Anna Vaha Srotas – GIT Disorders
Clinical Experience

Part-4

Prof. Muralidhar Sharma

Transcript by
Dr. Mayank Chouhan, JR 3, Dept of Kriya Sharir, IMS BHU,
&
Dr. Varsha More

based on the lecture available at- Anna Vaha Srotas – GIT Disorders

  Atisara/ Diarrhoea

It could be produced due to multiple causes so identification of the causes is a very important thing in diagnosing the condition and even treatment approaches are also based upon the identification of the causes.

———————————————–|
—————-स सुतरां जायतेऽत्यम्बुपानतः||1||

कृशशुष्कामिषासात्म्यतिलपिष्टविरूढकैः|
मद्यरूक्षातिमात्रान्नैरर्शोभिः स्नेहविभ्रमात्||2||

कृमिभ्यो वेगरोधाच्च तद्विधैः कुपितोऽनिलः|
विस्रंसयत्यधोऽब्धातुं हत्वा तेनैव चानलम्||3||

व्यापद्यानुशकृत्कोष्ठं पुरीषं द्रवतां नयन्|
प्रकल्पतेऽतिसाराय—————————–|4|
( A.H Ni 8/1-4)

Vataja Atisara

The common variety which we see frequently is Amoebic colitis. In our area it is quiet endemic. Amoebic colitis is the acute presentation it has all the clinical feature of Vataja Atisara.

शूलाविष्टः सक्तमूत्रोऽन्त्रकूजी स्रस्तापानः सन्नकट्यूरुजङ्घः ||
वर्चो मुञ्चत्यल्पमल्पं सफेनं रूक्षं श्यावं सानिलं मारुतेन ||
(Su . Ut 40/9,10)

Small quantity of stool passes every time, increased frequency with grabbing pain.  We can manage it without anti-amoebic medication. Following treatment for 3 weeks or slightly more than 3 weeks is useful.

• Agnitundi
• Anandbhairava rasa
• Mustakarishta + Ajamodarka for 3 weeks

Kaphaja Atisara– Amoebic colitis (Chronic)

तन्द्रानिद्रागौरवोत्क्लेशसादी वेगाशङ्की सृष्टविट्कोऽपि भूयः ||
शुक्लं सान्द्रं श्लेष्मणा श्लेष्मयुक्तं भक्तद्वेषी निःस्वनं हृष्टरोमा ||
(Su . Ut 40/11,12)

Amoebic colitis presents in a chronic condition many times the patient would have persistent clinical amoebiasis and stool test may become negative even but the patient has clinical symptoms of frequency is not much high, less tenderness, and a tendency for recurrence, and at times it could be even related to the food and characteristically the patient would have more of urge for defecation not much of mucus. That is exactly what we can see in the case of Kaphaja Atisara. Patient would have feelings of incomplete evacuation even after passing stools which is a typical presentation of Kaphaja Atisara. My treatment would be

• Gandhaka Rasayana
• Anandabhairava
• Mustakarishta

I would consider it a fertile area where we can manage chronic colitis better than that contemporary medicine.

#  A dietary restriction is important like consuming raw food should be as far minimized well cooked and less spicy food has to be advised.

Pittaja Atisara / Bacterial Colitis

Bacterial characteristically would have more of toxic symptoms and will have very high frequency of stools, many times watery. And that exactly mentioned in text-

दुर्गन्ध्युष्णं वेगवन्मांसतोयप्रख्यं भिन्नं स्विन्नदेहोऽतितीक्ष्णम् ||
पित्तात् पीतं नीलमालोहितं वा तृष्णामूर्च्छादाहपाकज्वरार्तः |
(Su . Ut 40/10,11)

 Along with watery or may be serous stools, systemic symptoms like sweating, symptoms of dehydration, fever can be observed. My prescription would be

• Mritynjaya rasa
• Anandabhairava
• Mustakarishta for 1 week

One very cautious would be there is always a possibility of dehydration.  Assessment of fluid condition is required. So, need for fluid replacement is mandatory.

