Significant Reduction of Carbohydrate 19-9 Antigen Levels in a Patient of Acute on Chronic Pancreatitis through Ayurvedic Treatment Protocol

Abstract

Pancreatitis is an inflammatory and irreversible disorder of Pancreas, though unpredictable in nature. It's broadly categorized in acute and chronic pancreatitis depending upon the diagnostic parameters. Both types of pancreatitis are managed by using tools of conventional treatment; however natural course of progression of the diseases process remains unbeatable. Pancreatitis may also lead to pancreatic cancer and a tumor marker called Carbohydrate 19-9 antigen (CA 19-9) is being used routinely to accesses the progression of the disease. The normal value of CA 19-9 in the serum is<37 U/mL, whereas, levels more than 300 U/mL are considered definite indicators of pancreatic cancer. Here, we report a case of 52 years old male form Eastern Uttar Pradesh in India who was initially diagnosed for Acute Necrotizing pancreatitis and was treated conservatively by subject experts. Later he suffered with seven more episodes within three years of initial diagnosis and was dealt in emergencies. His clinical condition continued to deteriorate and he lost 15 kg body weight during the course of disease. At this juncture, he opted to a north India based specialty Ayurvedic treatment centre and was treated with metal based Ayurvedic formulations, daily diet of 2000 to 2200 calories and complete mental and physical rest. He responded well to Ayurvedic treatment protocol (ATP) and showed overall improvement. There was also remarkable improvement in his rising CA 19-9 levels, that turned to normal in the first hundred eight days of ATP, which needs to be explored further for its path making therapeutic values.

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International Journal of Science and Research (IJSR)
ISSN: 2319-7064
SJIF (2022): 7.942
Volume 12 Issue 7, July 2023
www.ijsr.net
Licensed Under Creative Commons Attribution CC BY
Significant Reduction of Carbohydrate 19-9 Antigen
Levels in a Patient of Acute on Chronic Pancreatitis
through Ayurvedic Treatment Protocol
Vaidya Balendu Prakash1, Shikha Prakash2, Neha Negi3, Sneha Tiwari Sati4
Padaav – A Speciality Ayurvedic Treatment Centre, Uttarakhand
Corresponding Author: Vaidya Balendu Prakash, Prakash Villa, Near Rave Cinemas, Danpur Area, Rudrapur, Uttarakhand, India
Abstract: Pancreatitis is an inflammatory and irreversible disorder of Pancreas, though unpredictable in nature. It’s broadly
categorized in acute and chronic pancreatitis depending upon the diagnostic parameters. Both types of pancreatitis are managed by
using tools of conventional treatment; however natural course of progression of the diseases process remains unbeatable. Pancreatitis
may also lead to pancreatic cancer and a tumor marker called Carbohydrate 19-9 antigen (CA 19-9) is being used routinely to accesses
the progression of the disease. The normal value of CA 19-9 in the serum is<37 U/mL, whereas, levels more than 300 U/mL are
considered definite indicators of pancreatic cancer. Here, we report a case of 52 years old male form Eastern Uttar Pradesh in India
who was initially diagnosed for Acute Necrotizing pancreatitis and was treated conservatively by subject experts. Later he suffered with
seven more episodes within three years of initial diagnosis and was dealt in emergencies. His clinical condition continued to deteriorate
and he lost 15 kg body weight during the course of disease. At this juncture, he opted to a north India based specialty Ayurvedic
treatment centre and was treated with metal based Ayurvedic formulations, daily diet of 2000 to 2200 calories and complete mental and
physical rest. He responded well to Ayurvedic treatment protocol (ATP) and showed overall improvement. There was also remarkable
improvement in his rising CA 19-9 levels, that turned to normal in the first hundred eight days of ATP, which needs to be explored
further for its path making therapeutic values.
Keywords: Pancreatitis, Carbohydrate 19-9 Antigen, Ayurveda, Pancreatic Cancer
1. Introduction
The pancreas is an organ that produces substances which
impact digestion and blood sugar. When pancreas becomes
inflamed or swollen, it causes a serious health problem1. The
pancreas produces and secretes digestive enzymes and
bicarbonate. These enzymes include amylase, lipase and
proteases that break down carbohydrates, fats, and proteins
in the small intestine. Bicarbonates, on the other hand,
neutralize the acidic substances of the stomach as they enter
the small intestine. Pancreatic duct transports these digestive
enzymes and bicarbonate from the pancreas to the small
intestine. Blockage of the pancreatic duct causes enzymes
and bicarbonate reverse into the pancreas, leading to
inflammation and causing pancreatitis2.
