Anna Vaha Srotas – GIT Disorders
Clinical Experience

Part-2

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

Plummer Vinson syndrome- Pandu, Kshaya upadrava

It happens as a consequence of prolonged iron deficiency anemia. Characteristic appearance will be a bald tongue, and oral mucosa will also be quite bald or somewhat dry. The patient would have a rare appreciation of taste. Rarely, a membrane formed at the base also, which makes difficulty in swallowing could be another clinical presentation. These types of features were described in Ayurvedic texts in the context of Rakatja Kshaya Upadrava.

तेषामुपद्रवान् विद्यात्कण्ठोद्ध्वंसमुरोरुजम्||
जृम्भाङ्गमर्दनिष्ठीववह्निसादास्यपूतिताः| (A. H.Ni –  5/15)

Considering Pandu my treatment would be, Chandraprabha as Rasayan. Punarnavamandoora and Draksharishta are specific drug for Pandu. Once haemoglobin improves patient may have better feeling. Patient may require prolonged treatment.

Prescripton- 1. Punarnavamandoora

2. Chandraparbha
3. Draksharishta

Oral carcinoma 

The incidence of carcinoma is increasing worldwide now, mostly due to the consequences of submucous fibrosis resulting in malignancy, or sometimes it could be leucoplakia produced as a source of irritation. It is incurable, and most of the time, I would not treat them with any of our medicines, and the patient has to be referred to a centre where either surgery or radiation would be the preferred treatment, and the outcome would be very poor. But if the patient prefers our treatment only and there is virtually no other possibility, my prescription would be Kachnaar Guggulu and Arogyavardhini Vati as palliative treatment. Identification of this condition is important. Oral lesions that are very fragile and indurated swelling need to be diagnosed at an early stage.

Denture Stomatitis

A person who uses dentures for a long time, either due to improper denture shape or unhygienic conditions, may experience irritation over an area or small fluid vesicle appearance in the denture. I don’t see that there is any other specific management. The only thing is the dentist needs to review it and modify either the position of the denture or maybe the material needs to be modified, but most important is to identify the condition.

Chemotherapy Induced Oral Lesions

Common typical presentations are either the tongue would be hairy or it may have a dark blackish colour appearance, and the patient would always be complaining of non-appreciation of taste and intolerance to mildly hot substances. It could be like mucositis where all mucosa looks very inflamed, which has the typical features of the Pittaja variety. Identification of the condition is relatively easier because you will have a history of chemotherapy being used. Symptomatic relief can be achieved by Tila tail gandusha, and Kamdugha rasa helps in reducing trouble to the patient to a certain extent.

Dyspepsia -Arochak   

ICD code 536.8 – Dyspepsia and other specified disorders of function of stomach.

I will refer to the dyspepsia where the undergoing pathologies are not really made out. Dyspepsia produces as a symptom of other diseases is not point which we are discussing. Dyspepsia could be produced due to multiple conditions and when the patient has some other systemic disorder they need to be treated and that could be the reason treatment for dyspepsia.

Vagabhata has mentioned specific causes for Arochaka.

अरोचको भवेद्दोषैर्जिह्वाहृदयसंश्रयैः|
सन्निपातेन मनसः सन्तापेन च पञ्चमः||(A.H Ni 5/2-2)

Either it could be some local pathology, local variations in the physiological condition in the tongue or oral cavity or it could be some psychological condition. And the identification of that pathology will be based upon every test appreciated by the patient as explained in following shloka.

कषायतिक्तमधुरं वातादिषु मुखं क्रमात्|
सर्वोत्थे विरसं शोकक्रोधादिषु यथामलम्|| (A.H Ni 5/2-29)

And most of the time, it does not require any specific treatment, and the best treatment would be a modification of food in the form of light food or overnight fasting. Oily and irritant food substances need to be avoided. Overnight fasting is the best remedy. If the patient requires any treatment, I would prefer Avipathikara choorna/ Hingvasthaka choorna for one or two days.

