Understanding

Liver Function Tests

in diagnosis and
management of
Kamala
KAMAL KISHORE
Post Graduate Scholar
Dept. of PG studies in Kayachiktsa
SKAMCH&RC Bangalore
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 Contents

• Introduction
• Functions of Liver
• Liver Function Tests
• Liver Disease Classification
• Pre Hepatic Jaundice
• Koshtashakhasrita Kamala
• LFT in Koshtashakhasrita Kamala
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• Management of Koshtashakhasrita Kamala
• Hepatic Jaundice
• Shakhasrita Kamala
• LFT in Shakhasrita Kamala
• Alcoholic Liver Disease
• Management of Shakhasrita Kamala
• Post hepatic jaundice
• Ruddhapatha kamala
• Kumbhakamala
• Limitations of LFT
• Discussion
• Conclusion
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 The liver is the second largest organ in the
body which plays central role in the
digestion & metabolism of proteins,
carbohydrates & lipids.

 The disease of the liver are a major cause for

the morbidity & mortality worldwide.

 One in forty deaths are due to liver diseases.

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 Liver function tests (LFTs) are group of
blood tests that give information about the
state of a patient's liver.

 These tests can be used to detect the

presence of liver disease, distinguish among
different types of liver disorders, gauge the
extent of known liver damage, and follow the
response to treatment.
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 Most of the liver diseases cause only mild
symptoms initially, but these diseases must
be detected early

 Jaundice is a clinical sign of most of the

liver diseases.

 Medical Jaundice refers to any type of

Jaundice that can be managed by non-
surgical conservative measures.
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 The liver disorders are seen in Ayurveda
mainly through the windows of Kamala.

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 Liver is mainly responsible for the
production of bile (Bilirubin) and synthesis
of serum proteins (Albumin & Globulin).

 Breakdown of RBC in spleen leads to

unconjugated bilirubin production which is
transported to liver through blood where it
is converted to conjugated bilirubin.
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 Bilirubin is stored in gall bladder as Bile
and is excreted into duodenum (s.intestine)
where it is converted into urobilinogen and
is excreted in stools(as stercobilinogen)
and in urine (as urobilinogen).

 A major portion of bilirubin is reabsorbed in

enterohepatic circulation.

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Test Normal Values
Total Bilirubin 0.3 – 1.0 mg/dl
Conjugated B. (DB) < 0.3 mg/dl
Alkaline Phosphatase 30 – 120 mg/dl
Aspartate Transaminase (AST/SGOT) 5 – 40 IU/L
Alanine Transaminase (ALT/SGPT) 5 – 35 IU/L
S. Albumin 3.5 – 5.0 g/dl
S. Globulin 2.0 – 3.5 g/dl
A/G ratio 1.2 – 1.5
Prothrombin Time 12 – 15 sec
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 HEMOLYTIC JAUNDICE / PRE HEPATIC JAUNDICE

1.Inherited – Sickle cell Anaemia, Thalassemias,

Glucose6phosphate deficiency.
Gilbert Syndrome, Rotor’s Syndrome

3.Acquired – B12 deficiency, Folate deficiency.

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HEPATOCELLULAR JAUNDICE / HEPATIC JAUNDICE

1.Viral Hepatitis – A, B, C, D, E

2.Parasitic Hepatitis – E. Histolytica

3.Autoimmune Hepatitis

4.Toxic Hepatitis – Drugs, Alcohol

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OBSTRUCTIVE JAUNDICE / POST HEPATIC JAUNDICE

1.Primary biliary cirrhosis, Primary sclerosing

cholangitis.

2.Choledocholithiasis, parasitic infection, carcinoma,

traumatic biliary strictures.

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 PRE HEPATIC/
HEMOLYTIC JAUNDICE
Abdominal pain Only present in Crisis
Clinical Itching Absent
Features
Drugs, Blood
Past history
transfusion
Icterus - color Lemon yellow
Pallor Present
On
Palpable gall bladder Absent
Examination
Splenomegaly Present
Bleeding tendency Absent 13
 PRE HEPATIC/
HEMOLYTIC JAUNDICE
Unconjugated/
Raised
Indirect Bilirubin
Liver Conjugated/Direct Normal
Function AST or ALT Normal
Tests A:G A>G (N)
Alkaline phos.& GGT Normal

Bile Salts & Bile Pigments Absent

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Often associated with Pandu (Anaemia)

Pitta kara ahara & vihara leading to dagdhata of pitta

asrik & mamsa.
Chronic & slow onset.
Haridra Netra Twak Nakhaanana
Raktha Peeta Shakrit Mootra
Clinical Features Bheka Varna, Krusha & Durbala

Indriya daurbalya
Daha ,Aruchi Avipaaka, 15
 Total Bilirubin ranges btw 4-6 mg/dl
Usually Unconjugated B. > Conjugated B.
Here liver enzymes may not be affected.
Bile Salts & Bile Pigments are absent in urine.

As Pandu is associated = Complete Blood picture required.

