Other symptoms||O/E Findings.||Action|
|18-11-10 8 am||>3+||Hungry||Vomiting –0–||Abdominal pain –0–||Afeb P-84/min BP 100/70||Sepia 200 4pills 4 hourly|
|18-11-10 ER||>3+||>3+ Tolerating soft diet and water||–0–||Vomiting –0–||Vomiting –0–||Abdominal pain –0–||Afeb BP- 130/80||Sepia 200 4pills 4 hourly.|
|19-11-10 8 am||>3+||>3+||Fever –0–||–0–||Vomiting –0—||–o—||Abdominal pain –0—||Afeb BP 130/90 P/A NAD||Sepia 200 4pills 4 hourly|
|19-11-10 9 pm||>3+||>3+||–0–||–0–||–0–||–0–||BP-150/70mm hg P/A NAD||Sepia 200 4pills 4 hourly|
|20-11-10 8 am||N||N||-0–||–0–||–0–||–0–||–0–||Vitals normal||Sepia 200 qds x 3 days Patient discharged|
|21-11-10||N||N||–0–||–0–||–0–||-0-||–0–||Chronic leg pain < night||Vitals normal||Phosphorus 200 1P Rii 6P HS x 1 week|
|30-11-10||No complaints||Phos 200 1P HS Rii 6P HS x 1 week|
|28-12-10||Had 2 episodes of self limiting mild leg pain and then no complaints||Vitals normal||Rii x 4 weeks|
While treating the patient in IPD regular monitoring was done, IV fluids were administered and Electrolyte correction was done by giving potassium drip.
|Therapeutic definition||Therapeutic resolution||End point||Precaution and dangers|
|Vomiting Abdominal Pain Suggestive of acute cholecystitis||Plan is to introduce the acute remedy Sepia 200 4 pills frequent repetition. Homoeopathic intervention has to be supported with I V Hydration in order to keep patient Haemo-dynamically stable. Persistent vomiting lead to electrolyte
(K+) imbalance which is taken care by KCL Drip. If vomiting persists than RT insertion and gastric content aspiration may be required. Constitutional Remedy Phosphorus 200 infrequent repetition.
|Till the time vomiting stops and patient is able to eat her three square meals.||In due course of cholecystitis treatment if patient starts spiking and icterus starts appearing à inflammation it indicates extending to liver cells or empyema of gall bladder. if abdominal pain persistent and there is developing guarding and rigidity then it may be a sign of peritonitis. EARLIEST OF ABOVE SYMPTOMS APPEARING WE MAY HAVE TO GO FOR SURGICAL INTERVENTION|
|CAUTION: The complication rate for acalculous cholecystitis exceeds than for calculous cholecystitis. Successful management of acute acalculous cholecystitis appears to depend primarily on early diagnosis and surgical intervention, with meticulous attention to postoperative care (Reference from Harisson)|
Learning from the case
- Managing refractory cases of gall bladder disorder.
- Managing cases which are hypersensitive to modern medicine ends up with addition of distress after its intervention.
- Role of IPD in managing cases with recurrent vomiting and abdominal pain.
- Role of auxiliary and ancillary line of treatment. Application of knowledge of patho-physiological processes (giving rest to gall bladder and allowing the inflammation to settle down) and electrolyte imbalance correction.
- Prescribing in acute condition and concept of remedy reaction while managing acute clinical conditions.
Dr Kumar Dhawale, Trustee, Dr M.L.Dhawale Memorial Homeopathic Institute. Palghar.
Dr Bipin Jain Principal and Director, Dr M.L.Dhawale Homeopathic Institute, Palghar.
Dr Anand Kapse, Director, , Dr M.L.Dhawale Homeopathic Institute, Palghar.
Dr Navin Pawaskar, Ex Clinical Director, Dr M.L.Dhawale Homeopathic Hospital, Palghar.
- William Boericke, Boericke’s New Manual of Homeopathic Materia Medica with Repertory, B Jain Publisher, 3rd revised and augmented edition based on 9th edition, 2014, Page no 518,519 & 520.
- Dr Anand Kapse, I.C.R operational Manual, Dr M.L.Dhawale Memorial Trust, Mumbai, Second Edition 2003, Page 30-34,100-105
- Dr S.R.Phatak, Materia medica of Homeopathic medicines, B Jain Publishers (P) Ltd, New Delhi, Second Edition revised, 2007, Page no 550-556, 581-587 and 639-645.
- John Henry Clarke M.D, A dictionary of Practical Materia Medica, B.Jain Publishers, New Delhi, 2006, Volume III, Page No 786,787,918 and 1168.
- Norton J.Greenberger, Gustav Paumgartner, Harrison’s Principles of Internal medicine, The Macgrow Hill Companies, Inc, USA, sixteenth edition, Volume II, Page 1885.
- Dr K.N. Kasad, Repertotial Syndrome Concept, Recognition, Representation and Differentiation, ICR Symposium Volume on Hahnemannian Totality, Dr. M.L. Dhawale Memorial Trust, 3rd 2003, Part II, Area D,D.99,D.100.