A Case Study Of
Chronic Hepatitis B & C
Presented by:
Hk.M.Ahmad Saleemi
Hepatitis:
Hepatitis is an inflammation of the liver characterized by the
presence of inflammatory cells in the tissue of the organ.
Viral Hepatitis:
Viral hepatitis is liver inflammation due to a viral infection. It
may present in acute (recent infection, relatively rapid onset)
or chronic forms. The most common causes of viral hepatitis
are the five unrelated hepatotropic viruses Hepatitis A,
Hepatitis B, Hepatitis C, Hepatitis D, and Hepatitis E. In
addition to the hepatitis viruses, other viruses that can also
cause hepatitis include Herpes simplex, Cytomegalovirus,
Epstein-Barr virus, or Yellow fever Virus.
Hepatitis-B
Chronic hepatitis B is a major global healthcare problem.
Affecting an estimated 350 to 400 million people worldwide,
1,Chronic hepatitis B results in approximately one million
deaths each year,
2 Making it the world's tenth leading cause of death.
In the US,1 to 1.25 million people have chronic hepatitis B,and
approximately 4000 to 5000 die each year of its complications.
3 The progression of chronic hepatitis B is variable, ranging
from mild asymptomatic infection to severe chronic liver disease.
In about 15% to 25% of patients, ongoing viral replication leads
to serious complications including hepatic decomposition,
cirrhosis, and Hepatocellular carcinoma (HCC).
- 4-5 Million people in Pakistan.
Hepatitis-C
• - 170 million people are chronic carrier of Hep-C
i.e.3 % of world population.
• - 2-4Million Persons in USA may be Chronically
affected.
• - 5-10 Million in Europe.
• - 12 Million in India
• - 4-6 Million in Pakistan
• * Source:
http://www.who.int/csr/disease/hepatitis/whocdscsrlyo2003/
en/index4.html
Modes Of Transmission
Difference between Hepatitis Types
HAV
HBV HCV HDV HEV
Size of Virus
40 nm
42 nm
30 nm
40 nm
30 nm
Type of Nucleus
RNA
DNA
RNA
RNA
RNA
Vaccine Available
Yes
Yes
No
No
No
Mean Incubation Time
25 Days 75 Days 50 Days 35 Days Unknown
Chronic Infection
No
Yes
Yes
No
No
Mode of Transmission
Fecal
or oral
Sexual
Trans
Blood
Trans
Blood
Trans
Fecal
Signs & Symptoms
•
•
•
•
•
•
Malaise(‫) بے چینی ۔ بے َقراری‬
Anorexia (Poor appetite)(‫)بھوک کی کمی‬
Nausea(‫) متلی۔ ابکائیاں‬
Abdominal pain(‫) درد شکم‬
Tenderness(‫)نرمی‬
Muscle & Joint Pain( ‫)درد پٹھاوجوڑ‬
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Diagnostic Tests
A. Biochemical Indicators
 ALT
 AST
0 – 20 times.
B. ELISA (Enzyme Linked Immune Sorbent assay)
C. RIBA (Recombinant Imunoblot assay)
D. PCR (Detects RNA of the actual HCV)
 Qualitative PCR
 Quantitative PCR
E. Liver Biopsy.
F. Other Biochemical Tests.





Hb
TLC
Alkaline Phosphatase
Bilirubin
ESR etc.
TREATMENT
A. Mono therapy with alpha interferon.
Work in 10 – 20 person out of 100.
• Side effect profile is high
Dosage reduced in 40 out of 100.
Treatment withdrawn in 15.
• Pregnant can not use.
B. Combination therapy Interferon + Ribavirin
Works in 30 – 40 out of 100
Ribavirin alone does not work.
Serious side effects like severe anemia myocardial infarction
The challenge of science
• Paracelsus, the Father of Pharmacology said..
“All that mankind needs for good health and
healing is provided in nature..
the challenge of science is to find it!”
Herbal Treatment
Main Ingredients
1. Glycyrrhiza (Mulathi)
2. Silybum marianum(Oont Catara)
3. Withania coagulans (Paneer Doodi)
4. Solanum nigrum Linn (Mako)
5. Piprum nigrum(Mirch sia)
6. Artemisia absinthium(afsanteen)
7.Chichorium intybus(kasni)
8.Aloe Vera (Kanwar Gundal)
Silibum marianum(Oont Catara)
- Milk thistle has been used for liver problems for over 2000 years
- It offers Hepato-protective action through a number of mechanisms
-
Anti-oxidant activity
Toxin blockade at the membrane level
Enhances protein synthesis
Anti fibroitic activity
Anti-inflammatory and
Immune-modulating effects.
