Lecture Note: Anna Vaha Srotas – GIT Disorders .. Clinical Experience

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Anna Vaha Srotas – GIT Disorders
Clinical Experience

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

 

Sushrut has mentioned 64 type of the Aasyapaka.

संस्थानदूष्याकृतिनामभेदाच्चैते चतुःषष्टिविधा भवन्ति||
शालाक्यतन्त्रेऽभिहितानि तेषां निमित्तरूपाकृतिभेषजानि|
यथाप्रदेशं तु चतुर्विधस्य क्रियां प्रवक्ष्यामि मुखामयस्य|| (Ch.Chi.26/122,123)
इति मुखरोगनिदानम्|

But though it may not be possible to make out all 64 types, I would like to pick up a few of those varieties of Aasyapka which is happen generally considered very simple issue.

1.Mickulicz Ulcer (aphthous ulcer) – Pittaja Mukharoga

The exact causes are not known, often are to claimed to be produced due to deficiency of vitamins and usual prescription the other contemporary system uses are vitamins B complex and so on. It is more related to food consumption, those who consume more spicy food, they tend to develop this kind of lesion. Characteristically these lesions are very superficial and size is smaller and quite painful also last for a few days to maximum two weeks, heals spontaneously and there will be no scar.  It has all the resemblance to that of Pittaja variety of Mukharoga. There would be redish colour and hyperamia around the lesion lesion is characterstic feature.

पित्तात् समूर्च्छा विविधा रुजश्च वर्णाश्च शुक्लारुणवर्णवर्ज्याः|| (Ch.Chi 26/120)

Diana V Messadi, DDS, MMSc, DMSc Professor of Dentistry, Associate Dean for Education and Faculty Development, Chair, Section of Oral Medicine and Orofacial Pain, University of California, Los Angeles, School of Dentistry

Key points

  • Repeated recurrence
  • Usually heal spontaneously without scar
  • 70 to 80% incidence

Prescription-

1.Kamadugha (Plain)

  1. Sootashekhara rasa
  2. Madhuyashtti choorna

And of course it is true that even without the medicine it gets cure but these medicine will reduce the duration of suffering and that also gives a better felling to the patient.

Aphtous ulcer (Suttons ulcer) – Kaphaja Mukhapaka

कफजे मधुरास्यत्वं कण्डूमत्पिच्छिला व्रणाः| (अ.हृ.उ.- २१/६२)

 Most common cause would be irritation sometimes due to food or irritant medicine. Characteristically they are deeper and surface would be half of whitish color which is typically of the Kaphaja variety of the Mukharoga.It takes longer time to heel (6 weeks) and thus there is a tendecy for multiple ulcers and if not treated they may cause another ulcer or merge with another ulcer and becoming bigger in size.

Mickulicz ulcer is more common and easy to treat whereas Suttons ulcer take longer time to cure. Because of involvement of Kaphaja variety my prescription would be Gandhaka rasayan, Arogyavardha and Khadirarishta/ Khadiradivati.

Key points 

Deep ulcer

Takes 6 week for healing.

Coalesce

  1. Gandhaka rasayana
  2. Arogyavardhaini
  3. Khadirarishta/ Khadiradivati

 

Major aphthous ulcer

स्फोटैः सतोदैर्वदनं समन्ताद्यस्याचितं सर्वसरः स वातात् | (सु.नि.- १६/६५)

Ulcers is quite deep and the inflammation is quitesignificant.                                                                                               Comparatively rare and most of times there will be some underlying systemic pathology like either very often seen in enteric fever, Leukaemia or Diabetes mellites etc. It tend to be quiet big apthus ulcer, huge indurated. In such conditions identification of underlying pathology is important and management would be based on underlying pathology. Once you have managed that underlying pathology I would prefer

Prescription- 1. Triphala guggulu

  1. Gandhaka rasayana
  2. Triphala quatha gargling

This condition has simillar with Vataj variety of Sarvagata Vyadhi.