Shokaja Atisara / Irritable Bowel Syndrome

It often due to the stress issue and many more causes.

तैस्तैर्भावैः शोचतोऽल्पाशनस्य बाष्पावेगः पक्तिमाविध्य(श्य)जन्तोः ||१३||

कोष्ठं गत्वा क्षोभयत्यस्य रक्तं तच्चाधस्तात् काकणन्तीप्रकाशम् |
वर्चोमिश्रं निःपुरीषं सगन्धं निर्गन्धं वा सार्यते तेन कृच्छ्रात् ||१४||

शोकोत्पन्नो दुश्चिकित्स्योऽतिमात्रं रोगो वैद्यैः कष्ट एष प्रदिष्टः |१५|||
(Su . Ut 40/13 -15)

A characteristic feature would be a patient would have incomplete feeling of defecation or increase the frequency of defecation. Patient may have gone to the loo and may not pass the stool. Stool could be either of foul smell or without the foul smell. Onset is often related with stress.

• Smritisagara Rasa
• Anandbhairava / Kamadugha
• Mustakarishta/ Saraswatarishta
• Piccha basti

When patient has more loose stools and less burning sensation my choice would be Anandbhairava and if patient has comparatively firm stools and more burning sensation, I would prescribe Kamdugha. Similarly, I do prescribe Mustakarishta/ Saraswatarishta. When patient would not respond to oral medication or in case of recurrence, I would prefer Piccha basti.

Ama Atisara / Grahani – Malabsorption Syndrome

Malabsorption is one of the troublesome complications which we see now in clinical practice which is produced due to a huge number of causes and characteristic feature is incomplete absorption and hence undigested food substances seen in the stool and it affects the nourishment, produces any of systemic symptoms like Karshya, general debility.

आमाजीर्णोपद्रुताः क्षोभयन्तः कोष्ठं दोषाः सम्प्रदुष्टाः सभक्तम् ||
नानावर्णं नैकशः सारयन्ति कृच्छ्राज्जन्तोः षष्ठमेनं वदन्ति ||
(Su.Ut 40/15,16)

Multiple causes                                                                                                          Post gastrectomy/ intestinal resection

• Post cholecystectomy
• Pancreatic pathology
• Hepatic disorder
• Hyperthyroidism
• Blind loop syndrome
• Genetic disorders
• Drugs

सामान्यं लक्षणं कार्श्यं धूमकस्तमको ज्वरः|
मूर्च्छा शिरोरुग्विष्टम्भः श्वयथुः करपादयोः||
(A.H. Ni 8/21)

Symptoms
Weight loss/ general debility

General Management would include following preparations

• Arogyavardhini
• Agnitundi for (reduced appetite)/Kamadugha(moderate appetite and having more Pitta)
• Mustakarishta (in case of loose stool)/ Kumariasav(reduced appetite, weight loss)

# I don’t say that patient can be completely cured but that approach we can manage the patients better & duration of treatment can be vary.

Tridoshaja Atisara – Ulcerative Colitis
Sushruta has mentioned that it is incurable in very young age and old age, also in fulminant stage.

तन्द्रायुक्तो मोहसादास्यशोषी वर्चः कुर्यान्नैकवर्णं तृषार्तः ||
सर्वोद्भूते सर्वलिङ्गोपपत्तिः कृच्छ्रश्चायं बालवृद्धेष्वसाध्यः |
( Su.Ut  40/1,13)

Acute ulcerative colitis is an acute medical emergency. I don’t think that only with our medicine we can manage but once the patient has become chronic condition definitely our medicines would be much better than so called supplemental or such other things. so, in the chronic recurrent condition my prescription would be –

• Gandhaka rasayana
• Anandabhairava
• Mustakarishta
• Smritisagara rasa SOS
• Pichcha Basti

Patient supplemented with drug like Sulfasalazine for long duration that can be withdrawn with Ayurvedic medication only thing is duration of treatment required is quiet long, some time for years.