Silybum marianum (Oont Catara)
Silybum marianum has been shown to have clinical applications in the treatment
of toxic hepatitis, fatty liver, cirrhosis, ischemic injury, radiation toxicity and
viral hepatitis.
- Significantly reduces insulin requirements
It also significantly reduces insulin requirement in cirrhosis related diabetes
mellitus patients.
Glycyrrhiza glabra
(Mulathi)
OUTSTANDING EFFICACY IN LIVER DISORDERS
• Glycyrrhiza Glabra offers out standing surveillance rate in liver patients.
•Reduces The Risk Of Liver Carcinoma
•Glycyrrhiza Glabra has reduced half the rate of hepatocellular carcinoma as
compared to other supportive therapy.
•Restores Liver Functions
•Hepatitis treatment with Glycyrrhiza Glabra restores AST & ALT plasma
concentrations.
Withania coagulans (Paneer Doda)
IMPROVES LIVER FUNCTIONS
• Increases thyroxine (T4), hepatic glucose and decreases liver lipid
peroxidation.
•Anti Inflammatory Action
•Anti-inflammatory action is comparable to hydrocortisone.
• Reduces Hepatotoxicity
• Hepatotoxicity is reduced by withania comparable to hydrocortisone.
Piper nigrum(Kali mirch
or Black pepper )
Black pepper has stimulant, expectorant, carminative, antipyretic, anthelmintic,
antiperiodic action when used internally and externally it acts as rubefacient,
stimulant, resolvent. Pepper has long been known for stimulating the appetite and
relieving nausea. In India it had been used as a medicine for variety of ailments
from paralysis to toothache. According to Ayurveda it is useful in treatment of
asthma, chronic indigestion, colon toxins, obesity, sinus congestion, fever,
intermittent fever, cold extremities, colic pain, cholera, gastric ailments, diarrhea,
piles, worms and sore throat. Externally it can be applied to boils and other skin
diseases in form of paste.
DETOXIFYING AGENT
- Hepatotoxicity is decreased reducing lipid peroxidation, enzymatic leakage of
GPT, AP and preventing depletion of GSH.
Chichorium intybus
(Chicory) (Kasni)
Chicory (especially the flower) was used as a treatment in
Germany, and is recorded in many books as an ancient German
treatment for everyday ailments. It is variously used as a tonic
and as a treatment for gallstones, gastro-enteritis, sinus
problems and cuts and bruises. (Howard M. 1987). Inulin, the
dietary fiber found in Chicory finds application in diabetes and
constipation.
Chicory has demonstrated antihepatotoxic potential in animal
studies.,[
Artemisia absinthium
(Afsanteen)
• Its active substances include silica, two
bitter substances (absinthin and
anabsinthine), thujone, tannic and
resinous substances, malic acid, and
succinic acid. It is used medicinally as a
tonic, stomachic, antiseptic,
antispasmodic, carminative, cholagogue,
febrifuge and anthelmintic. It has also
been used to remedy indigestion.
Compound medicine
•
•
•
•
•
•
•
Majoon Dabeed ul ward
Jawarish Amla
Dawa ul Qurkum kabir
Dawa ul Misk
Sharbat Deenar
Sharbat Kasni
Sharbat Bazoori
•
•
•
•
•
•
Hepta Care
Akseer e Jiger Syrup & Tab
Aloe Care Cap & Syrup
Jigreen
Actirn Tab
Berisal Syrupetc
Condition
Chronic Hepatitis B & C
Investigational drugs.
A combination of herbal ingredients mainly Glycrrhiza, Silybum marianum.
Investigational
Tests & frequency.
Tests
Frequency
Hb
3 Week Interval
ALT
“
AST
“
Platelets
“
ESR
At start and end of therapy
Urea
“
Biliribin
“
Anti HCV.
“
PCR Quantitative
“
Data collection procedure
On a specific designed format through patient interview & lab reports.
Location of trial
Private clinic
R&D Qarshi Industries
Qarshi Health Shop
Time frame One year.
Clinical Trials of
Herbal medicine on Hepatitis C Patients
Hepatitis C Study
PATIENTS & METHODS
All patients who were Hepatitis B surface antigen negative, and had
impaired liver functions were tested for Hepatitis C virus antibodies. PCR
was done in those who tested positive for HCV antibodies. Patients who
had detected virus on PCR and abdominal ultra sound showed no
stigmata of portal hypertension were included in the study.
