Translate this page into:
Homoeopathic management of chronic replapsing pancreatitis in a paediatric patient: A case report
*Corresponding author: Dr. Bipin Sohanraj Jain, Department of Hom Materia Medica, Dr. M. L. Dhawale Memorial Homoeopathic Institute, Palghar, Maharashtra, India. drjainbipin@gmail.com
-
Received: ,
Accepted: ,
How to cite this article: Jain BS, Nayak AD. Homoeopathic management of chronic replapsing pancreatitis in a paediatric patient: A case report. J Intgr Stand Homoeopathy 2021;4:133-41.
Abstract
Chronic relapsing pancreatitis in the paediatric age group is a challenging case, especially when presenting in its acute exacerbation. This case report highlights the management of chronic relapsing pancreatitis in a 9-year-old female patient with homoeopathic treatment. The patient reported a year-long history of recurrent fever, abdominal pain, and raising titres of lipase and amylase; she had been admitted to a higher centre twice. The totality was constructed on day 1 and a homoeopathic remedy was prescribed. Detailed case taking, done after a week, confirmed the same remedy. Later, when the patient had an acute exacerbation, the same remedy-frequently repeated, helped settle the acute episode in a couple of days. The patient has been following up regularly for 3 years; the frequency and intensity of relapses reduced considerably over time and there have been no episodes for more than a year.
Keywords
Chronic relapsing pancreatitis
Paediatric age group
Acute exacerbation
Chronic
Homoeopathic
INTRODUCTION
Peadiatric cases are often challenging due to multiple factors: Case taking, understanding the susceptibility, judgement in quick action, and managing parental anxieties. With these concerns in the background, a case of pancreatitis poses a significant challenge, as there is the involvement of a vital organ, which might progress to fatal outcomes.
Pancreatitis has several etiological factors: hereditary, metabolic, ductal malformations, idiopathic[1] and alcoholic.[2] However, chronic relapsing pancreatitis in children is frequently hereditary or due to congenital anomalies of the pancreatic or biliary ductal system; it is usually difficult to conclude.[3]
Usually, an attack of pancreatitis is characterized by severe constant epigastric or umbilical pain that may radiate to the back or shoulders. The pain is exacerbated by food and is not relieved by antacids. The patient will find abdominal movement uncomfortable. Fever, rapid pulse, nausea, vomiting may also occur. Pancreatitis episodes can be mild, causing minimal damage to the organ itself or adjacent tissue. In contrast, severe episodes can cause life-threatening complications like haemorrhagic bruising of the flanks with paralytic ileus, circulatory collapse, hyper or hypoglycaemia, pleural effusions, and pancreatic pseudocysts.[1]
CASE REPORT
This is a case report of a 9-year-old girl who presented to the outpatient department (OPD) during a quiescent period of the illness. The following history was collected.
Preliminary data
Ms. SM, Female, 9 years, Studying in 4th std Date of case taking: November 26, 2018.
Chief complaints
The chief complaints [Table 1] are written in the Location-Sensation-Modality-Concomitant format for better understanding.[4]
| Location | Sensation | Modalities | Concomitant |
|---|---|---|---|
| Abdomen< Gastro-intestinal system: Pancreas For 1 year < (Last attack 1 month prior October 6, 2018) O: sudden F: twice a month< D: 2–3 days In 1 year |
Fever Vomiting pain2+Increased amylase/lipase Stool: N Weight loss: 4 kg No abdominal bloating No gas |
<Soya sticks2+ <Rich food2+ |
App: Reduced Thirst: Reduced Dull++ |
Family history
Maternal grandfather: Died of myocardial infarct (MI) at 65 years of age
Paternal grandfather: diabetes, hypertension, died due to MI, 54 years of age
Paternal grandmother: cancer (CA) breast, died at 54 years of age
Paternal aunt: CA kidney, died within 3 years of CA
Mother: Tonsillectomy 30 years prior.
Medical history
Admitted in the hospital twice in view of acute exacerbation of chronic pancreatitis (June 2018 and October 2018). Recurrent throat infection due to cold drinks. Ophthalmia neonatorum for 2–3 days.
