1. A Case Study Of Chronic Hepatitis B & C
Presented by:
Hk.M.Ahmad Saleemi

2. Hepatitis: Viral 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.

3. 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.

4. Hepatitis-C
million people are chronic carrier of Hep-C i.e.3 % of world population.
- 2-4Million Persons in USA may be Chronically affected.
Million in Europe.
- 12 Million in India
Million in Pakistan
* Source:

5. Modes Of Transmission

6. Difference between Hepatitis Types
HAV
HBV
HCV
HDV
HEV
Size of Virus
40 nm
42 nm
30 nm
Type of Nucleus
RNA
DNA
Vaccine Available
Yes No
Mean Incubation Time
25 Days
75 Days
50 Days
35 Days
Unknown
Chronic Infection
Mode of Transmission
Fecal or oral
Sexual Trans
Blood Trans
Fecal

7. Signs & Symptoms Malaise(بے چینی ۔ بے قَراری )
Anorexia (Poor appetite)(بھوک کی کمی)
Nausea(متلی۔ ابکائیاں )
Abdominal pain(شکم درد )
Tenderness(نرمی)
Muscle & Joint Pain( پٹھاوجوڑ درد)

13. Diagnostic Tests A. Biochemical Indicators ALT 0 – 20 times. AST
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.
ALT
0 – 20 times.
AST

14. 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

15. 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!”

16. Herbal Treatment 1. Glycyrrhiza (Mulathi) Main Ingredients
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)

17. 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.

18. 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.

19. OUTSTANDING EFFICACY IN LIVER DISORDERS
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.

20. IMPROVES LIVER FUNCTIONS
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.

21. 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.

22. 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.,[

23. 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.

24. 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

25. Condition Investigational drugs. Chronic Hepatitis B & C
A combination of herbal ingredients mainly Glycrrhiza, Silybum marianum.
Tests
Frequency Hb
3 Week Interval
ALT “
AST
Platelets
ESR
At start and end of therapy
Urea
Biliribin
Anti HCV.
PCR Quantitative
Investigational
Tests & frequency.
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.

26. Clinical Trials of Herbal medicine on Hepatitis C Patients

27. 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  30 (N < 40 L/ml)
Mean ALT 115  42 (N < 41 L/ml)

28. 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 (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.

29. Herbal medicine on Hepatitis B Patients
Clinical Trials of
Herbal medicine on Hepatitis B Patients

30. 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 (N < 40µl/ml)
MEAN ALT (N < 42 µl/ml)

31. 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
After
(Mean period 60 days)
No major side effect was reported.

32. Herbal Treatment Feedback of Hepatitis B Patients
No. of patients registered for Treatment:
patients
Regular Patients:
- 92 patients
Defaulters:
- 8 patients

33. Hep-B virus DNA detected / not detected
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 4
Ghulam Mustafa
Muhammad Ismail 35
DK # 16722 5
Ghulam Hyder 21
DK # 16723 6
Khadim Hussain
Ahmed Bux 29
DK # 16724 7
Noor Ahmed 30
DK # 16725 8
Rafiqe Ahmed
Abdul Karim 17
DK # 16726 9
Shafiqe Ahmed 14
DK # 16727 10
Sajid Hussain
Noor Hassan 18
DK # 16728

34. Hep-B virus DNA detected / 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 13
Abdul Wahab
Yaar Muhammad 22
DK # 16757 14
Muhammad Ishaqe
Abdul Rahim 20
DK # 16758 15
Nisar Ahmed
Haji Ghulam Yaseen
DK # 16759
Detected 16
Zubair Ahmed
Shehzado 10
DK # 16760 17
Mai Zohra
Shaukat Ali 25
DK # 16761 18
Shahzad Ali
Khuda Bux
DK # 16762 19
Ali Gohar
Abdul Rasheed
DK # 16763
Muhammad Hanif
Abdul Wahid
DK #

