Treatment of Grade 3 Fatty Liver by the Principles of Persian Medicine: A Case Report

Introduction: Nowadays, societies have witnessed a rapid increase of Fatty Liver, which is one of the most common liver diseases worldwide, due to some changes in lifestyle and the increased obesity and metabolic syndrome. Case presentation: in this study, the patient under research was a 41-year-old woman who was diagnosed with grade 3 fatty liver caused by the absence of a healthy diet and lifestyle. She was successfully treated using the methods of Traditional Iranian Medicine. Discussion: Classical medicine is not able to develop a certain treatment for this disease yet. Therefore, this article has mainly concentrated on the therapeutic effects of medicinal herbs on the liver. Conclusion: Delays in the diagnosis and treatment of fatty livermay lead to irreversibility or liver Cirrhosis, which cannot be treated using any method, but by liver transplants. However, the principles of PM (Persian Medicine) can be useful as useful in the prevention and treatment of this disease. Short Research Article Niknafs et al.; JPRI, 32(45): 8-13, 2020; Article no.JPRI.64237 9


INTRODUCTION
Fatty Liver, which is one of the most common liver diseases worldwide, usually emerges due to lipid aggregation (mostly triglyceride) in hepatocytes. Fat exists in the liver naturally, but if it surpasses 5 -10% of the liver's total weight, it can result in fatty liver. This disease should be considered serious due to the destruction of hepatocytes, making it possibly irreversible if proper diagnosis and treatment are delayed. Moreover, it may even result in Liver Cirrhosis, which is incurable, except by liver transplant [1].
This disease is the most common disorder in industrial societies according to its direct connection with lifestyle. Also, it is equally common among men and women. Early diagnosis and proper treatment of this disease can prevent the critical complications caused by that and also make it reversible. In this regard, the most recognized clinical symptom of fatty liveris the lack of symptoms, making it impossible to be detected, except via ultrasonography. Accordingly, the other possible symptoms include tiredness, nausea, vomiting, lack of appetite, pain in the liver area, itching, changes in the urine and stool color, and the increased liver enzymes [2].
Ultrasonography has proven as the first step in the diagnosis of fatty liverbecause of its high accessibility and cost-effectiveness, as well as high sensitivity in detection. Accordingly, liver biopsy has been proven to be the most accurate method of the diagnosis and assessment of liver damage [3].
Classical medicine has not determined a certain verified method of treatment for fatty liveryet. In this regard, the most of the current methods are only capable of reducing the risk of factors [4]. PM can not only offer an improvement of lifestyle but can also present several treatments.

CASE PRESENTATION
The patient was a 41-year-old woman, mother of three children, relatively obese, with a weight of 97 kg, a height of 162 cm, and pain under right side ribs. She referred to a PM clinic on March 30, 2018, reporting a sense of heaviness, hasty tiredness, feeling of warmth throughout her body, general weakness throughout her body, dyspnea followed by stress, and excessive sweating after physical movement mostly in her head and neck area. She suffered no constipation but mentioned bloating, belching, and dyspepsia. She also had PND, (Paroxysmal nocturnal dyspnea) infraorbital edema, occasional headaches, and feelings of dizziness.
The other reported symptoms were as follows: feelings of weakness, warmth, and occasional muscle spasm in limbs, especially on the plantar surface of the feet. Notably, urine color was natural. However, periods were disordered despite having normal density, amount, and color of the menstrual blood. She had no records of special medications or any cardiovascular problems. In addition, she had three successful attempts at giving birth by cesarian section. Also, blood pressure was 120/80 mmHg and other vital signs were normal. She had accidentally noticed grade 1 fatty livervia ultrasonography on July 30, 2018, but ignored it and refused to conform proper lifestyle instructions, while she was disorderly eating, consuming a high amount of junk foods, and habitually drinking ice-cold water.
In her first admission session, a diet consisting of a vegan soup with oat, carrots, parsley, coriander, and condiments such as salt and turmeric, was prescribed for the patient. Daily exercise and drinking herbal tea, which contained thyme, jujube, anise, chamomile, celery seeds, and licorice, were also suggested 3 times per day as well as Rheum Officinale(Chinese rhubarb)capsules twice a day for 40 days.
After 4 months -during which there had been no change in neither her exercising habits nor weight -on her second admission (August 29, 2018), the patient was generally feeling better and experiencing less stomachache, so the medications were repeated. Afterward, 35 days later, during the third admission session,another ultrasonography report was prescribed for the patient, which indicated normal liver parenchyma proportions and the absence offatty liver. Moreover, the diameter of the liver's interior was normal and she was feeling generally well enough to stop the medications (Fig. 2). Two and a half months later (November 22, 2018), during a phone call with the patient, she stated that she was feeling completely good and had no complaints.