General examination
Temp: Afebrile
Weight: 34 kg
Nails: white spot, nail biting
Throat: tonsils enlarged bilaterally
Palms: moist to touch
Tongue: moist, white thin coated posteriorly.
Systemic examination
P/A: Soft, non-tender.
Investigations
First Visit: June 20, 2018: Magnetic resonance imaging (MRI): Pancreas bulky and oedematous. Peripancreatic fluid and fat stranding, predominantly present in the body and tail. Findings are suggestive of acute edematous pancreatitis. Pancreatic duct not dilated. There is no obvious evidence of pancreas division.
June 19, 2018: Serum amylase: 670 U/L; Serum lipase: 624.3 U/mL
Probable diagnosis with understanding
Chronic relapsing pancreatitis with the idiopathic origin.
The above data were collected during the patient’s first visit. After going through the data, the following totality was constructed and the acute remedy was prescribed
The patient was calm throughout the session and was busy playing with the mobile.
Acute totality
Boger’s approach[5] Time, pathogenesis (location and pathology), sensation, physical general, modalities, and mental state [Figure 1].
Recurring complaints
Abdomen – glands – pancreas
Gland: inflammation – edema
Thirstlessness+2
Dullness+2.
- Acute totality.
Acute remedy differentiation
Final remedy: Pulsatilla 30 [Table 2]
| Pulsatilla | Merc sol | Belladonna |
|---|---|---|
| Great sleepiness during the day, wakes confused unrefreshed | Sleepless at night, from nervous excitability, restlessness | Acuteness of all senses. Restless, crying out, starting in sleep |
| Thirstlessness with almost all complaints | Intense thirst for cold water | Great thirst for cold water |
| Catarrhal conditions | Suppurating necrotic conditions. Glandular activity | Congestions |
| Erratic temperature in fevers | Fever after suppuration | High feverish state with absence of toxaemia. No thirst in fever |
| Several hours after eating has not digested food in the stomach Digestion is slow |
Weak digestion with continuous hunger | Cutting pain in epigastrium. Loss of appetite[6,7] |
On noting the patient’s temperament in the clinic, along with the involvement of glands and the concomitant generals, it was thought that Pulsatilla could even be her constitutional remedy. Therefore, one dose in 30C potency was prescribed.
The completed history form was received on November 29, 2018 and the case was defined in full. The following were there important points received from history and interview. The patient’s complaints started with abdominal pain after eating fatty and rich food. She required hospitalisation and was administered intravenous fluid for a week before oral food was permitted. The child was distressed due to food restriction and limited activity. She had lost 4 kg in the past 6 months.
Thermals: hot
All milestones were normal; she was a full-term vacuum-assisted delivery; ophthalmia neonatorum for 2–3 days.
Cravings: Milk++, Butter milk +++, Spicy +++, Cheese+++, Paneer+++, Chocolate++, Watermelon++.
Aversion: Vegetable+++, Rice++.
Sleep: clinging to father, talking of daily routine, Dreams- Barbie++, cartoon++, and fantasy++.
Life space
The patient is born and brought up in K. The family comprises four members: patient, father, mother, and sister. All family members have good interpersonal relationships; however, the patient is extremely attached to her father and vice versa. She shares all her thoughts and occurrences with him; sleeps next to him and misses him terribly when he is away.
She is very conscious about how she looks. She is very intelligent, studious, sociable, and enjoys new things. She is artistic, affectionate, and somewhat fearful, but calms down quickly. She is very sensitive to criticism and often retorts; however, if reprimanded, often listens calmly. Apologises easily, except for when she feels she is not at fault. She weeps readily for trifling matters.
She likes to watch when someone cooks her favourite dishes. She likes gardening and watching movies or cartoons. She uses her mobile phone a lot. She is beloved by everyone in the family. She fears her school teacher but is attached to her tuition teacher. Has excellent relationships with friends.
