Anna Vaha Srotas – GIT Disorders
Clinical Experience
Part-3
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
Chardi:
The issue of controversy revolves around whether chardi is considered a disease in itself or a symptom of other diseases. In cases where vomiting is presented as a symptom of other diseases, a thorough assessment of the patient is necessary. Only when no definite underlying pathology is found can it be considered as a chardi vyadhi. Sushruta also mentions that the causes of chardi can be varied, including physical, psychological, or due to other systemic conditions.
अतिद्रवैरतिस्निग्धैरहृद्यैर्लवणैरति |
अकाले चातिमात्रैश्च तथाऽसात्म्यैश्च भोजनैः ||
श्रमात् क्षयात्तथोद्वेगादजीर्णात् कृमिदोषतः |
नार्याश्चापन्नसत्त्वायास्तथाऽतिद्रुतमश्नतः ||
अत्यन्तामपरीतस्य छर्देर्वै सम्भवो ध्रुवम् |
(बीभत्सैर्हेतुभिश्चान्यैर्द्रुतमुत्क्लेशितो बलात्) (Su.Ut .49/3-5)
So, it’s important to assess all the possible conditions which will responsible for it. I have suggested a list and it is not a complete list, just a common condition or general guideline. (For more details readers may refer Davidson’s Principles and Practice of Medicine, 21st Edition)
History of consumption of alcohol is commonest cause. Consumption of NSAIDs or irritant drugs is another condition. Diseases like hepatitis, gastroenteritis has to be ruled out. Diabetic pathologies like ketoacidosis needs to be ruled out. Similarly peptic ulcer like conditions has to be ruled out.
When there is no obvious evident condition requiring direct intervention, a general management in patient presenting with vomiting as symptom of other disease condition.
Management:
Food poisoning typically presents with a history of consuming contaminated or unusual food for a day or two. Vomiting becomes less frequent once the stomach is emptied, and patients may also experience diarrhoea. Additionally, there could be a low-grade fever indicating toxicity. For treatment, Agnitundi and Anandabhairava are prescribed, followed by a light diet like khichadi. Patients usually respond well to this treatment unless dehydration is present, in which case fluid supplementation may be required.
Gastritis– Burning sensation and irritation in the stomach are common symptoms, with a characteristic pattern of vomiting and upper abdominal pain immediately after consuming food. The prescribed treatment includes Sootashekhara, Kamadugha, and occasionally Godanti, along with Avipattikar.
Peptic ulcer – It need prolonged treatment minimum period of three months or more may require.My prescription would be Sootshekhara, Kamadugha, Godanti+Avipathikara or Bhoonimbadi Kwath. When patient present with loose stool, I would prefer Bhoonimbadi Kwath.
Worm infestation– Krimikuthara rasa, Agnitundi for 4 days, if necessary, repeat it after a month.
Hepatitis- Mrityunjaya, Arogyavardhani, Kumari Asava it is not treatment for vomiting but it is comprehensive treatment of hepatitis, vomiting subsides by itself.
Vestibular pathology/motion sickness- Incidence of vomiting would be lesser with empty stomach. Even though when it persists or in case of Meiners disease where vestibular pathology is present, characteristically this vomiting would be always related with posture. When the patient is moving about vomiting would occur, in lying down posture there would not no vomiting prescription would be Kamadugha, Smritisagar Rasa. These are often more useful than over the counter drugs like Avomine.
- Food poisoning – Agnitundi, Anandabhairava
- Gastritis – Sootashekhara, Kamadugha
- Peptic ulcer – Sootshekhara, Kamadugha, Godanti+Avipathikara/ Bhoonimbadi Kwath – prolonged treatment
- Worm infestation – Krimikuthara rasa, Agnitundi for 4 days, if necessary, repeat it after a month.
- Hepatitis – Mrityunjaya, Arogyavardhani, Kumari asava
- Vestibular pathology- Kamadugha, Smritisagar rasa
- Neurosis – Smritisagar with Saraswatarishta
# Mayur pichcha bhasma as a symptomatic remedy irrespective of pathology when other treatment doesn’t produce satisfactory result.
When underlying cause could not be ruled out and intractable vomiting due to underlying pathology, one of the ways to reduce vomiting effectively is Mayur pichcha bhasma. In cases of uraemia virtually it reduces vomiting.
Pain in abdomen – R10.1 Pain localized to upper abdomen /SHOOLA
I am referring to those pain in abdomen conditions where you may not have a specific underlying pathology in initially then we go into that condition where the underlying pathologies are identified. Even then that pain in abdomen is also is specific diagnosis in current system in the ICD CODE 10 and 10.1 code is for pain in upper abdomen. Causes of the pain in abdomen mentioned in text is quite relevant.