Asadhaya Atisara – Fulminent Colitis
Recurrent fulminant colitis symptoms are typically mentioned in the text and that exactly is-

सर्पिर्मेदोवेसवाराम्बुतैलमज्जाक्षीरक्षौद्ररूपं स्रवेद्यत् |
मञ्जिष्ठाभं मस्तुलुङ्गोपमं वा विस्रं शीतं प्रेतगन्ध्यञ्जनाभम् ||
राजीमद्वा चन्द्रकैः सन्ततं वा पूयप्रख्यं कर्दमाभं तथोष्णम् |
हन्यादेतद्यत् प्रतीपं भवेच्च क्षीणं हन्युश्चोपसर्गाः प्रभूताः ||
असंवृतगुदं क्षीणं दुराध्मातमुपद्रुतम् |
गुदे पक्वे गतोष्माणमतीसारकिणं त्यजेत् ||
( Su. Ut 40/19-21)

Stool would have appearance like ghee or lots of fat, foul smell, decayed substance or mixed with blood. Description is same which is mentioned in the text is absolutely perfect. So, it is severe complication condition and it’s a cannot be managed with our conservative management alone. It needs a either some other medical management.

Constipation – icd CODE – K59.00

आटोपशूलौ परिकर्तनं च सङ्गः पुरीषस्य तथोर्ध्ववातः ||
पुरीषमास्यादपि वा निरेति पुरीषवेगेऽभिहते नरस्य ||
( Su.Ut 55/ 8-9)

Patient complain of constipation with various conditions. And important is that it also is not a symptom alone it considered as a specific disease entity and icd code K59.00 is given.

 In our text Purisha vega avrodha is the primary cause of constipation. But now in current terminology when we discuss about the constipation there are two important issues one is about the consistency and forms of the stool and others is the frequency of the defecation.

For the assessment of the consistency of the stool there is a standard Bristol stool chart.

The Bristol Stool Chart categorizes stool into seven types, each associated with different bowel conditions.

Type 1: Stool appears as separate hard lumps, indicating severe constipation.
Type 2: Stool is lumpy and sausage-like, suggesting mild constipation.
Type 3: Stool takes on a sausage shape with cracks on the surface, considered normal.
Type 4: Stool is smooth, soft, and shaped like a sausage or snake, also considered normal.
Type 5: Stool appears as soft blobs with clear-cut edges, suggesting a lack of fibre in the diet.
Type 6: Stool has a mushy consistency with ragged edges, indicative of mild diarrhoea.
Type 7: Stool has a liquid consistency with no solid pieces, pointing to severe diarrhoea.

(For more details readers may refer Blake, M.R.; Raker, J.M.; Whelan, K. Validity and reliability of the Bristol Stool Form Scale in healthy adults and patients with diarrhoea-predominant irritable bowel syndrome. Aliment. Pharmacol. Ther. 2016, 44, 693–703)

Rome IV Criteria – Constipation
A patient must have experienced at least two of the following symptoms over the preceding 6 month:

• Fewer than three spontaneous bowel movement per week (These criteria need to be modified as Indian consume more fibres in diet. Therefore, if person does not pass stool once in two days, I would consider it as constipation)
• Straining for more than 25% of defecation attempts
• Lumpy or hard stools for at least 25% of defecation attempts
• Sensation of anorectal obstruction or blockage for at least 25% of defecation attempts
• Sensation of incomplete defecation for at least 25% of defecation attempts
• Manual manoeuvring required to defecate for at least 25% of defecation attempts

We will not follow that guideline rigidly.