Due to her condition, she cannot eat her favourite food like cake, chocolate, sweets, and ice cream. While she feels sad about this, she settles when explained the situation by her parents. Father’s impression: loving, caring, mature and understanding.
Stage of pathology: structural reversible disease.
Chronic totality:
- Chronic totality.
Caring+2
Clinging+2
Precocious child+2
Sensitive to reprimands+2
Non-arguing+2
Biting nails+2
Craving sweets+2
Craving milk+2
Craving buttermilk+2
Craving spicy+2
Craving cheese+2
Craving chocolate+2
Craving melons+2
Aversion vegetables+2
Tongue white-coated posteriorly
Palms moist.
Chronic remedy differentiation
Chronic remedy differentiation is done in tabular format for better understanding. Refer [Table 3]
| Pulsatilla | Nat mur | Lycopodium |
|---|---|---|
|
|
Planning and programming
After going through the history form submitted by the patient and the data from the case definition, a chronic totality was constructed. The posology was determined after evaluating the susceptibility, sensitivity and mind and body, and reversibility of the pathology. On initial prescription, the potency selected was 30 [Table 4], as the complete history was not there. Later, the potency was increased to 200 according to patient susceptibility assessed through planning and programming.
| State | Potency | Repetition |
|---|---|---|
| Susceptibility (tissue level) onset: sudden, progressive Pathology: structural reversible Symptoms: characteristic concomitants during acute attack |
200 | Infrequent |
| Sensitivity (mind and nerves): mind+3 | 200 | Infrequent |
| Structural changes: reversible | 200 | Frequent |
| General vitality: good | 200 | Frequent |
Final remedy: Pulsatilla 200 1P weekly
Reports
The reports are given in image and tabular form for better understanding.
For investigations Refer [Table 5].
| Date | Investigation |
|---|---|
| February 23, 2019 | Sr. amylase: 44.16 IU/L Sr. lipase: 54.8 IU/mL [Figure 5] |
| April 05, 2019 | Sr. amylase: 331.84 IU/L, Sr. lipase: 872.5 [Figure 6] |
| April 11, 2019 | Sr. amylase: 331.84 IU/L, Sr. lipase: 872.5 IU/mL Sr. amylase: 62.35 IU/L [Figure 7] Sr. lipase: 84.8 IU/mL USG Abdomen: Pancreas normal in calibre with heterogenous echotexture, prominent pancreatic duct rest all normal [Figure 8] |
| June 20, 2018 | MRI: Pancreas bulky and oedematous. Peripancreatic fluid and fat stranding, predominantly present in body and tail. Findings are suggestive of acute oedematous pancreatitis. Pancreatic duct not dilated. There is not obvious evidence of pancreas division |
| June 19, 2018 | Serum Amylase: 670 IU/L Serum Lipase: 624.3 IU/mL |
| July 16, 2018 | USG abdomen: total regression [Figure 3] |
| October 06, 2018 | Sr amylase: 574.62 IU/L Sr. lipase: 765.8 IU/mL [Figure 4] |
| April 15, 2019 | C-reactive protein: 1.170 mg/L Parathyroid hormone: 12.7 pg/dL Creatinine: 0.39 mg/dL [Figures 9-11] |
| April 16, 2019 | Magnetic resonance cholangiopancreatography reveals mild irregularity involving main pancreatic duct in body-tail region with mild parenchymal atrophy [Figure 12] |
For report images, refer [Figure 3] for USG abdomen.
- Ultrasound abdomen date July 16, 2018 1st visit-A.
Refer [Figures 4,5,6,7] for serum Amaylase [Figure 8 for USG abdomen].
- Sr. amylase dated October 06, 2018 1st visit-B.
- Sr. Amylase dated February 23, 2019 5th visit.
- Sr. Amylase dated April 05, 2019 6th visit.
- Sr Amylase dated April 09, 2019 9th visit-A.
- Ultrasound abdomen dated April 11, 2019 9th visit-B.
Refer [Figure 9] for serum creatinine.
- Sr Creatinine dated April 15, 2019 10th visit-A.