Pancreatitis is an inflammation of the pancreas that leads to
implacable abdominal pain radiating to back, along with
nausea and vomiting. The TIGAR-O (Toxic-Metabolic,
Idiopathic, Genetic, Autoimmune, Recurrent and Severe
Acute Pancreatitis, Obstructive) pancreatitis etiology is a
classification system of factors that contribute to
malnutrition, exocrine and endocrine insufficiency,
formation of pseudocyst, obstruction of bile duct and
pancreatic cancer3.
Carbohydrate 19-9 antigen (CA19-9), discovered in 1982, is
regularly expressed in the pancreatic-biliary cells4. In
healthy individuals, it is found in low concentration in the
serum (<37 U/mL), whereas, levels more than 300 U/mL are
considered definite indicators of pancreatic cancer5. CA19-9
has been analyzed in many cancer entities i.e., colorectal
cancer, gastric cancer, ovarian cancer, and bile duct cancer,
but in pancreatic cancer patients it shows highest sensitivity
and specificity6. Worldwide pancreatic cancer represents the
seventh leading cause of mortality in spite of being only the
twelfth most common malignancy7.
Ayurveda comprises of drugs derived not only from herbs
but also from minerals and metals. A specialized branch of
Ayurveda – “Rasashaastra” means the “Science of Mercury”.
Combination of mercury with any drug was supposed to
reduce its dose and increase its efficacy8. The use of mercury
in therapeutics has transformed the management of diseases
and the medicines are referred to as bio-enhancers rather
than drugs. Here, we present the case report of an Uttar
Pradesh based man who was first diagnosed for Necrotizing
Pancreatitis in September, 2019. He opted for Ayurvedic
Treatment Protocol (ATP) in 2022 and presented with
elevated Serum CA19-9 level.
2. Case Report
A 52-year-old man from UP had an episode of severe
abdominal pain with vomiting and fever in September, 2019
and consulted the Gastroenterologist at King Georges
Medical University, Lucknow. He was admitted for six days
and treated with intravenous fluids, painkillers, antacids, and
antibiotics. His ultrasonography of the abdomen revealed
diffuse bulky and heterogeneous pancreas with into
pancreatic and peripancreatic collection, mild hepato-
splenomegaly, and mild ascites with raised values of serum
amylase (292U/L), CRP (304), TLC (13200) and low
sodium (129) in blood examination.
In October 2019, the patient again experienced severe
abdominal pain and fever and was admitted to the same
hospital for nine days and treated with intravenous fluid,
Paper ID: SR23703130835
DOI: 10.21275/SR23703130835
235

International Journal of Science and Research (IJSR)
ISSN: 2319-7064
SJIF (2022): 7.942
Volume 12 Issue 7, July 2023
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Licensed Under Creative Commons Attribution CC BY
painkillers, antacids, and antibiotics. His CECT whole
abdomen revealed Necrotizing pancreatitis with raised
values of serum amylase (549.3U/L), serum lipase
(152.5U/L), CRP (110.5), total serum bilirubin (2.38) in
blood examination.
The patient experienced seven more similar episodes of pain
and was admitted for about a week each time (Table 1). The
diagnosis consistently indicated Acute Necrotizing
Pancreatitis. In January 2020, his CECT whole abdomen
revealed Pancreatitis with Pseud pancreatic cyst with
extension and internal foci and communication with main
pancreatic duct. During one such attack in October 2022, the
patient was diagnosed with Acute on Chronic Pancreatitis
with walled off necrotic collection and portal hypertension.