I would be considering them mainly under the four categories –

1. Normal – transit constipation (NTC)
2. Slow – transit constipation (STC)
3. Outlet obstruction (may require surgical intervention)
4. Pelvic floor dyssynergia- feeling of incomplete defecation

(Secondary constipation) Another group of condition where patient would have an incomplete defecation due to-

Drugs
Diabetes mellitus
Hypothyroidism
Neuromuscular diseases
Fissure
Haemorrhoid
Tumours

Also, important point is need to a history of drug consumption and very well know common drugs cause constipation are-

Antidepressants
Metals anticholinergics
Opioids
Antacids
Calcium channel blockers
Nonsteroidal anti-inflammatory drugs
Sympathomimetics
Many psychotropic drugs
Cholestyramine and stimulant laxatives ( long term use)

Where ever possible stop that medication or modify it depending upon possibility, so that it can provide huge relief to patient.

Management –

1. Normal transit constipation

वर्चोवाहीनि दुष्यन्ति दुर्बलाग्नेः कृशस्य च||
व्यायामादतिसन्तापाच्छीतोष्णाक्रमसेवनात् |
(Ch. Vi 5/21)

 It is very often observed that the symptoms of constipation are mostly related with stress and certain specific food.

It is often observed that if a person is suffering from constipation-like symptoms would have better bowel movements when they consume chilies. Usually, in other persons, chilies would be reducing bowel movements but in persons with normal transit, chilies will increase bowel movement. Patient may have better passage of stool and usually stools are harder.

 Causes

• Mostly stress induced
• Related to quality of food
• Hard stools

Management

Lifestyle suggestions –

One of the important causes is stress. Persons under continuous stress are not able to maintain a time for defecation. Proper bowel movements can be achieved by maintaining a time schedule and developing a physiological cycle. Everyday going for defecation at specific times natural bowel movements would be better. If time schedule would not be maintained then can lead to constipation.

Water intake                                                 

Fibre diet

Avipathikara choorna/ Draksharishta

2. Slow transit constipation

मन्दस्तु सम्यगप्युपयुक्तमुदरगौरवाध्मानविबन्धाटोपान्त्रकूजनमुख़शोषवायुस्तम्भादीन्यामलिङ्गानि दर्शयित्वा चिरात् पचति||
A.H Sha. 5/1

Features are typical of Mandagni where a patient would have impaired appetite and loose stools. Occasionally stools could be harder. Patient would not have proper bowel movements. Pain, nausea, and abdominal discomfort are the features of slow transit constipation. Patient with slow transit constipation has to be managed with Deepan Aushadhi. Buttermilk is one of the best options. A Person who consumes buttermilk regularly   rarely   suffers from such complications.

Symptoms

Passing bowel motions infrequently

Constipation

Uncontrollable soiling

Abdominal pains

Nausea

Poor appetite

Treatment:

Line of treatment is simple Deepan Pachana.

मन्दाग्निः शीलयेदामगुरुभिन्नविबद्धविट्||
तक्रं सौवर्चलव्योषक्षौद्रयुक्तं गुडाभयाम्|
तक्रानुपानमथवा तद्वद्वा गुडनागरम्||

• Agnitundi
• Arogyavardhini
• Kumari Asava

Buttermilk (one of the best options)

In children

• Gandhaka Rasayana
• Kumari Asava

Avoiding junk food and encouraging more consumption of fruit and vegetable helps to improve slow transit constipation.

रुग्विबन्धानिलश्लेष्मयुक्ते दीपनपाचनम्||A.H.Chi 1/54

The basic issue of treatment is the maintenance of Deepan and Pachana followed by nourishing food substances like Ghee, and buttermilk.

3. Normal and dyssynergia defecation

It is one of the most common presentations for unsatisfactory defecation. In basic defecation physiology, there is a complex neurological control of involuntary activity of defecation becoming voluntary activity. In children, new-borns and lower animals’ defecation is involuntary activity. But later it became a voluntary activity.

Primarily to have continents when the stool does not pass out or leak out that’s prevented by a pressure gradient between rectum and anus. In the resting condition anal pressure would be more whereas rectum pressure would be lower & during defecation the rectal pressure increases and anal pressure reduces so that anal allows the stool to pass out. Dysynergia impairment of above mechanism.   And I would consider this as Udavarta.