Refer [Figure 10] for serum PTH
- Sr parathyroid hormone dated April 15, 2019 10th visit-B.
Refer [Figure 11] for CRP
- C-reactive protein dated April 15, 2019 10th visit-C.
Refer [Figure 12] for MRCP.
- Magnetic resonance cholangiopancreatography dated April 16, 2019 10th visit-D.
FOLLOW UP SUMMARY
For better understanding follow up summary has been given in a tabular format. Refer [Table 6].
| Date | Visit | Symptoms | Investigations | Treatment |
|---|---|---|---|---|
| 26/11/18 | 1st visit | After the data collected during the 1st visit, Pulsatilla was indicated for the current picture. Thus, Pulsatilla was prescribed. | 20/06/18: MRI: Pancreas bulky and oedematous. Peripancreatic fluid and fat stranding, predominantly present in body and tail. Findings are suggestive of acute oedematous pancreatitis. Pancreatic duct not dilated. There is not obvious evidence of pancreas division. 19/06/18: Serum Amylase: 670 IU/L Serum Lipase: 624.3 IU/mL 16/07/18:USG abdomen: total regression (Fig. 3) 06/10/18: Sr amylase: 574.62 IU/L Sr. lipase: 765.8 IU/mL (Fig. 4) |
Pulsatilla 30C 1 dose |
| 29/11/18 | 2nd visit | Patient submitted history form and chronic case taking was done. After going through this data, Pulsatilla was indicated as the constitutional remedy. | Placebo | |
| 8/12/2018 | 3rd visit | Halitosis ++ in morning After evaluating the susceptibility and sensitivity of the patient at the level of mind and body and the reversibility of the pathology, the posology was changed accordingly. |
Pulsatilla 200C 1 dose | |
| 05/01/2019 | 4th visit | Patient had no complaints in between, today acute cold and coryza yellow in colour, with throat pain. On examination tongue moist and throat congested on the left side |
Merc Sol 30C qds for 2 days followed by weekly Pulsatilla 200C 1 dose | |
| 05/01/2019 to 03/04/2019 | 5th visit | Patient had no complaints. Repeat lipase and amylase per the paediatrician’s advice on 23/02/2019 were normal. Patient had put on 2 kg weight and was tolerating all types of food | Sr. amylase: 44.16 IU/L Sr. lipase: 54.8 IU/mL (Fig. 5) |
Pulsatilla 200C weekly was going on |
| 05/04/19 | 6th visit | Fever since 2 days, vomiting, pain in epigastrium and umbilicus, activity reduced, thirst reduced, appetite reduced crying in pain. acute attack of pancreatitis with same totality |
Sr. amylase: 331.84 IU/L, sr. lipase: 872.5 (Fig. 6) | Pulsatilla 200C 2 hourly × 3 days |
| 06/04/19 | 7th visit | Pain in abdomen since 2 days. No vomiting. O/E: epigastric tenderness. With greenish productive cough. |
Pulsatilla 200C 2 hourly × 2 days | |
| 08/04/19 | 8th visit | Had solid food. No pain, no any complaints | Pulsatilla 200C 4 hourly × 2 days | |
| 11/04/19 | 9th visit | Tolerating solid food well. | Sr. amylase: 331.84 IU/L, Sr. lipase: 872.5 IU/mL Sr. amylase: 62.35 IU/L (Fig. 7) Sr. lipase: 84.8 IU/mL USG Abdomen: Pancreas normal in calibre with heterogenous echotexture, prominent pancreatic duct rest all normal (refer fig; 8) |
Pulsatilla 200C TDS × 1 week |
| 20/04/19 | 10th visit | Patient better, oral intake good | 15/04/19: C-reactive protein: 1.170 mg/L Parathyroid hormone: 12.7 pg/dL Creatinine: 0.39 mg/dL (Fig. 9,10,11) 16/04/19: Magnetic resonance cholangiopancreatography reveals mild irregularity involving main pancreatic duct in body-tail region with mild parenchymal atrophy (Fig. 12) |
Pulsatilla 200C 1P HS × 7 days |
| 04/05/19 | 11th visit | Abdominal pain since 2 days, 1 episode of vomiting. Started Pulsatilla 2 hourly → pain reduced, hunger present | ||