Hemoglobin SGPT (ALT), AST, White cell count. Platelets were done at the
interval of every three weeks. Liver function test, Renal function test, PCR
was done Pre and Post treatment.
The study comprised of 18 patients (12 males, 6 females)
The mean age was
(40  15)
Mean AST
105  30
Mean ALT
115  42(N < 41 L/ml)
(N < 40 L/ml)
Hepatitis C Study
These patients were treated with a combination of herbal ingredients mainly glycyrrhizinate,
silybum marianum, zinc compound, withinia coagulant, ginseng, Rheum emodi given in
divided doses daily for one year. With serial monitoring of AST, ALT, hemoglobin and
platelets.
Of initial 18 patients 5 patients lost follow up. Of the 13 patients who completed this study
for 6 months, a subjective improvement was seen in 12 patients (93 %).
Out of 13 only 8 patients completed the study for 11 months ( Recommended duration of
treatment is one year).
The response to therapy with Herbal medicine depending on biochemical and molecular
biological test (PCR) were as follows.
Improvement in ALT & AST levels
12
(93%)
Results PCR – Non Detected
5 out of 8 (62.5 %)
(in patients taken the medicine for recommended duration i.e. 11 months)
The Mean level of ALT, for the 13 patients who completed the study successfully, fell from
(115  42) to 40  24 UL/ml and that of AST fell from (105  30) to 43  21 UL/ml.
There was no major side effect. Two patients complaint of colic pain in abdomen.
Sr. #
Name
AST
ALT
Age
(Years) Clinical
Trials
of After
Before After
Before
46
182
94
225
106
Duration
PCR
Negative
Kits
Months
13
11
12
10
1
Mrs. Bashir
2
Mr. Pervaiz
3
Mr. Niamat
50
86
24
75
32
Negative
13
11
4
Fehmeeda
55
17
20
48
23
Negative
13
11
5
Ali Amir
30
36
23
41
15
Negative
13
11
6
Mrs. Akram
41
44
72
41
58
Positive
13
11
7
Nasim Akhtar
37
42
28
53
37
Positive
13
11
8
Mr. Nadeem*
21
29
38
22
22
not done
12
10
9
Shah Mohammad**
45
139
78
92
82
Positive
8
7
10
Mehar Sajid**
52
51
68
56
60
Positive
8
7
11
Abdul Hameed**
40
72
58
57
42
Positive
7
6
12
Mr. Jamil**
25
131
84
130
67
Positive
7
6
13
Mr. Abid**
30
130
34
91
28
Positive
6
6
Herbal medicine
on36Hepatitis
B
Patients
20
43
21
Negative
Hepatitis B Study
All patients were confirmed Hepatitis ‘B’ surface antigen positive, and had
increased SGPT & SGOT levels.
PCR was done and willing patients (child bearing female exempted) were
included in the study. Pregnant ladies and patients with diabetes and
leumpensated cirrhosis were included.
Hemoglobin, SGPT (ALT), AST, Blood chemistry were done at the interval of
every three weeks , pcr was done pre & post treatment.
The study comprised of 10 patients (6 male, 4 female)
The Mean age was 40
MEAN AST
1300
(N < 40µl/ml)
MEAN ALT
1950
(N < 42 µl/ml)
These patients were treated with a combination of herbal ingredients mainly
glycyrrhizinate, silybum marianum, zinc compound, withinia coagulant,
ginseng, Rheum emodi given in divided doses daily maximum 180 days
with periodic monitoring of AST, ALT & CBC. At the initial stage 10
patients completed the study and showed 100% results within 180 days
response was as follows.
Improvement in ALT & AST
10
(100%)
PCR Non Detected
10
(100%)
(Mean period in which PCR became –ve in 155 days)
Mean improvement in ALT & AST
Before
1950
1300
After
22
20
(Mean period 60 days)
No major side effect was reported.
Herbal Treatment
Feedback of Hepatitis B Patients
No. of patients registered for Treatment:
- 100 patients
Regular Patients:
- 92 patients
Defaulters:
- 8 patients
PCR Test Reports
From Aga Khan University Hospital Karachi
Sr. No.