Dyspepsia -Arochaka with Avipaka

Arochaka with Avipaka is an abnormality of digestion persisting for a longer duration. This condition requires specific treatment. A patient would not have an appreciation of the taste of food at all, which is a typical presentation. A patient may have pain in the chest or upper part of the abdomen, which is what we often say is a gastritis-like condition, suggesting involvement of the lower part of the gastrointestinal tract. It could be like a burning sensation or heaviness in the chest area. These are symptoms that can be seen in Arochaka and Avipaka. All dyspepsia patients need not be subjected to the investigation. This is not followed regularly in general practice; usually, patients are prescribed with proton pump inhibitor or H2 receptor blocker, and a series of investigations like endoscopy are done regularly that are not required as per guidelines.

NICE guidelines for the management of dyspepsia in adults in primary care-

1. Most patients with dyspepsia can be managed without investigation Indication for referral is based on alarm signs/symptoms.
2. Chronic gastrointestinal bleeding (either in visible form or presence of occult blood positive in stool)
3. Progressive unintentional weight loss
4. Progressive dyspepsia
5. Persistent vomiting
6. Iron deficiency anaemia
7. Epigastric mass

If patient has any of alarming signs   mentioned in above list, then patient has to be referred for further investigation.

Dyspepsia (no alarm symptoms, and EGD ± biopsies negative)

Functional Dyspepsia: Mechanisms of Symptom Generation and Appropriate Management of Patients

Below guideline is issued by the gastroenterology clinics of North America and it’s categorized into four that is –

1.Predominent Heartburn – Life style modification PPI Rx

2.Nasuea/Vomiting – Anti -emetic PPI Rx

3.Postprandial distress syndrome – Patient would have abnormality in the mobility of stomach. Investigating : Gastric emptying ± AJEERNA

4.Epigastric pain syndrome – Antidepressants, Behaviroral/HypnoRx

(For more details interested readers may visit, Functional Dyspepsia: Mechanisms of Symptom Generation and Appropriate Management of Patients Article· Literature Review in Gastroenterology Clinics of North America 36(3):649-64, xi-x · October 2007)

Very interesting is that this is exactly on the same as Sushrut has categorized.   Vataja is symptoms predominantly associated with pain,  Pittaja is associated with  burning and Kaphaja is associated with emesis.  I considered postprandial distress syndrome as Ajeerna.

Management

From our point of view first point that is predominant heartburn & second is nausea/ vomiting, I considered both of them as the Pittaja variety of Arochaka.  Life style modification is essential part of management. My prescription for this condition would be

• Soota shekhara Rasa/Arogyavardhinivati (PPI related)
• Kamadugha(plain)
• Godanti
• Avipathikara

Nowadays, proton pump inhibitors are being consumed as an over-the-counter drug. Persons who take proton pump inhibitors regularly tend to have rebound symptoms. In this condition, my specific treatment would be Arogyavardhini, Kamadugha, and Avipathikara. In the absence of proton pump inhibitor (PPI) intake, my prescription would be Soota Shekhara Rasa, Godanti, and Avipathikara, considering the Pittaja subtype.

Epigastric pain syndrome

दोषैः पृथक् सह च चित्तविपर्ययाच्च भक्तायनेषु हृदि चावतते प्रगाढम् |
नान्ने रुचिर्भवति तं भिषजो विकारं भक्तोपघातमिह पञ्चविधं वदन्ति ||
हृच्छूलपीडनयुतं विरसाननत्वं वातात्मके भवति लिङ्गमरोचके तु |
कण्डूगुरुत्वकफसंस्रवसादतन्द्राः श्लेष्मात्मके मधुरमास्यमरोचके तु |
संरागशोकभयविप्लुतचेतसस्तु चिन्ताकृतो भवति सोऽशुचिदर्शनाच्च |Su. Ut. 57/3,4,5,6)

My prescription would be

• Agnitundi
• Soota shekhara
• Godanti
• Avipathikara

A condition in which there is an abnormality in gastric emptying is considered as Ajeerna. The contemporary method of classifying it includes delayed gastric emptying, accelerated gastric emptying, or normal emptying period. Delayed or accelerated gastric emptying can be assessed clinically based on the symptoms of patients. If a patient complains of heaviness in the stomach after the consumption of food, having distension, and passing stools in insufficient quantity, it suggests delayed emptying. In the case of accelerated emptying, the patient would experience more pain after the intake of food and passage of either frequent or liquid stool. In the case of normal gastric emptying, bowel movements are normal, and the patient would not have a reduced appetite.

