Rapid recovery from choledocholithiasis in a teenage girl treated with individualised homoeopathic remedy: A case report

INTRODUCTION

Choledocholithiasis is the presence of stone(s) in the common bile duct (CBD). The clinical symptoms include pain in the right hypochondrium, nausea, vomiting, jaundice and clay-coloured stool. Conventional management for choledocholithiasis typically involves surgery (open or laparoscopic), endoscopy, or a combination of both: endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy with bile duct exploration.^[1,2] Gallstones diseases predominantly affect women; the incidence tends to increase with age.^[3,4] Age ≥55 years is a moderate predictor for choledocholithiasis.^[1] Pharmacologic and medicinal options include ursodiol and chenodiol for cholelithiasis; however, they are used less frequently due to limited evidence supporting their effectiveness or perceived low efficacy.^[3,5] However, no medication is available to treat choledocholithiasis (CBD stone).^[1] Surgical intervention has its drawbacks and might be complicated by bleeding, bile duct injury and allergic reaction to anaesthesia. Endoscopic removal of CBD stones can cause post-ERCP pancreatitis, haemorrhage, cholangitis and perforation.^[1,6,7] Homoeopathy is a centuries-old method discovered by Dr. Hahnemann in 1796. Here, we report a case of choledocholithiasis, that was successfully treated within 2 months with an individualised homoeopathic medicine.

CASE REPORT

Case history

A 19-year-old girl attended the outpatient department (OPD) with complaints of pain in the upper right and middle abdomen (right hypochondrium and epigastrium) and vomiting for 3 months. The case presentation is as follows:

• Location: right hypochondrium and epigastric region

• Sensation and nature of complaints: The spell of pain (+) compelled her to bend double to bear it, lasting for 5–15 min. Attacks of vomiting followed after meals (+) (2–3, with vomitus of undigested food in considerable amounts. The patient also complained of weight loss (though she could not quantify it) and weakness.

• Modalities: She felt better after vomiting. Complaints aggravated after eating (+), at night, while walking, and lying down, and improved with hard pressure.

• Concomitant: She became mildly irritable and preferred to be silent during this period.

Before attending our OPD, she consulted a surgeon and was diagnosed with choledocholithiasis from an ultrasonography (USG) report [Figures 1 and 2]. She was advised to undergo surgery, but refused. However, the patient did not present other investigation reports, such as liver function tests, blood/urine for routine examination, or lipid profiles. On advice, they avoided further investigation, most likely due to financial constraints.

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Figure 1:

Whole abdomen ultrasonography report before initiation of homoeopathic treatment.

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Figure 2:

Whole abdomen ultrasonography image before initiation of homoeopathic treatment.

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She had jaundice at 3 years of age. She was married for 1.5 years with a 4-month-old female baby, conceived naturally with no significant obstetrical event.The patient had regular menstruation without any significant abnormalities to note. No other significant past medical, family, or personal history was reported.

Prescriptions and follow-up

After taking the case history, based on the totality [Table 1 and Supplementary Figure 1] for repertorial totality and analysis, Cinchona officinalis was prescribed. The prescription was guided by Boericke’s Homoeopathic Materia Medica and Allen’s Keynotes [Comparison of different drugs provided in Supplementary Table 1].^[8,9] The fifty millesimal (LM or Q) potency was chosen based on Hahnemann’s guidelines and the direction provided in his Organon of Medicine (6^th edition).^[10] Table 2 shows the timeline of prescriptions and follow-ups. The patient began to improve within 2 weeks and fully recovered from the choledocholithiasis in approximately 2 months and 4 days, as confirmed by the USG findings [Figures 3 and 4].

Supplementary Figure 1

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Supplementary Table 1

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Table 1: Totality of symptoms.

1) Loss of vital fluid due to frequent vomiting after every food intake.

2) Desire for sour, vegetables

3) Biliary colic compels her to bend double, < after eating

4) Vomiting after eating

5) Chilly patient

Table 2: Timeline of prescription and follow-up.