Patient's Name
F/H Name
Age
AKU Lab. Code
PCR Test Result
Hep-B virus DNA
detected / not detected
1
Abdul Hafeez
Ali Nawaz
27
DK # 16719
Not detected
2
Ali Asghar
Muhammad Usman
47
DK # 16720
Detected
3
Fahmida
Ghulam Yaseen
25
DK # 16721
Detected
4
Ghulam Mustafa
Muhammad Ismail
35
DK # 16722
Not detected
5
Ghulam Hyder
Ali Nawaz
21
DK # 16723
Not detected
6
Khadim Hussain
Ahmed Bux
29
DK # 16724
Detected
7
Noor Ahmed
Ahmed Bux
30
DK # 16725
Not detected
8
Rafiqe Ahmed
Abdul Karim
17
DK # 16726
Not detected
9
Shafiqe Ahmed
Abdul Karim
14
DK # 16727
Not detected
10
Sajid Hussain
Noor Hassan
18
DK # 16728
Not detected
PCR Test Reports
From Aga Khan University Hospital Karachi Through Collection Unit Dhairki
Sr. No.
Patient's Name
F/H Name
Age
AKU Lab. Code
PCR Test Result
Hep-B virus DNA
detected / not detected
11
Muhammad Islam
Ellahi Bux
26
DK # 16755
Not detected
12
Allah Yar
Dhani Bux
30
DK # 16756
Not detected
13
Abdul Wahab
Yaar Muhammad
22
DK # 16757
Not detected
14
Muhammad Ishaqe
Abdul Rahim
20
DK # 16758
Not detected
15
Nisar Ahmed
Haji Ghulam Yaseen
22
DK # 16759
Detected
16
Zubair Ahmed
Shehzado
10
DK # 16760
Not detected
17
Mai Zohra
Shaukat Ali
25
DK # 16761
Detected
18
Shahzad Ali
Khuda Bux
20
DK # 16762
Not detected
19
Ali Gohar
Abdul Rasheed
18
DK # 16763
Not detected
20
Muhammad Hanif
Abdul Wahid
10
DK # 16764
Not detected
PCR Test Reports
From Aga Khan University Hospital Karachi Through Collection Unit Dhairki
Patient's Name
Sr. No.
F/H Name
Age
AKU Lab. Code
PCR Test Result
Hep-B virus DNA
detected / not detected
21
Ali Raza
Muhammad Sadiq
16
DK # 16781
Detected
22
Wajid Ali
Maula Bux
17
DK # 16782
Detected
23
Sajid Hussain
karim Bux
12
DK # 16783
Detected
24
Mai Rukhsana
Qurban Ali
22
DK # 16784
Not detected
25
Muhammad Zeesahn
Ghulam Akbar
22
DK # 16785
Not detected
26
Amjad Ali
Muhammad Aslam
31
DK # 16786
Not detected
27
Muhammad Ameen
Rehmat Ali
42
DK # 16787
Not detected
28
Abdul Latif
Sher Muhammad
20
DK # 16788
Not detected
29
Daulat Ali
Dahar Ali
23
DK # 16789
Not detected
30
Asad Ali
Anwar Ali
10
DK # 16790
Not detected
PCR Test Reports
From Aga Khan University Hospital Karachi Through Collection Unit Dhairki
Patient's Name
Sr. No.
F/H Name
Age
AKU Lab. Code
PCR Test Result
Hep-B virus DNA
detected / not detected
31
Abdul Hameed
Muhmmad Younis
38
DK # 16831
Not detected
32
Akhtiar Ahmed
Bilal Shar
22
DK # 16832
Not detected
33
Atta Ellahi
Ameer Bux
15
DK # 16833
Not detected
34
Kalsoom
Muhammad Yaqoob
30
DK # 16834
Detected
35
Meer Hassan
Abdul Wahid
17
DK # 16835
Not detected
36
Rizawan
Sher Muhammad
18
DK # 16836
Not detected
37
Saeed Ahmed
Muhammad Yaqoob
30
DK # 16837
Detected
38
Zahid Ali
Luqman
20
DK # 16838
Not detected
39
Bashir Ahmed
Jamal Din
18
DK # 16839
Not detected
40
Shehzado
Muhammad Usman
20
DK # 16840
Not detected
PCR Test Reports
From Aga Khan University Hospital Karachi Through Collection Unit Dhairki
Patient's Name
Sr. No.
F/H Name
Age
AKU Lab. Code
PCR Test Result
Hep-B virus DNA
detected / not detected
41
Jahanzaib
Shehbaz Ali
14
DK # 16873
Detected
42
Mai Meerul
Shehbaz Ali
30
DK # 16874
Detected
43
Sadia
Shehbaz Ali
10
DK # 16875
Not detected
44
Aneeta
Shehbaz Ali
12
DK # 16876
Not detected
45
Moomal
Sain Dad
30
DK # 16877
Not detected
46
Sanawli
Momin Ali
16
DK # 16878
Not detected
47
Gul Hassan
Soomer Khan
25
DK # 16879
Not detected
48
Hussana
Soomer Khan
20
DK # 16880
Not detected
49
Lal Bux
Gul Muhammad
25
DK # 16881
Not detected
50
Noor Muhammad
Gul Muhammad
23
DK # 16882
Not detected
PCR Test Reports
From Aga Khan University Hospital Karachi Through Collection Unit Dhairki
Patient's Name
Sr. No.