वातमूत्रपुरीषाणां निग्रहादतिभोजनात् ||
अजीर्णाध्यशनायासविरुद्धान्नोपसेवनात् |
पानीयपानात् क्षुत्काले विरूढानां च सेवनात् ||
पिष्टान्नशुष्कमांसानामुपयोगात्तथैव च |
एवंविधानां द्रव्याणामन्येषां चोपसेवनात् ||
वायुः प्रकुपितः कोष्ठे शूलं सञ्जनयेद्भृशम् |
निरुच्छ्वासी भवेत्तेन वेदनापीडितो नरः ||(Su. Ut .42/77-80)
The consumption of the food either the time or the duration or the quality or quantity all these are the issues which are to be considered.
Vataja Shoola
निराहारस्य यस्यैव तीव्रं शूलमुदीर्यते |
प्रस्तब्धगात्रो भवति कृच्छ्रेणोच्छ्वसितीव च ||
वातमूत्रपुरीषाणि कृच्छ्रेण कुरुते नरः |
एतैर्लिङ्गैर्विजानीयाच्छूलं वातसमुद्भवम् ||(Su. Ut. 42/82-83)
Some temporary phenomena where the person would have pain in abdomen with the diet- related factors and usually for a short duration.
Typical Vataja shoola occurs in a person who is not consuming the food properly and it tends to occur quite frequently and the patient may also have constipation such conditions one of the drugs which gives immediately it could be –
1.Nabhivati 2. Jeerkadyarishta+ (few drops) of Ajamoda Arka
- Agnitundi Vati (Severe Condition)
KAPHAJA SHOOLA
शूलेनोत्पीड्यमानस्य हृल्लास उपजायते ||८५||
अतीव पूर्णकोष्ठत्वं तथैव गुरुगात्रता |
एतच्छ्लेष्मसमुत्थस्य शूलस्योक्तं निदर्शनम् ||८६|| (सु.उ.तं.- ४२/८५-८६)
It often occurs after consumption of food where patient would have excessive of salivation and heaviness in the stomach and distress pain as such that’s the typical Kapha.
- Agnitundi vati (more discomfort and less appetite)
- Bhoonimbadi Kwath/ Hingwashtaka choorna (moderate appetite and moderate discomfort)
PITTAJA SHOOLA
तृष्णा दाहो मदो मूर्च्छा तीव्रं शूलं तथैव च |
शीताभिकामो भवति शीतेनैव प्रशाम्यति ||
एतैर्लिङ्गैर्विजानीयाच्छूलं पित्तसमुद्भवम् | (Su. Ut 42/84,85)
Pittaja variety of shoola mimics lots of other diseases conditions wherever inflammatory pathology domain, it could be in appendix or pelvic area, or gall bladder in any of those inflammatory conditions there will be reflux vomiting and it is the exact clinical presentation what we see in Pittaja variety where pain and as well as systemic symptoms of toxaemia like symptoms fever, etc. hence it needs to be thoroughly assessed to find out underlying pathology.
Depending upon the location of pain, if it is on right side, we need to think of pathologies of gall bladder, gastric ulcer. Occasionally pancreatic pathology, pain could be either at the centre of abdomen. When pain is at lumbar area renal pathologies have to be considered. When it is in iliac area pelvic pathology or appendicular pathologies are to be considered.
In general, we may categories into either obstructive pathology or inflammatory pathology.
Specific diseases entities presenting with vomiting and pain –
- Obstructive pathologies
Pyloric stenosis
Intestinal obstruction
- Intra-abdominal infective pathologies
Cholecystitis
Pancreatitis
Appendicitis etc.
In case of infective pathologies quantity of vomitus get subsequently reduced and become dry while in obstructive pathology quantity of vomitus gradually going on increasing. Even the stomach is empty secretion of intestine are vomited out.
Treatment could be based upon these specific conditions and I don’t suggest any specific treatment or a generalized treatment for all these conditions. Those underlying pathologies I would consider them as Gulma,Udara, Antarvidradhi, not exactly as per our text, it’s a slight modification of the concepts of the text. I will consider those underlying pathologies as – Gulma, Udara, Antarvidradhi.