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Mridu Shodhana
(Virechana)

Shamana Rx

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 Snehapana for a max of 3 - 4 days with
 Mahatiktaka gritha
 Kalyanaka gritha
 Panchagavya gritha
 Indukantha gritha

 Vishrama kala – 3 days (Ushanajala snana for swedana)

 Virechana karma with
 Trivrut lehya ( 30gms) + Draksa / Triphala kashaya
 Manibhadra guda ( 30gms )
 Katuki churna ( 10gms )
 Samsarjana krama (3 – 5 days)
 Pathya Sevana & continuation with Shamana aushadhi.
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 HEPATIC/
HEPATOCELLULR JAUNDICE

Icterus - color Orange yellow

Itching Transient
Clinical features
Contact with jaundice
Past History
patient, Drugs
Pallor Absent
Palpable gall
Not palpable
bladder
On examination Splenomegaly May be present
Bleeding
Present
tendency
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 HEPATIC/
HEPATOCELLULR JAUNDICE
Unconjugated/
Normal
Indirect Bilirubin

Conjugated/Direct Increased
Liver
Function AST or ALT Markedly Raised
Test
ALP & GGT Normal

A:G G>A (Chronic diseases)

Bile Salts & Bile Pigments Present

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• Acute in onset.
• Ashayapakarshaka hetu
 Haridra Netra Mutra Twak
 Tila Pista Nibha Varchas
 Jwara. Aruchi
Clinical Features
 Alpa Agni, Atopa
 Hrut Gaurava
 Daurbalya
 Hikka,Swaasa

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AST & ALT is raised in hepato - cellular
conditions/infective hepatitis.
ALT is generally greater raised than AST.
Usually ALP is raised in cholestatic/malignant
infiltrations
Usually Conjugated B. > Unconjugated B.
Bile Salts & Bile Pigments are present

Serological testing needed for – Hepatitis A, B, C, D, E

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AST & ALT is raised in Alcoholic Hepatitis.
AST is greater raised than ALT.
Usually ALP is raised.
Usually Conjugated B. > Unconjugated B.
Albumin : Globulin ratio reversed
GGT is raised and is important marker of alcoholic
hepatitis.

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Kaphahara chikitsa

Mridu Shodhana
(Virechana)

Shamana chikitsa

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Kaphahara chikitsa
Katu, Teekshna, Ushna, Lavana, Amla Rasa
Pradhana dravyas like
 Kulattha yusha, Mulaka yusha
 Lemon juice + maricha (long & black) + Ardraka
swarasa with madhu
 Trikatu choorna with Madhu/Ardraka swrasa

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Once the Mala Ranjana occurs
 Swasthaanam Aagatam Pittam
(Bile Pigments & Bile Salts Negative)
 Vayuscha Prashamam Bhavet
 Nivrutha Upadrava- jwara, atopa, vistamba,
hrit gaurva, daurbhalya, alpagni, aruchi.

Go for Mridu Shodana

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Mridu Shodana
 Snehana
 Mrudu Abhyanga & Usna Jala Snana
 Virechana Yogas like Gomutra Hareetaki
 Samsarjana Krama
 Pathya sevana
 Continuation of the Shamana till vyadhi shamana.

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 POSTHEPATIC /
OBSTRUCTIVE JAUNDICE
Icterus - color Greenish yellow
Itching Present
Clinical features Pain(stones), weight
Past History loss(neoplasm, surgery
(strictures)
Pallor Absent
Palpable gall
Palpable
bladder
On examination
Splenomegaly Absent
Bleeding
Absent
tendency 28
 POSTHEPATIC /
OBSTRUCTIVE JAUNDICE
Unconjugated/
Normal
Indirect Bilirubin

Conjugated/Direct Increased
Liver
Function AST or ALT Increased
Test
ALP & GGT Markedly increased

A:G G>A (Chronic diseases)

Bile Salts & Bile Pigments Present

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 Common causes for Post hepatic
jaundice/obstructive jaundice are choledocholithiasis,
biliary strictures, tumors and after LFT, USG
abdomen is the usual choice of investigation.
 It is managed surgically.

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 Kalantarat kharibhoota
 Shoona/ Shootha
 Krishna peeta shakrit mootra, Rakta netra
 Tandra, Moha
 Aruchi, Nashtagni
Advanced liver diseases like cirrhosis,
encephalopathy etc has similar signs & symptoms as
that of Kumbhakamala like oedema, ascites, mental
confusions, coma, anorexia etc
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 False positive
 False negative
 Rarely suggest a specific diagnosis
 Assess limited number of functions
 One testing = no diagnosis
 Misnomer
 Battery testing
 Repeated testing

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 Assessing most of liver diseases is easy through
LFT.
 The pattern of abnormalities found in LFT
generally points to
 Pre Hepatic/Hepatic/Post Hepatic jaundice.
 Acute/Chronic Liver disease.
 Staging of a disease .

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 Despite of bahupaittika nature of the
koshtashakhasrita kamala, the amount of
pitta/bilirubin that comes to settle in shakha/skin
and conjunctiva is far minimal. Therefore it
becomes reasonable to interpret and treat the
conditions associated with haemolytic jaundice on
the lines of koshtashakhasrita kamala where
pandu/anaemia is the pre stage for it.

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 Based on the tilapishtanibha varchas found in
shakhasrita Kamala, it can be interpreted more
correctly as cholestatic phase of hepatocellular
jaundice which is an umbrella term and includes
many underlying pathologies like viral, bacterial,
alcoholic, autoimmune, drugs, tumor, granuloma etc
 Kumbhakamala as explained in Ayurveda is
kaalantarat (long term standing/progressed kamala)
which can be taken under Advanced Liver disease.

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 Based on LFT, nidana & samprapti can be better
understood and vighatana can be planned
accordingly.
 LFT are very important as a documentation part to
assess the disease progression or regression.

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 LFT is the first choice of Laboratory
investigations whenever a patient approaches
with hallmark of Kamala.
 Til pishta nibha varchas and LFT are the prime
considerations to diagnose types of Kamala.
 Every Kayachikitsak has to rule out Surgical
jaundice through LFT & Imaging techniques
before planning treatment.

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 It is not advisable to completely rely only on LFT.
 Lakshanas and imaging techniques are to be
considered along with LFT for the accurate
diagnosis and management of kamala in a better
way.

“Rogamaadou parikshet tato anantaram

aushadham” (Cha.Ch.20/20)

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THANK YOU