Date	Medicine, Dose, Repetition*	Follow-up
05 February 2018	Cinchona officinalis LM 1, 16 doses, TDS×5 days Followed by Cinchona officinalis LM 2, 16 doses, BD×8 days	1st prescription
19 February 2018	Cinchona officinalis LM 3, 16 doses, BD×8 days Followed by Cinchona officinalis LM 4, 16 doses, BD×8 days	The pain reduced in frequency and intensity>sitting, <night. Vomiting only once last week. Improved weakness, and ability to work.
19 March 2018	Cinchona officinalis LM 5, 16 doses, BD×8 days Followed by Cinchona officinalis LM 6, 16 doses, BD×8 days	Pain reduced significantly, no vomiting but nausea present. Appetite is still less. Menstruation was delayed by about 15 days.
09 April 2018	Cinchona officinalis LM 7, 16 doses, AD×32 days Followed by Cinchona officinalis LM 8, 16 doses, AD×32 days	No pain, vomiting or nausea, appetite improving. But a complaint of chronic headache, which was not present for months. USG report of no stone in the common bile duct [Figures 3 and 4]
25 June 2018	Cinchona officinalis LM 8, 16 doses, AD×32 days Followed by Cinchona officinalis LM 9, 16 doses, AD×32 days*	No abdominal or related complaints. Appetite improving. The patient gained 3 kg in weight.

*TDS: Thrice a day, BD: Twice a day, AD: Alternate days, LM: 50 millesimal, USG: Ultrasonography. ‘<’ sign for aggravation, ’>’ sign for amelioration

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Figure 3:

Ultrasonography report (of the whole abdomen) after about 2 months of treatment.

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Figure 4:

Ultrasonography image after about 2 months.

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In the next follow-up, the patient was free from the presenting complaint and reported improved appetite. Then she started medication for her chronic headache. Table 3 provides a summary comparison between the USG findings before and after the treatment.

Table 3: Comparison of before and after treatment USG report of the whole abdomen

Organs/Reporting Categories	Before Treatment	About 2 months after treatment
Liver	‘Central intrahepatic biliary radicles are mildly dilated’	‘Intrahepatic biliary radicles are mildly dilated’
Common bile duct	‘It is dilated. It measures 8.2 mm at porta. There is a calculus (6.4 mm) in the lower part of the common bile duct.’	‘It is not dilated. No obvious calculus is seen in the visualised part of the common bile duct’
Gall Bladder	‘It is distended. Wall thickness is normal. No calculus is seen.’	‘It is adequately distended. Wall thickness is normal. No calculus is seen.’
Retroperitoneum	‘Minimal-free fluid in the pouch of Douglas’	‘Minimal-free fluid in the pouch of Douglas’
Impression	‘Choledocholithiasis with extra-hepatic biliary obstruction. Distended gall bladder. Minimal-free fluid in the pouch of Douglas.’	‘Minimal-free fluid in the pouch of Douglas. Otherwise, USG study of the whole abdomen is within normal limits.’

USG: Ultrasonography

The checklist score using the Modified Naranjo Criteria also suggested improvement from individualised medication [Table 4].^[11,12]