Gulma
हृद्बस्त्योरन्तरे ग्रन्थिः सञ्चारी यदि वाऽचलः |
चयापचयवान् वृत्तः स गुल्म इति कीर्तितः ||(Su.Ut 42/4)
Udara
कोष्ठादुपस्नेहवदन्नसारो निःसृत्य दुष्टोऽनिलवेगनुन्नः ||
त्वचः समुन्नम्य शनैः समन्ताद्विवर्धमानो जठरं करोति || (Su. Ni 7/6,7)
Antarvidradhi
अधिष्ठानविशेषेण लिङ्गं शृणु विशेषतः ||
गुदे वातनिरोधस्तु बस्तौ कृच्छ्राल्पमूत्रता |
नाभ्यां हिक्का तथाऽऽटोपः कुक्षौ मारुतकोपनम् ||
कटीपृष्ठग्रहस्तीव्रो वङ्क्षणोत्थे तु विद्रधौ |
वृक्कयोः पार्श्वसङ्कोचः प्लीह्न्युच्छ्वासावरोधनम् ||
सर्वाङ्गप्रग्रहस्तीव्रो हृदि शूलश्च दारुणः |
श्वासो यकृति तृष्णा च पिपासाक्लोमजेऽधिका ||( Su.Ni 9/19-22)
Practically relevant methods of making diagnosis are described by Sushruta has to be considered before staring management. Some of the condition we can manage to great extent and there has to be a caution in all this to go into every detail of this aspect would be beyond the scope of what we can discuss but I will be referring to some of the common diseases conditions where we can have some specific approach from ayurvedic point of view and among them appendicitis is quite common.
Appendicitis:
Appendicitis in general is considered as a surgical disease and indications for the surgery in the contemporary science are almost every appendicitis is considered as a surgical but the specific indications are when the TLC more than 14,000 and obstructive appendicitis complications are present. But from my point of view, I manage the patient with the ayurvedic approach, I will be stretching this indication to even a count of more up to twenty thousand then I go for surgery.
A course of antibiotics followed by Agnitundi, Anandbhairava, Jeerkadyaishta can help in resolution of appendicitis and in a large number of patients surgery can be avoided.
Surgery is indicated:
TLC more than 20.000
Obstructive appendicitis
Complications
My clinical experience in appendicitis is described below in graphical diagram-
These are changes that occurred during the course of my practice. The number of acute appendicitis patients has increased from 1983 to 2019. Initially, the number of patients treated surgically was higher. Contrary to this, the number of appendicitis patients managed with medicine became more. Also, the graph represents a reduced incidence of surgery over a period of time. In this scenario avoiding surgery is specific contribution of Ayurvedic management. Surgery is recommended for cases where the total leukocyte count (TLC) exceeds 20,000, particularly in instances of obstructive appendicitis, complications like intestinal perforation may arise.
Cholecystitis
It’s also a Pittaja Shoola variety. General guidelines for every calculous cholecystitis involve treatment with surgery. Nowadays, every case of gall bladder pathology is treated with gallbladder surgery, but we can manage a large number of patients without surgery if we are selective and careful in the clinical assessment. My approach to the condition is that if a person has acalculous cholecystitis and has come in an acute state, an antibiotic regime may be necessary. Recurrence can then be effectively prevented by treatment – Arogyavardhini, Mritunjaya rasa, Kumari Asava.
Indication for surgery
Only when ultrasonography suggests gall bladder thickening of 10 mm or more than 10 mm, then the choice of treatment may be surgery; otherwise, in the case of acalculous cholecystitis where no stone is present, surgery is not required. Calculus cholecystitis with an acute presentation often may require surgery, and surgery is the choice because the course is unpredictable.
Asymptomatic cholelithiasis/biliary sludge, a large number of patients with this condition, show no clinical evidence but are confirmed by ultrasonography. In that condition, my prescription would always prefer nonsurgical management. If it is a large single stone, usually a cholesterol stone, we can give a drug like Arogyavardhini and Kumari Asava for a prolonged duration like three to four months, which can help in complete resolution. However, in the case of multiple small stones, there is one risk – the stone may migrate, causing common bile duct obstruction and obstructive jaundice, which essentially requires surgical treatment. So, the choice has to be made, and the patient has to be educated about that risk.
Pancreatitis:
Acute pancreatitis is definitely a medical emergency, and we need to administer large amounts of intravenous fluids; antibiotics are necessary. I don’t think that only Ayurvedic treatment would be enough to manage.
But for chronic recurrent pancreatitis, the contemporary medicine system doesn’t have any satisfactory solution. Whereas treatments like Arogyavardhini, Angitundi, Kumari Asava are typical Pittaja Shoola chikitsa. If the patient has episodes of fever during that, Mritunjaya rasa can be prescribed, giving more reliable results. The only thing is the treatment duration may have to be prolonged. It can be managed considering Pittaja shoola management.