The patient lost 15kg of body weight during this periodand
his condition was being deteriorated day by day. At this
juncture, he came to know about Uttarakhand based
specialty Ayurvedic treatment center and started treatment
there. He was admitted in December 2022 for three weeks
residential Ayurvedic treatment protocol (ATP), comprising
of herbo mineral Ayurvedic formulations, customized diet,
and lifestyle following Ayurvedic concepts of Aahar, Vihar
and Aushadh. The patient presented with raised CA19-9
levels and symptoms of abdomen pain, weakness, and
vomiting. He was put on herbo-mineral Ayurvedic
formulations including Amar9, Abhrak Bhasam10, Kamdudha
Ras11, Navabal Rasayan12, Rasonvati13 and Ajeernari vati14
(Table 2).
He was given a 1600-2000 calorie diet including dairy
products, divided into three meals and three snacks in a day
(Table 3).
The patient was advised complete mental and physical rest
with eight hours of sleep at night. He was asked to stop
consuming tea, coffee, aerated drinks, alcohol, refined flour,
onion, garlic, tomato, and packaged or reheated food items.
Table 1: Details of hospitalizations due to Pancreatitis
Number Date Symptoms Hospital Investigations on admissions Treatment
1st September 2019 Severe abdominal
pain, vomiting,
fever
King Georges Medical
University, Lucknow
Serum Amylase – 292, Serum lipase –
95.9, CRP – 304.2, TLC – 13,200
USG whole abdomen - diffuse bulky and
heterogeneous pancreas with into
pancreatic and peripancreatic collection
IV fluids, painkillers,
and antacids
2nd October 2019 Severe abdominal
pain, fever King Georges Medical
University, Lucknow
Serum Amylase – 549.3, Serum lipase –
152.5, Serum bilirubin – 2.38, CRP –
110.5. CECT – Necrotizing pancreatitis
IV fluids, painkillers
and antacids, enzymes
3rd December 2019 Severe abdominal
pain, fever,
weakness
King Georges Medical
University, Lucknow USG whole abdomen – Acute
Necrotizing Pancreatitis IV fluids, painkillers
and antacids, enzymes
4th January 2020 Abdominal pain,
vomiting King Georges Medical
University, Lucknow CECT – Pancreatitis with Pseudo
pancreatic cyst IV fluids, painkillers
5th February 2020 Abdominal pain,
vomiting King Georges Medical
University, Lucknow --- IV fluids, painkillers
6th March 2020 Abdominal pain,
vomiting King Georges Medical
University, Lucknow Ultrasound – Necrotizing Pancreatitis IV fluids, painkillers
7th August 2022 Abdominal pain Local clinic at
Shahjahanpur --- IV fluids, painkillers
8th October 2022 Abdominal pain,
vomiting King Georges Medical
University, Lucknow Serum amylase – 273, Serum lipase –
116, Plasma glucose – 189 IV fluids, painkillers
9th November 2022 Abdominal pain,
vomiting King Georges Medical
University, Lucknow
CECT – Acute on Chronic Pancreatitis
with walled off necrotic collection
Endoscopy – Portal hypertension and
sequel of Pancreatitis
IV fluids, painkillers
Table 2: Details of medicines given
Name of medicine Medium Dose schedule Duration
Abhrakbhasam62.5mg +
Kamdudharas 250mg With honey Thrice a day at 7am, 3pm and 6pm
8th December, 2022 Amar capsule 45mg With malai+chana Thrice a day just before breakfast,
lunch, and dinner
Ajeernarivati With normal
water 2 tablets thrice a day after meal
Abhrakbhasam 62.5mg +
Kamdudharas 250mg With saliva Twice a day at 7am and 5pm 9th December, 2022 to 18th
December, 2022
Navabalrasayan250mg With honey Thrice a day
Kamdudharas 250mg With saliva Four times a day at 6:30am, 12:30pm,
3:30pm and 6:30pm 19th December, 2022 to 27th
December, 2022
Amar capsule – 45mg with malai and
chana With malaichana Thrice a day just before breakfast,
lunch, and dinner
Rasonvati - 2 tablets thrice a day after
meal With hot water Two tablets after breakfast, lunch, and
dinner
Abhrakbhasam 62.5mg +
Kamdudharas 250mg – twice a day With saliva Twice a day at 7am and 5pm 28th December, 2022 to 29th
December, 2022
Paper ID: SR23703130835
DOI: 10.21275/SR23703130835
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ISSN: 2319-7064
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Amar capsule – 62.5mg thrice a day
with malai and chana With malaichana Thrice a day just before breakfast,
lunch, and dinner
Rasonvati - 2 tablets thrice a day after