Table 4: Modified Naranjo criteria for homoeopathy scoring

S. No.	Domain	Yes*	No*	Do not know or Not Applicable*
1	Was there an improvement in the main symptom or condition for which the homeopathic medicine was prescribed?	+2 ☒	−1 ☐	0 ☐
2	Did the clinical improvement occur within a plausible timeframe relative to the drug intake?	+1 ☒	−2 ☐	0 ☐
3	Was there an initial aggravation of symptoms?	+1 ☐	0 ☒	0 ☐
4	Did the effect encompass more than the main symptom or condition (i.e. were other symptoms ultimately improved or changed)?	+1 ☒	0 ☐	0 ☐
5	Did overall well-being improve?	+1 ☒	0 ☐	0 ☐
6A	Direction of cure: did some symptoms improve in the opposite order of the development of symptoms of the disease?	+1 ☐	0 ☐	0 ☒
6B	Direction of cure: did at least two of the following aspects apply to the order of improvement of symptoms:- from organs of more importance to those of less importance? -from deeper to more superficial aspects of the individual? -from the top downwards?	+1 ☐	0 ☐	0 ☒
7	Did ‘old symptoms’ (defined as non-seasonal and non-cyclical symptoms that were previously thought to have resolved) reappear temporarily during the course of improvement?	+1 ☒	0 ☐	0 ☐
8	Are there alternate causes (other than the medicine) that – with a high probability – could have caused the improvement? (Consider a known course of disease, other forms of treatment, and other clinically relevant interventions)	−3 ☐	+1 ☒	0 ☐
9	Was the health improvement confirmed by any objective evidence? (e.g., laboratory test, clinical observation)	+2 ☒	0 ☐	0 ☐
10	Did repeat dosing, if conducted, create similar clinical improvement?	+1☐	0☐	0☒
	Total Score	(+8)+(+1)+0=9 (Highest possible score is 13)

*checked (‘x’) are the domain-specific scores for this case

DISCUSSION

Here, we report a case of choledocholithiasis which was treated with an individualised homoeopathic medicine. Dr. Carleton, in his book ‘Homoeopathy in Medicine and Surgery’ provided indications of some homoeopathic medicines for cholelithiasis with illustrations.^[13] Dr. Thayer reported similar cases of gallstones cured with China officinalis.^[14] Sahoo et al reported a case of chronic cholelithiasis, treated with Lycopodium in fifty millesimal (LM) potency, and recovered within 3 months from gallstones.^[15] Sitharathan et al. reported a retrospective study of 12 cases of gallstones improved with homoeopathic medication.^[16]

We employed an individualised treatment approach, as mentioned and followed in homoeopathic practice at large, which, although not absent, is lacking in conventional management. The rapid resolution of this case shows that, contrary to the widespread belief of homoeopathy having slow action, one can expect considerable speedy action if it is well guided and supported by an individual’s or ‘vital force’ response. Aside from the homoeopathic treatment approach, another significant point in this case was the patient’s young age.

This case study has several limitations. Whether the patient recovered due to homoeopathic treatment or as a part of a ‘natural course’, an argument can be raised, as she had a 4-month-old child. Gallbladder diseases are known to occur during pregnancy and often resolve after childbirth. It is uncommon for these conditions to persist for 3 to 4 months following delivery. Since ultrasound is a standard procedure in maternal care, necessary interventions are typically performed after 6 weeks postpartum. However, the spontaneously resolved stones are generally asymptomatic or smaller.^[17] The normal CBD diameter is approximately 4 mm (<6 mm).^[18] Again, though CBD stones are expected to be resolved automatically (passing out from the tract), the literature is not very supportive of it and rather recommends elective surgery. Saito et al. provided a concise table on the recommended management of CBD stones.^[19] Neither was this case asymptomatic, nor did the stone size (6.4 mm) or disease duration reported in this case fit the criteria of supporting spontaneous resolution. Moreover, we have not observed any complications or recurrences; the patient has continued treatment for chronic headaches.

In cases of cholelithiasis, the conservative approach is not new, but quite uncommon in modern medicine.^[3] However, there is no known medicine useful in choledocholithiasis in modern medicine.^[1]

Being a case report, this study cannot provide the validity and confidence of practice similar to that provided by randomised controlled trials. Further studies are required to explore the effect of homoeopathy and other medicinal ways to manage gallstones.

CONCLUSION

This case demonstrates that individualised homoeopathic treatment, based on the totality of symptoms, can effectively manage gallstone diseases, such as choledocholithiasis. The quick relief of symptoms, along with ultrasound evidence indicating the absence of stones, underscores the potential benefits of homoeopathy in treating gallstones. However, it is essential to note that this is a single case report, and there is limited research on this topic. Therefore, further clinical trials are necessary to thoroughly assess the effectiveness of homoeopathic medicine in treating gallstone disease. This study also highlights the occurrence of seemingly ‘unexpected’ adult-onset diseases at relatively young ages.