वातविण्मूत्रजृम्भाश्रुक्षवोद्गारवमीन्द्रियैः |
व्याहन्यमानैरुदितैरुदावर्तो निरुच्यते ||
(Su. Ut 55/4)

आटोपशूलौ परिकर्तनं च सङ्गः पुरीषस्य तथोर्ध्ववातः ||८||

पुरीषमास्यादपि वा निरेति पुरीषवेगेऽभिहते नरस्य |९|
(Su. Ut 55/8,9)

Dyssynergia are categorized into four types –

TYPE 1-

During defecation the rectum pressure increases but the anal pressure instead of getting reduced it tends to increase and hence it produces a difficulty in passage of stool. Typical history patient has to strain for long period, very often patient would have fissure Also history of, manipulation with fingers, is very common. Initial passage of stool is difficult, hard mass followed by soft stool. And usually, it is seen in Vata Prakriti.

(For more details readers may refer Constipation: Evaluation and Treatment of Colonic and Anorectal Motility Disorders Gastroenterology Clinics – Volume 36, Issue 3 (September 2007)

 Management

Lifestyle suggestions – Stress has to be avoided; Punctuality of defecation has to be maintained.

Considering Panchana and Anulomana, my prescription would be

Agnitundi,
Arogyavardhini,
Abhyarishta,

Bala Tail Matra Basti- is indicated only when oral medication  does not improve condition.

TYPE 2-

Rectum pressure doesn’t increase during the straining and what happens is patient is strains but he is not able to pass stool for many days like two days to three days or so on. And because the patient has delayed defecation the stool is harder.

When patient goes for defecation, it takes lot of time for the initiation of the activity once the stool has opened up the passage, patient would pass this stool comparatively easier.

And this is often seen in Pitta prakriti patient:

Straining doesn’t evacuate

Takes long time for the act

Reduced frequency of defecation

 My prescription would be

Ghandaka Rasayana

 Kumari Asava

High fibre diet

 Occasionally Videhan also help

TYPE 3-

The condition is where the increased rectal pressure whereas anal pressure doesn’t correspondingly increase. The patient would have an increased frequency of defecation and doesn’t have a sense of satisfaction, even after passing stool patient has a feeling of something retained (incomplete evacuation).  These patients need to be accessed carefully because similar symptoms can be seen in mass in a rectum. There could be flatulence and pain in abdomen.

• Agnitundi
• Jeerakadyarishta

TYPE 4 –

It happens due to old age or neurological patients where the tone of the muscles is reduced and hence, they may not have an urge at all and they may pass stool involuntary.

Incontinence is the major features that in such conditions.

• Chandraprabha Vati
• Ashvagandharishta

In dissynergia per rectal examination is also a very useful method for checking variation in the grip. In normal conditions when we put the finger in, we can feel the anal grip is more whereas the rectal grip will be lesser.

In type 1 dyssynergia you can feel that the grip of anal as well as rectum more frequently or faster grip can be seen whereas in type 4 grip is being lesser.

Incidence of dis synergia

Type 1- more common > 50%

Type 2 – neurological condition

(For more details refer,Effect of biofeedback therapy on anorectal physiological parameters among patients with fecal evacuation disorderAbhai Verma1&Asha Misra1&Uday C Ghoshndian J GastroenterolDOI 10.1007/s12664-017-0731-y)

Overflow diarrhoea –   Often seen in patients with chronic constipation hence fecoliths are common. Therefore patient would not be able to pass stools but some components of liquid passes. Fecoliths can be palpated by per rectal examination and require manual removal. Sometimes mass in rectum can be identified.

1. Only fluids are expelled.
2. It most often has the colour of faeces.
3. It is not accompanied by abdominal pain.
4. It is often difficult for the patient to reach the toilet before it is expelled.
5. If a gloved finger is put down into the fluid it will feel threadlike due to mucus in the stool.

 # Accompanied with tenesmus – Carcinoma Rectum