Unani interventions in the Management of Acute Necrotizing Pancreatitis (Waram-i-B?nqar?s Nakhri H?d): A Case Report

Necrotizing pancreatitis is a serious and life-threatening complication of acute pancreatitis known as Waram-i-B?nqar?s H?d in Unani medicine, which is characterized by an acute inflammatory condition of the pancreas.[1] Pathophysiologically, acute pancreatitis occurs as a consequence of premature activation of zymogen granules, releasing proteases that digest the pancreas and surrounding tissue.[1] In about 80% of all cases, acute pancreatitis is mild and self-limiting with a mortality of less than 5%., but in 20% of the patients, however, it is severe, with local complications such as necrosis, pseudocyst, or abscess, and systemic complications leading to multi-organ failure, associated with 98% of mortality.[1] If less than 30% of the pancreas is necrotic, the morbidity prevailed at 40%, but mortality, infection, and organ failure rates have been reported at 20%. If more than 50% of the pancreas is necrotic, the rate of morbidity rises to 100%, mortality to 40%, infection to 50%, the need for debridement to 70%, and multi-organ dysfunction to 65%. Gall stones and alcohol are the most common causes of acute necrotizing pancreatitis. [2] Although the pancreas and its pathology have not been mentioned in any classic literature of Unani medicine, similar illnesses to acute pancreatitis can be explained under Waram-i-H?r (acute inflammation), Waram-i-Falgham?ni (sanguineous inflammation), ?umm? ‘Uf?niyyah (infective fever), and  ?umm? Waramiyyah (inflammatory fever) described by Ali Ibn Al-Abb?s Maj?si (930-994 AD) and Al-Sheikh al-Ra'is Ab? ?Al? al-?usayn ibn ?Abd All?h ibn Al-Hasan ibn Ali ibn S?n? (Bu Al? S?n?) (980-1037 AD) in his famous book, Kamil al-Sana'ah al-Tibbiyyah (The Complete Art of Medicine), and Al-Q?n?n f? al-?ibb (The Canon of Medicine), respectively. [3,4]  Waram-i-B?nqar?s Nakhri H?d (acute necrotizing pancreatitis) usually can be treated by adopting a regimen of Waram-i-H?r (acute inflammation) and Fas?d-i-Dam wa Uf?nat (blood impurities & sepsis). The principles of treatment for Waram-i-H?r (acute inflammation) are to abolish the causes (Asb?b), reduce congestion (Imtil?’), and provide rest (Suk?n) to the inflamed organ, and these can be achieved by utilizing Unani drugs that have multiple spectrum of actions including Muhallil-e-Waram (anti-inflammatory), Musakkin-i-Alam (analgesic), Mudirr-i-Bawl (diuretic), Mufatti?-i-Sudud (deobstruents), and Dafey-i-Safra (antibilious) in this patient.[5] Fas?d-i-Dam wa Uf?nat (blood impurities & sepsis) can basically be managed by various modes of care: Ta?fiyyah wa Ta‘d?l-i-Dam (blood purification and moderation), Taly?n wa Ish?l (laxation and purgation), Ta‘r?q wa Idr?r (diaphoresis and diuresis), Daf‘-i-Ta‘affun (removal of putrefaction), and I?l??-i-Ha?m (to improve digestion), and these can be accomplished by employing Unani drugs that have Mu?aff?-i-Dam (blood purifier), D?fi‘-i-Ta‘affun (anti-infective), D?fi‘-i-Jar?seem (antibacterial), Mudammil (vulnerary), H??im (digestive), K?sir-i-Riy?? (carminative)  Mu??fi?-i-Jigar (hepatoprotective), Mu??fi?-i-Kulyah (nephroprotective), and immune enhancer properties.[6]

MATERIALS AND METHODS

Case Presentations

A 44-year-old married male patient suffering from alcohol-induced acute necrotizing pancreatitis visited the Government Unani Dispensary, North Kota, Rajasthan, India, for treatment on 28 April 2024 with the chief clinical features of recurrent fever, abdominal pain, abdominal distension, nausea, vomiting, and loss of appetite for the last 10 weeks. When queried about the background of his current ailment, he replied that he was quite well prior to 9 February 2024. After intake of heavy alcohol, suddenly he felt severe abdominal pain, abdominal distension, nausea, and vomiting. With these complaints, he was admitted to Maharaja Bheem Singh (MBS) Hospital, Kota, Rajasthan, on 9 February 2024. Here diagnosed as acute pancreatitis and treated till 20 February 2024 but with no relief. Eventually he shifted to Jeevan Rekha Super Specialty Hospital Jaipur with manifestations of high-grade fever, dyspnea, severe abdominal pain, nausea, and vomiting. Here acute necrotizing pancreatitis (ANP), ascites, and bilateral pleural effusions were diagnosed and treated by a gastroenterologist pulmonologist. Pleural effusions and ascites were resolved, but acute necrotizing pancreatitis persisted. Percutaneous catheter drainage (PCD) was placed for peripancreatic collections on 23 February 2024. The patient was discharged with advised medications on 4 March 2024. The patient was readmitted to that hospital with complaints of abdominal pain, nausea, vomiting, fever, and loss of appetite under his consultant on 11 April 2024 and treated here till his condition stabilized, then he was discharged on 17 April 2024, continuing treatment of ANP. The patient was again admitted to that hospital with complaints of abdominal pain, nausea, vomiting, fever, loss of appetite, and deterioration in kidney function on 23 April 2024 and treated here till his condition stabilized. He was discharged on 25 April 2024 with advised medication of ANP.  Physical examination of the patient was expressed as he was extremely weak and bedridden. His body weight was dropping 27 kg from 74 kg to 47 kg. He had a percutaneous catheter drainage (PCD) inserted for peripancreatic collections, draining foul-smelling, thick pus of approx. 50-60 cc/day. He was on a liquid diet. Pallor was found positive.  On examination of vital signs, the patient’s body temperature was 98.6^? Fahrenheit, pulse rate was 110 beats per minute, blood pressure was 120/80 millimeters of mercury, and respiratory rate was 20 per minute. On systemic examination of the central nervous system, the patient was conscious and oriented; of the cardiovascular system, the first and second heart sounds were normal; of the respiratory system, the bilateral chest was clear; and of the digestive system, the tenderness was present in the upper abdomen region. The pathological investigations of blood were expressive that hemoglobin (Hb) was lowered, random blood sugar was normal, serum creatinine was raised, total leucocyte count was higher, and neutrophils were also higher, as shown in Table 1. Hepatitis B surface antigen (HBsAg) was found negative. 

Table 1: Pathology Reports

The magnetic resonance cholangiopancreatography (MRCP) screenings were suggestive of necrotizing pancreatitis sequelae with intra- and extra-pancreatic walled-off collections and peripancreatic fat necrosis. The detailed findings were shown in Table 2.

Table 2: Radiology Reports