meal. With normal
water Two tablets after breakfast, lunch, and
dinner
Abhrakbhasam 62.5mg +
Kamdudharas 250mg – twice a day With saliva Twice a day at 7am and 5pm
30th December, 2022 to 6th
April, 2023
Amar capsule – 35mg thrice a day
with malai and chana With malaichana Thrice a day just before breakfast,
lunch, and dinner
Rasonvati - 2 tablets thrice a day after
meal. With normal
water Two tablets after breakfast, lunch, and
dinner
Table 3: Details of prescribed diet
Snacks/Meals Items
8am (Breakfast) 30gm Jaudaliya/ poha/upma + chenna + 1bowl seasonal fruits + chutney/ Soojikhee + kishmish +
banana + chenna
11am (Mid-morning snacks) Roasted puffed rice/ Makhana + herbal tea / 200ml buttermilk / 1 bowl seasonal fruits/ sugarcane
juice
1pm (Lunch) Moong dal khichdi/ Jhangora millet + Dal (moong/masoor/arhar) + curd + seasonal green vegetable +
roasted papad + chutney + lemon pickle
4pm (Evening snacks) Roasted puffed rice/ Makhana + herbal tea / 200ml buttermilk / 1 bowl seasonal fruits/ sugarcane
juice
7pm (Dinner) Jhangora millet Khichdi/ Chapati (chokar:jau:chana) + seasonal green vegetable + curd + roasted
papad + chutney + lemon pickle/ moong dal soup + lemon
9pm (post-dinner snacks) 1 small serving custard/ Jhangorakheer/ fruit cream
3. Result
Gradually the patient became asymptomatic during the
initial indoor treatment and his overall general health also
started improving. Patient was discharged from the center on
30th January, 2023 with one month treatment to continue at
home with daily monitoring over phone and through mails.
Effect of treatment was assessed based on physical
symptoms, laboratory parameters, and improved quality of
life. There was marked improvement in his CA19-9 levels
within three months of commencement of ATP (Figure 1).
Figure 1: Lowering effect onCA19-9levelsin CP Patient through ATP
x-axis represents the dates on which blood tests were conducted and Y-axis represents the CA19-9 levels in U/mL.
4. Discussion
Pancreatitis is a condition characterized by inflammation of
the pancreas, resulting in debilitating abdominal pain,
nausea, and vomiting. Pancreatitis is broadly classified as
acute and chronic pancreatitis. The etiology of chronic
pancreatitis can be multifactorial, including toxic-metabolic,
idiopathic, genetic, autoimmune, recurrent, severe acute
pancreatitis, and obstructive factors (TIGAR-O
classification). As per reports, up to about 40% patients of
Chronic Pancreatitis are known to develop pancreatic cancer
in the long run. Pancreatic cancer is a highly lethal
malignancy and ranks as the seventh leading cause of
cancer-related deaths worldwide. Therefore, screening is
crucial for timely diagnosis and treatment.
Carbohydrate 19-9 antigen (CA19-9) is a biomarker
expressed in pancreatic-biliary cells and is commonly used
as a diagnostic marker for pancreatic cancer. The
Carbohydrate Antigen 19-9 is present in the normal
epithelial cells of the gall bladder, biliary cells, stomach and
pancreas. Its elevated values are not pathognomonic of
cancer of the pancreas but might be indicative of other
malignancies as well as in benign conditions. Serum CA19-9
levels was elevated in patients with AP, especially in patients
with biliary pancreatitis. AP patients with significantly
increased CA19-9 levels may have a higher risk for the
presence of pancreatic cancer15. In healthy individuals,
CA19-9 levels are typically lower than 32 U/mL, while
significantly elevated levels (>300 U/mL) are considered
indicative of pancreatic cancer. The elevated CA19-9 values
also effects survival rate of patients starting from one year
survival rate in 38% patient with baseline CA19-9 >
Paper ID: SR23703130835
DOI: 10.21275/SR23703130835
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ISSN: 2319-7064
SJIF (2022): 7.942
Volume 12 Issue 7, July 2023
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1000ng/mL, the median OS was 6.1 months and theone year
survival rate was 15%16.Hence, routinely monitoring of
CA19-9 levels during hospitalization for AP patients are
mandatory and significant increased CA19-9 levels in acute
pancreatitis patients predicts the presence of pancreatic
cancer.
