Abstract
Chronic pancreatitis (CP) is a persistent, long-term pancreatic inflammation that causes irreversible loss of exocrine and endocrine pancreatic function as well as permanent structural damage characterized by ductal strictures and fibrosis with the global prevalence ranges from 13.5 to 163 cases per 100,000 individuals. Pancreatic pseudocysts are fluid collections surrounded by fibrous and granulation tissue, rich in pancreatic enzymes, and are a complication of acute pancreatis or CP, forming a heterogeneous group of cystic pancreatic lesions. Previous literature suggests that increasing use of complementary and alternative medicine (CAM) including yoga and acupuncture therapy for the pain management in patients with CP. However, no studies reported the impact of yoga and naturopathy (YN) in patients with peripancreatic pseudocyst and CP. Hence, the objective of this study was to report the impact of YN on pain and ultrasonographic changes in a 23-year-old female diagnosed with peri-pancreatic pseudocysts and CP. She visited our hospital with complaints of pain in the abdominal area and lower back, gradual weight loss, numbness in both legs, and oily stools for the past 6 months. She underwent 20-days of YN-based lifestyle modification. Compared with the baseline, the post-intervention assessments showed reduction in pain and improvement in the ultrasonographic changes in the pancreas and liver. However, as this is a single case report, more studies are recommended to validate the results of this study.
Introduction
Chronic pancreatitis (CP) is a persistent, long-term pancreatic inflammation that causes irreversible loss of exocrine and endocrine pancreatic function as well as permanent structural damage characterized by ductal strictures and fibrosis. 1 The global prevalence of CP ranges from 13.5 to 163 cases per 100,000 individuals, and the incidence of CP ranges from 5 to 31.7 new cases per 100,000 person-years. 2 Pancreatic pseudocysts (PP) are fluid collections surrounded by fibrous and granulation tissue, rich in pancreatic enzymes, and are a complication of acute pancreatitis or CP, forming a heterogeneous group of cystic pancreatic lesions. 3 The prevalence of PPs is ranging from 10% to 26% in acute pancreatitis and 20%–40% in CP. 4 Yoga and naturopathy (YN) are a drugless medical approach that uses noninvasive intervention techniques to establish a healing environment for the body. It promotes the innate ability of nature to heal. 5 Previous studies reported that complementary and alternative medicine such as yoga improves quality of life, stress, mood changes, and well-being, 6 and acupuncture provides analgesic and immune-modulatory effect7,8 in patients with CP. However, no studies reported the impact of YN-based lifestyle modifications in patients with peripancreatic pseudocyst and CP. Hence, the objective of this study was to report the impact of YN-based lifestyle modifications on pain and ultrasonographic changes in a patient with peripancreatic pseudocyst and CP.
Patient Information
On April 10, 2024, a 23-year-old female with peripancreatic pseudocyst and CP visited our hospital. She had persistent pain in the epigastric region often radiating to the lower back and midback, nausea, vomiting, anorexia, oily stools (loose, pale stools that don’t flush away easily), gradual weight loss, and numbness and heaviness in both legs for the past 6 months. She had a relevant family history of asymptomatic pseudo pancreatic cyst for her paternal aunt. She was not interested in allopathy medications and surgery due to the fear of adverse effects and visited a siddha practitioner and was under siddha medications (the patient did not know the name of the medicine) for the past 3 months before visiting our hospital. Despite regular use of siddha medications, the severity of her symptoms and pain did not reduce; hence, she was looking for a nonpharmacological therapy and visited our YN hospital.
Clinical Findings
The clinical examination revealed pain in the epigastric, umbilical, and left hypochondriac regions and presence of tenderness in the epigastric and left hypochondriac region of the abdomen on palpation. Her investigation reports of ultrasonography (USG) of whole abdomen on April 4, 2024, showed features of CP, peripancreatic pseudocysts adjacent to head, uncinate (6.7 × 3.8 × 3.3 cm/vol—44 mL), and tail (7.9 × 4.6 × 5.7 cm/vol—108 mL) of the pancreas, and subscapular pseudocyst (6.5 × 3.2 × 2 .8 cm/vol—30 mL) in left lobe of liver with no evidence of ascites and pleural effusion. Her blood pressure was 84/69 mmHg, her pulse rate was 133 bpm, her respiratory rate was 12 breaths per minute, and her body mass index was 14.9 kg/m2 (underweight) at the time of admission.
Timeline
An overview of the study, from the patient’s hospital admission to the follow-up, is provided in Table 1.
Timeline
Diagnostic Assessment
Ultrasonography
On April 2024, the patient was diagnosed with CP, peripancreatic pseudocysts adjacent to the head, uncinate process, and tail of pancreas, and subcapsular pseudocysts in left lobe of liver using USG—whole abdomen.
Visual analog scale for pain
It was used to assess the patient’s pain intensity on a scale of 0–10, with 0 denoting no pain and 10 denoting the greatest possible pain. The patient was instructed to place a mark on the scale to represent the degree of her pain. 9
Therapeutic Intervention
The patient underwent 20 days of YN: (a) yoga therapy that incorporates asana, pranayama, and relaxation techniques; (b) naturopathy, which includes hydrotherapy, mud therapy, heliotherapy, chromotherapy, massage, and acupuncture in the morning and evening sessions on a regular basis; (c) diet therapy: a plant-based, raw diet-based lifestyle modifications. The details of the intervention are provided in the Table 2.
A Detail of Yoga and Naturopathy Intervention Given to the Patient
CV, conception vessel; LI, large intestine; SP, spleen; ST, stomach.