DISCUSSION
Symptoms of alcoholic and non-alcoholic fatty liverare very similar, whereas the difference between them is detectable through a detailed assessment of the patient's symptoms [5]. In this regard, it is noteworthy that non-alcoholic fatty liverhas a high insulin resistance and a close connection to obesity and lifestyle. It is also the major reason of liver transplant in worldwide.
More than 50% of patients with fatty liverexperience the increased liver enzymes. Ultrasonography is the first step in the diagnosis of fatty liverdue to its high accessibility, sensitivity and cost-effectiveness. [6] In this study, diagnosis of the patient was performed through ultrasonography and the assessment of clinical symptoms and liver enzymes.
The patient refused to perform the instructions concerning eating and drinking habits. Also, she had a high amount of cold water consumption, which resulted in gastrointestinal symptoms and weakness in the stomach and gastrointestinal tract, followed by weakness and dyspepsia [7]. Aggregation of lipids in the liver can also result in coldness, moisture, enlargement, and weight increase in the liver; tension in the Glisson membrane; and pain under the ribs, which is categorized as swelling in PM. In addition, the other factors capable of causing a dysfunction in the liver and preventing it from producing normal humor include aggregation of lipid, dysfunction of liver cells, their enzymatic and biologic processes, and excessive pressure on vessels and ducts, which is referred as a liver stagnation. Therefore, in this case, aggregation of abnormal humor resulted in chronic fatigue, general weakness, feeling of malaise, and suborbital edema.
PM considers fatty liveras a combination of coldwet distemper, swelling, and stagnation. Accordingly, the clinical symptoms related to these conditions have been mentioned in PM books and references [8].
Classical medicine has not detected a certain verified method to treat Fatty Liver yet. Also, the most of the current treatment methods are only capable of reducing the risk of factors [9]. In this study, the patient under research was treated by the improvement of her diet and lifestyle, along with the consumption of medicinal herbs as described below: The most important therapeutic effects of thyme (Thymus vulgaris) include the following: the opening of stagnation; dilution of humor; and cleansing of lungs, liver, stomach, and intestines [10].
Jujube (Ziziphus jujuba) can not only dilute highconsistency humor and flow diluted humor but can also produce normal humor and reduce thirst and inflammation. Furthermore, it reduces pain in the liver area and its usefulness for the hepatotoxicity effect has been proven [11].
Rhubarb(Rheum officinale) has pharmacological activities such as anti-inflammatory, antioxidative, so it has been widely used alone or in combination with other crude drugs for the treatment of cholestatic hepatitis from ancient times in China. The major active ingredient of the herb responsible for its hepato-protective effect is emodin, an antraquinone [15].

CONCLUSION
Fatty liver, as one of the most common chronic liver diseases, is directly connected to obesity, diabetes type 2, mood disorders, chronic fatigue, sleep disorders, the unusual function of the thyroid gland, and metabolic syndrome. If diagnosis and a proper treatment of this disease are delayed, it may result in many complications such as liver dysfunction and Cirrhosis.
Classical medicine has not suggested a definite treatment for fatty liveryet. Furthermore, the chemical medications prescribed to reduce its factors often cause many complications.
In this regard, the prevention and control of this disease highly depend on the patient's lifestyle, habits, and weight control [9].
The principles and orders of TIM combined with the use of natural herbal medicine recommended for fatty liverin TIM books and resources, have been proven to be effective on the treatment and control of this disease. However, more research and statistic assessment should be still performed in a wider field of research.

CONSENT
As per international standard or university standard, patients' written consent has been collected and preserved by the author(s).

ETHICAL APPROVAL
This study was approved by the Ethical Committee at the University of Medical Sciences (Code: IR.ARAKMU.REC.1399.189 ).