| 07/05/19 | 12th visit | No pain, tolerating solids well | Pulsatilla 200C 1P HS × 7 days | |
| 15/06/19 | 13th visit | Pt better | Pulsatilla 200C 1P HS × 7 days | |
| 29/06/19 | 14th visit | Abdominal pain and vomiting since morning. Had outside food | Pulsatilla 200C 2 hourly × 2 days | |
| 01/07/19 | 15th visit | No pain, no vomiting, tolerating semi solid food well | Pulsatilla 200C 1P HS | |
| 03/08/19 | 16th visit | Fever, throat pain, thirst and appetite reduced | Pulsatilla 200 1P HS × 4 days | |
| 10/08/19 | 17th visit | Fever with productive cough sticky. > warmth | Kali Bi 30C QDS × 4 days → Pulsatilla 200C 1P HS 3P | |
| Pt better during this period | Placebo | |||
| 07/10/19 | 18th visit | 2 episodes of vomiting, abdominal pain | Pulsatilla 200C 2 hourly | |
| 13/10/19 | 19th visit | Pain better, coryza yellowish greenish | Placebo | |
| Pt better during this period | Placebo | |||
| 07/12/19 | 20th visit | Coryza yellowish greenish | Pulsatilla 200C 1 P HS 3P | |
| 04/01/20 | 21st visit | Epigastric pain today, one episode of vomiting | Pulsatilla 200C 3P | |
| 07/01/2020 | 22nd visit | Loose stool since 4 days, no epigastric pain, watery offensive stool | Ars iod 30C TDS × 4 days | |
| 25/11/20 | 23rd visit | Pt had mild 2-3 episodes of coryza. Otherwise better | Was kept on Pulsatilla 200C 3P weekly | |
| 05/05/2021 | 24th visit | Patient normal no episode of pancreatitis since last one and half year frequent cold episode so in between Pulsatilla 1M infrequently given now on SL |
CONCLUSION
Homoeopathy shows good scope in treating acute exacerbations of chronic relapsing pancreatitis as well as chronic state in paediatric patients
Homoeopathy also shows good scope in treating frequency and intensity of chronic relapsing pancreatitis in paediatric patients
Clinico-pathological understanding of stage of disease is helpful in successful prescription through sound understanding of susceptibility
Assessment of susceptibility is helpful in understanding posology and regulation of doses over time in pediatric patients
Homoeopathic medicine is helpful in the treatment of chronic relapsing pancreatitis in paediatric patients without complications
Chronic medicine if given as per the demand of the susceptibility and totality during acute exacerbation resolves the acute faster without much suffering and complication.
Declaration of patient consent
Patient’s consent not required as patients identity is not disclosed or compromised.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
- Inpatient department management an alcoholic man with acute exacerbation of pancreatitis. J Intgr Stand Homoeopathy. 2020;3:51-6.
- [CrossRef] [Google Scholar]
- Nelson Textbook of Pediatrics. Vol 2. (18th ed). Amsterdam: Saunders Elsevier; 2008. p. :2227.
- [Google Scholar]
- ICR Symposium Volume on Hahnemanian Totality, D2 Repertorial Concept and Technique the Bridge that Gulfs the Gap between the Natural and the Drug Disease (3rd ed). Mumbai: ML Dhawale Memorial Trust; 2003.
- [Google Scholar]
- Materia Medica of Homoeopathic Medicines New Delhi: Mayur Jain, Indian books and Periodicals Publishers; 2011.
- [Google Scholar]
- New Manual of Homoeopathic Materia Medica and Repertory with Relationship of Remedies (9th ed). New Delhi: Mayur Jain, Indian Books and Periodicals Publishers; 2011.
- [Google Scholar]
- Perceiving Scientific Method: Repertorisation, Standardization (2nd ed). Mumbai: ML Dhawale Memorial Trust; 2003.
- [Google Scholar]