Follow-up and Outcomes
The results showed reduction in visual analog scale (VAS) score for pain and an improvement in the ultrasonographic changes including reduction in the size of the peripancreatic pseudocyst adjacent to head, uncinate process, and tail of pancreas and subcapsular pseudocyst in left lobe of liver, reduction in the volume of the PP up to 38.11 mL in head and uncinate process and up to 100.77 mL in tail of the pancreas, reduction in size of few ductal calculi, and reduced main pancreatic duct (MPD) dilatation after 20 days of intervention (Table 3). The patient was followed up through regular outpatient department visit and telecommunication for a period of 1 month and was advised to follow yoga, diet, and other treatments at home. The patient did not report any adverse effects during the intervention and after follow-up period on June 1, 2024.
Baseline and Post-Assessment of the Patient
MPD, main pancreatic duct; USG, ultrasonography; VAS, visual analog scale.
Discussion
Peripancreatic pseudocyst and CP was often accompanied with pain, distress, and functional disability in the patient. This study showed a reduction in VAS score for pain and an improvement in the ultrasonographic findings and pain in the posttest assessments compared with the baseline assessments. It suggests that YN-based lifestyle intervention is beneficial in reducing pain and the size of the PP adjacent to head, uncinate process, and tail of pancreas and subcapsular pseudocyst in left lobe of liver, reduction in the volume of the PP, reduction in size of few ductal calculi, and reduced MPD dilatation in patient with peripancreatic pseudocyst and CP.
Literature showed that inflammation and PP are interrelated. PP is formed due to inflammatory or obstructive processes in the pancreas, resulting in pancreatic duct disruption and enzyme-rich pancreatic juice leakage into the retroperitoneum, which promotes progression of the inflammatory infiltrate, acute fluid accumulation, and formation of an encapsulated fluid accumulation. 10
Previous literature suggests that hydrotherapy techniques utilizing cold applications, such as cold hip baths, activate the transient receptor potential melastatin-like 8 ion channel, which is associated with anti-inflammatory effects primarily by reducing proinflammatory cytokines such as tumor necrosis factor (TNF)-α through the inhibition of nuclear factor kappa B (NF-κB) activity. Conversely, heat applications, such as steam baths, enhance glucose utilization via the expression of HSP-70, which contributes to decreased inflammatory signaling and improved vasoprotection. 11 Yoga may help regulate inflammation by reducing proinflammatory markers such as TNF-α and blood immunoglobulin A levels while increasing CD8+ and CD56 counts, which are involved in immune function. 9
Higher intake of fruits and vegetables leads to a significant reduction in systemic inflammation as indicated by inflammatory biomarkers including high-sensitivity C-reactive protein, TNF-α, interleukin (IL)-6, and E-selectin and improvement in immune cell profile indicated by increased proliferation of lymphocytes and γ δ-T cell population. 12 External applications of mud are shown to relieve inflammatory reactions and modulate immune response by reducing levels of the proinflammatory cytokines such as IL-1β, TNF-α, IL-8, IL-6, and transforming growth factor-β and elevating anti-inflammatory IL-10. 13
The CP, an uncontrolled inflammation of the pancreas, increases the risk of malignancies due to immune cell activation and recruitment, promoting cancer development and impairing immune detection of tumor. 14 Acupuncture is shown to reduce pain and modulate innate and adaptive immune responses that involve descending regulatory pathways, including the cholinergic anti-inflammatory, vagal–adrenal, spinal–sympathetic, and brain–gut pathway. Acupuncture can block the proliferation and differentiation of pro-inflammatory M1 macrophages, increase the anti-inflammatory M2 phenotypes, and regulate the neutrophils. It can also control the adaptive immune system by controlling the development of T cells, maintaining the balance between proinflammatory Tregs and anti-inflammatory T helper 17.7,8
Massage reduces inflammation and improves muscle cell recovery. It also alters NF-κB behavior, reducing its accumulation in the nucleus, which results in less cellular stress and inflammation, as heat shock proteins and immune cytokines are less active, indicating a reduction in cellular stress and inflammation. 15 The findings of this literature are supporting the results of our study (reduction in pain and improvement in USG findings). Furthermore, it implies that the results of the study may have been influenced by the YN-based lifestyle modifications.
Strengths of this study
This is the first-ever study that reported the impact of YN-based lifestyle modifications on USG changes in a patient with peripancreatic pseudocyst and CP. No adverse effects were reported by the subject. It was feasible and safe for the patient, and the patient felt comfortable with the treatments.
Limitations of this study
The intervention was provided for a short duration, objective variables like inflammatory bio-markers were not evaluated, and the validity and reliability of this findings may vary due to a single case study. Hence, further well-planned randomized controlled trials are recommended with a larger sample size to validate the results of this study.
Conclusions
Twenty days of YN-based lifestyle modification may be beneficial in reducing pain, size, and volume of the peripancreatic pseudocysts in a patient with PP and CP. However, the validity and reliability of this study may differ as this is a single case report. Therefore, further studies with a larger sample size are recommended to validate these findings and elucidate the long-term effect of YN-based lifestyle modification in the management of peripancreatic pseudocysts and CP.
Footnotes
Authors’ Contributions
D.Y.: Conceptualization and methodology. V.A.: Writing—original draft. P.K.: Methodology and investigation; N.s.R.: Methodology and investigation. M.A.: Writing—review and editing.
Informed Consent
Written informed consent was obtained from the patient to present this case report.
Author Disclosure Statement
No potential conflict of interest relevant to this article was reported.
Funding Information
No funding was received for this article.