अजीर्णमामं विष्टब्धं विदग्धं च यदीरितम् |
विसूच्यलसकौ तस्माद्भवेच्चापि विलम्बिका |(Su.Ut56/3)

From an Ayurvedic point of view, Ajeerna is classified mainly under the same head:

1. Vishtabdhajeerna (Delayed gastric emptying)
2. Vidagdha – where the patient may have more burning sensation, faster movement of bowels, and digestion is not poor
3. Visuchi – the patient may have diarrhoea-like symptoms
4. Alasaka – the patient would be having more distension of the abdomen
5. Vilambika – exactly what is mentioned as delayed gastric emptying.

The Ayurvedic classification of Ajeerna is more detailed than the contemporary approach.

Amajeerna:

कुक्षिरानह्यतेऽत्यर्थं प्रताम्यति विकूजति |
निरुद्धो मारुतश्चापि कुक्षौ  विपरिधावति ||
वातवर्चोनिरोधश्च कुक्षौ यस्य भृशं भवेत् |
तस्यालसकमाचष्टे तृष्णोद्गारावरोधकौ  ||(Su.Ut56/7,8)

Patient would have distension of stomach followed by gurgling sounds and stool would not pass regularly. These are typical feature of Alasaka which are indicative of delayed gastric emptying. My prescription would be

• Agnitundi
• Arogyavardhini
• Jeerakadyarishta (for pain)
• Kumari Asava (for reduced appetite)

Visuchika:

मूर्च्छातिसारौ वमथुः पिपासा शूलं भ्रमोद्वेष्टनजृम्भदाहाः |
वैवर्ण्यकम्पौ हृदये रुजश्च भवन्ति तस्यां शिरसश्च भेदः ||(Su.Ut.56/6)

Accelerated gastric emptying is a typical feature of Visuchika. Stools pass very rapidly, accompanied by an increased frequency of stool passing. Symptoms include a burning sensation, appearance of systemic symptoms like thirst, and rarely, dehydration-like conditions. Many times, these symptoms are related to stress. In this condition, my treatment would be-

• Sootshekar
• Anandabhairav
  Bhoonimbadi kwath (when consistency of stool is not much liquid) Mustakarishtha (when consistency of stool is more liquid)
• Smritisagar Rasa (if stress-related symptoms appear and visible evidence of stress)

The duration of treatment required would be longer than Alasak variety.

Vilambika:

दुष्टं तु भुक्तं कफमारुताभ्यां प्रवर्तते नोर्ध्वमधश्च यस्य |
विलम्बिकां तां भृशदुश्चिकित्स्यामाचक्षते शास्त्रविदः पुराणाः ||(Su. Ut. 56/9)

In these conditions, the typical description mentioned in the text is that after consuming food, the patient will feel that the food neither moves up nor down. They may have an urge for defecation but don’t pass stool. There may be nausea, but they are not able to vomit, and there will be continuous discomfort. That’s the typical presentation of Vilambika and our prescription would be

• Agnitundi
• Arogyavardhini (when heaviness) or Chitrakadi vati(when pain is present)
• Kumariasava
• Smritisagarrasa- sometimes may needed

In total, the approach of treatment is definitely better than the contemporary system can provide.

न तां परिमिताहारा लभन्ते विदितागमाः |
मूढास्तामजितात्मानो लभन्ते कलुषाशयाः  ||(Su.Ut 56/5)

The basic and important issue is to always maintain a proper diet. By proper diet, I mean consuming within physiological limits. Those who adhere to this regimen are less likely to develop these complications, and their overall health will be positively affected. Following this guideline is crucial to prevent such conditions.