F/H Name
Age
AKU Lab. Code
PCR Test Result
Hep-B virus DNA
detected / not detected
51
Amjad Ali
Muhmmad Yaqoob
28
DK # 16910
Not detected
52
Amina
Muhammad Abbass
40
DK # 16911
Not detected
53
Bilal Asghar
Abdul Wahab
27
DK # 16912
Detected
54
Khalid Mehmood
Mehmood
17
DK # 16913
Detected
55
Ishfaqe Ahmed
Abdul Shakoor
15
DK # 16914
Detected
56
Zaheer Ahmed
Jailkum Khan
27
DK # 16915
Detected
57
Abdul Razaque
Haji Dhollan
32
DK # 16916
Detected
58
Ghulam Mustafa
Jeewan Khan
32
DK # 16917
Detected
59
Asad Ali
Muhmmad Hussain
12
DK # 16918
Detected
60
Naeem Ahmed
Sultan Ahmed
16
DK # 16919
Not detected
PCR Test Reports
From Aga Khan University Hospital Karachi Through Collection Unit Dhairki
Patient's Name
Sr. No.
F/H Name
Age
AKU Lab. Code
PCR Test Result
Hep-B virus DNA detected
/ not detected
61
Qaim Din
Allah Wadhayo
43
DK # 16941
Not detected
62
Shafiqe Ahmed
Anwar Din
10
DK # 16942
Detected
63
Khalil Ahmed
Luqman
19
DK # 16943
Not detected
64
Arshad Ali
Sabzal
20
DK # 16944
Not detected
65
Khalid Hussain
Mitho Khan
20
DK # 16945
Detected
66
Mai Willaitan
Mohib Khan
15
DK # 16946
Not detected
67
Allah Wasai
Qamar Din
15
DK # 16947
Not detected
68
Farman Ali
Jeeand Khan
20
DK # 16948
Detected
69
Insaf Ali
Jeeand Khan
10
DK # 16949
Detected
70
Bilal Ahmed
Abdul Malik
10
DK # 16950
Detected
PCR Test Reports
From Aga Khan University Hospital Karachi Through Collection Unit Dhairki
Patient's Name
Sr. No.
F/H Name
Age
AKU Lab. Code
PCR Test Result
Hep-B virus DNA
detected / not detected
81
Shahida
Muhammad Bachal
16
DK # 16980
Not detected
82
Abdul Jabbar
Muhammad Chhuttal
22
DK # 16981
Not detected
83
Faiz Muhammad
Allah Bux
20
DK # 16982
Not detected
84
Aqib Ali
Manzoor Ahmed
12
DK # 16983
Not detected
85
Muhammad Irfan
Muhammad Ramzan
12
DK # 16984
Not detected
86
Imam Khatoon
Abdul Ghafoor
50
DK # 16985
Not detected
87
Mai Hanifan
Mir Muhammad
22
DK # 16986
Detected
88
Niaz Ali
Gul Hassan
35
DK # 16987
Detected
89
Mai Sharifan
Ghulam Mustafa
35
DK # 16988
Detected
90
Akshay Kumar
Roshan Lal
12
DK # 16989
Detected
Herbal Treatment
Feedback of Hepatitis B Patients
Observations:
Medication
1. 8 patients out of 100 didn't complete the course of medicine (7 patients left
the course and 1 was Cirrhotic patient).
2. 82 patients out of 92 were healthy and feeling better than before taking the
medicine.
3.
10 patients out of 92 patients had one of these problems like constipation,
flatulence, weakness & insomnia.
Herbal Treatment
Feedback of Hepatitis B Patients
Observations:
PCR Test Results:
1.
PCR test of 90 patients was conducted to find out the Hepatitis - B virus in
patients after treatment.
2. As per PCR Tests Report from Aga Khan University Hospital Karachi, in
66% patients (59 patients) Hepatitis – B virus was not detected.
3. Whereas in 34% patients (31 patients), Hepatitis B + virus was detected.
Herbal Treatment
Feedback of Hepatitis C Patients
No. of Patients Registered for Treatment:
- 40 patients
Results:
- Treatment of Hepatitis C Patients under process
- Treatment process will be completed till April 2011
Thanks