In the present case report, the patient was initially diagnosed
with acute necrotizing pancreatitis and subsequently
developed acute on chronic pancreatitis with walled-off
necrotic collection and portal hypertension. He had elevated
CA19-9 levels on admission (6762 U/mL). Subsequent
laboratory investigations showed that the CA19-9 levels
gradually reduced and reached normal level at 108th days of
starting of Ayurvedic treatment. Patient also experienced a
gradual improvement in other symptoms and gained overall
general health.
Ayurveda, an ancient Indian system of medicine,
encompasses various treatments derived from herbs,
minerals, and metals. The specialized branch of Ayurveda
known as “Rasashastra” focuses on the use of mercury-
based preparations to enhance the efficacy of medications. In
this case report, the patient sought Ayurvedic Treatment
Protocol (ATP) at a specialized Ayurvedic treatment center
in Uttarakhand.During the ATP, the patient received a
combination of herbo-mineral Ayurvedic formulations, a
customized diet, and lifestyle modifications based on
Ayurvedic principles. The herbo-mineral formulations
included Amar, AbhrakBhasam, KamdudhaRas,
NavabalRasayan, Rasonvati, and Ajeernarivati. The patient
also adhered to a specific dietary regimen and lifestyle
recommendations, including avoiding certain foods and
practicing mental and physical rest.
The observed decrease in CA19-9 levels in this case
suggests a potential beneficial effect of Ayurvedic treatment
on pancreatic health. Although CA19-9 is commonly
associated with pancreatic cancer, its levels can also be
influenced by various factors, including inflammation and
tissue damage. It is possible that the Ayurvedic treatment
contributed to the reduction in inflammation and improved
pancreatic function, leading to a decrease in CA19-9 levels.
It is imperative to mention that CA19-9 lowering effect seen
in this case report is in continuation to the earlier
studyadding to the therapeutic values of metal based
Ayurvedic formulations17. Similarly, MBAF have also
demonstrated pancreatitis protective properties in
experimental studies18. This case report might be an add on
to anecdotal evidencesrelated to the role of Ayurvedic
interventions in the management of Pancreatitis. However,
further researches are necessary to understand the intrigue
phenomena of MBF by conducting appropriate in vivo and
in vitro experimental studies along with randomized clinical
trials. Though MBFT have No Observed Adverse Effect
Level (NOAEL)in acute, sub acute and chronic toxicological
studies (data on file), more pragmatic studies need to be
design to ascertain multi level safety.
In conclusion, this case report highlights the potential of
Ayurvedic Treatment Protocol in improving symptoms and
reducing CA19-9 levels in a patient with chronic
pancreatitis. CA19-9 values are significant in monitoring the
disease process if the value is same disease will be stable,
decreasing CA19-9 value may mean treatment is working
and subsequent rise in CA19-9 may suggest that the disease
is growing up. There are reports that CA19-9 value decrease
after receiving radiation, chemotherapy and surgery among
cancer patients but there is no reference about spontaneous
induced CA19-9 levels among patients of pancreatitis.
In the above background, normalizations of CA19-9 from
6762U/mL to 29U/mLwithin 108 days of Ayurvedic
treatment protocol are highly significant. It is interesting to
note that the initial days of ATP, CA19-9 rose to 8876and
then started showing sharp fall in the values after completing
first ten days of ATP and leading to complete normalcy in
108 days of ATP.
MBAF did not possess cytotoxic properties and the gradual
fall indicates that MBF might have immunemodulator effect.
In-vitro and in-vivo studies could be carried to access its
impact on cell regulation and anti-inflammatory properties
in pancreatic disorders.
5. Conclusion
The study shows that Ayurvedic treatment protocol which is
effective in managing Pancreatitis might also have a crucial
role to play in the prevention of pancreatic cancer.
6. Future Scope
The ATP, comprising of MBAF, customized diet and life
style might pave the ways for its scientific scrutiny and the
consequent development of this approach might add a novel
therapy in the prevention and treatment of pancreatic
disorders.
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