35. Hep-B virus DNA detected / 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 21
Ali Raza
Muhammad Sadiq 16
DK # 16781
Detected 22
Wajid Ali
Maula Bux 17
DK # 16782 23
Sajid Hussain
karim Bux 12
DK # 16783 24
Mai Rukhsana
Qurban Ali
DK # 16784
Not detected 25
Muhammad Zeesahn
Ghulam Akbar
DK # 16785 26
Amjad Ali
Muhammad Aslam 31
DK # 16786 27
Muhammad Ameen
Rehmat Ali 42
DK # 16787 28
Abdul Latif
Sher Muhammad 20
DK # 16788 29
Daulat Ali
Dahar Ali
DK # 16789 30
Asad Ali
Anwar Ali 10
DK # 16790

36. Hep-B virus DNA detected / 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 31
Abdul Hameed
Muhmmad Younis 38
DK # 16831
Not detected 32
Akhtiar Ahmed
Bilal Shar 22
DK # 16832 33
Atta Ellahi
Ameer Bux 15
DK # 16833 34
Kalsoom
Muhammad Yaqoob 30
DK # 16834
Detected 35
Meer Hassan
Abdul Wahid 17
DK # 16835 36
Rizawan
Sher Muhammad 18
DK # 16836 37
Saeed Ahmed
DK # 16837
Zahid Ali
Luqman 20
DK # 16838 39
Bashir Ahmed
Jamal Din
DK # 16839 40
Shehzado
Muhammad Usman
DK # 16840

37. Hep-B virus DNA detected / 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 41
Jahanzaib
Shehbaz Ali 14
DK # 16873
Detected 42
Mai Meerul 30
DK # 16874 43
Sadia 10
DK # 16875
Not detected 44
Aneeta 12
DK # 16876 45
Moomal
Sain Dad
DK # 16877 46
Sanawli
Momin Ali 16
DK # 16878 47
Gul Hassan
Soomer Khan 25
DK # 16879 48
Hussana 20
DK # 16880 49
Lal Bux
Gul Muhammad
DK # 16881 50
Noor Muhammad 23
DK # 16882

38. Hep-B virus DNA detected / 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 51
Amjad Ali
Muhmmad Yaqoob 28
DK # 16910
Not detected 52
Amina
Muhammad Abbass 40
DK # 16911 53
Bilal Asghar
Abdul Wahab 27
DK # 16912
Detected 54
Khalid Mehmood
Mehmood 17
DK # 16913 55
Ishfaqe Ahmed
Abdul Shakoor 15
DK # 16914 56
Zaheer Ahmed
Jailkum Khan
DK # 16915 57
Abdul Razaque
Haji Dhollan 32
DK # 16916 58
Ghulam Mustafa
Jeewan Khan
DK # 16917 59
Asad Ali
Muhmmad Hussain 12
DK # 16918 60
Naeem Ahmed
Sultan Ahmed 16
DK # 16919

39. Hep-B virus DNA detected / 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 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 64
Arshad Ali
Sabzal 20
DK # 16944 65
Khalid Hussain
Mitho Khan
DK # 16945 66
Mai Willaitan
Mohib Khan 15
DK # 16946 67
Allah Wasai
Qamar Din
DK # 16947 68
Farman Ali
Jeeand Khan
DK # 16948 69
Insaf Ali
DK # 16949 70
Bilal Ahmed
Abdul Malik
DK # 16950

40. Hep-B virus DNA detected / 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 81
Shahida
Muhammad Bachal 16
DK # 16980
Not detected 82
Abdul Jabbar
Muhammad Chhuttal 22
DK # 16981 83
Faiz Muhammad
Allah Bux 20
DK # 16982 84
Aqib Ali
Manzoor Ahmed 12
DK # 16983 85
Muhammad Irfan
Muhammad Ramzan
DK # 16984 86
Imam Khatoon
Abdul Ghafoor 50
DK # 16985 87
Mai Hanifan
Mir Muhammad
DK # 16986
Detected 88
Niaz Ali
Gul Hassan 35
DK # 16987 89
Mai Sharifan
Ghulam Mustafa
DK # 16988 90
Akshay Kumar
Roshan Lal
DK # 16989

41. Herbal Treatment Feedback of Hepatitis B Patients
Observations:
Medication
patients out of 100 didn't complete the course of medicine (7 patients left the course and 1 was Cirrhotic patient).
patients out of 92 were healthy and feeling better than before taking the medicine.
patients out of 92 patients had one of these problems like constipation, flatulence, weakness & insomnia.

42. 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.

43. 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

44. Thanks