Angular cheilitis – Vataja mukhapaka

कर्कशौ परुषौ स्तब्धौ कृष्णौ तीव्ररुगन्वितौ |

दाल्येते परिपाट्येते ह्योष्ठौ मारुतकोपतः ||५|| ( Su. Ni16/5)

Diana V Messadi, DDS, MMSc, DMSc Professor of Dentistry, Associate Dean for Education and Faculty Development, Chair, Section of Oral Medicine and Orofacial Pain, University of California, Los Angeles, School of Dentistry

The exact causes are not known, one of the characteristic features of angular cheilitis is a location and it is at the angle of mouth and there will be scaling and mucous membrane becomes thicker, rough and that’s exactly described in text i.e Vataj aoustha roga. And these types of lesions is often seen in patients who are malnourished or have poor nourishment or sometimes it can also be seen as a familiar pathology in some families.

It also could be a consequence of local irritation, due to chemical applied  over the area, diseases like psoriasis or pemphigus. When there is  no  specific condition like psoriasis or pemphigus found then my treatment choice would be as follows.

Prescription- 1. Kaishor guggulu

  1. Sarivadyasava
  2. Avipathikara choorn

Characteristically Angular cheilitis tends to recurs and persist for a long duration. In such condition where it tend to occur repeatedly and becomes quite troublesome, Virechana also is often preferred. Most of the times Virechana gives a more definite and prolonged relief from the conditions than the Shamana chikitsa.

Nicotinic Stomatitis- Kapha Vataja Mukhapaka   

James E Cade, DDS American Academy of Oral and Maxillofacial Pathology, American Academy of Oral Medicine, American Dental Association

Sushrut might not have exactly mentioned the aetiology but the etiologic of it is well known due to consumption of nicotine either in the form of smoking or tobacco and it produces irritation. In the beginning, it presents as stomatitis later it results in sclerosis. Initially, lesion will be seen as a small superficial erosion and then slightly the surface is elevated & the pain is felt only after food consumption. It is not limited to buccal mucosa it could be even present over the palate. As the condition progresses you may see changes over the tongue surface too. The surface may become rough, presence of large polyps and increased vascularity are typical features of nicotine stomatitis

The most important management would be avoiding nicotine.

Many of patient responded very well once they have stopped nicotine.

Prescription- 1. Arogyavardhini

  1. Agnitundi (for Vata / Kapha lakshna)/

Kamadugha(for Pitta lakshan)

  1. Bhoonimbadi Kwatha- it may be related with Amlapiitta
  2. Triphala Kwath gargling.

In case of more Pitta lakshana  I prefer Kamadudha & more Vata lakshana I use Agnitundi.  Although Sushruta described this condition under Kaph vataj mukhapak, clinically Pittaja lakshana too present. Many times, persons may have the systemic symptoms related to nicotinic effects too that’s what Sushruta has mentioned.

कण्डूर्गुरुत्वं सितविज्जलत्वं स्नेहोऽरुचिर्जाड्यकफप्रसेकौ|

उत्क्लेशमन्दानलता च तन्द्रा रुजश्च मन्दाः कफवक्ररोगे|| ( Ch. Chi 26/121)

Key points: Characteristically comparatively less pain, irritation after consumption of food.

 

Candidiasis- Kaphapitta/Tridoshaja

Surbhi Gupta: American Medical Association/Foundation

It is a consequence of a systemic pathology like immunocompromised conditions HIV, tuberculosis, or even a case of Diabetis melitus, or leukemias, these are all the conditions where candidiasis tend to occur. For almost every patient of candidiasis is absolutely necessary to identify the underlying pathology & that underlying pathology requires specific treatment.

Candidiasis lesions are very scattered, multiple scattered and typical adherent slimy material seen over. Whole surface is seen as inflamed part.

सर्वाणि रूपाणि तु वक्ररोगे भवन्ति यस्मिन् स तु सर्वजः स्यात्| ( Ch. Chi 26/122)

Tridoshaja lakshanas are seen, main target of treatment is Pitta and Kapha. My treatment of plan would be

Management– 1. Gandhaka Rasayana

  1. Kamadugha
  2. Manjishtadi/ Khadirarishta
  3. Triphala quatha gargling

Key points:

  • Tendency for recurrence
  • Underlying pathology should be managed

Oral Submucous Fibrosis

Delayed consequences of different forms of Paan chewing. Initially, it is presented as a nicotine ulcer but later on, with continuous physical contact with oral mucosa, submucous fibrosis occurs. And it is also considered as a pre- cancerous condition too.

Sushruta has not identified this etiology but Vagbhata described the features very clearly.

करोति वदनस्यान्तर्व्रणान् सर्वसरोऽनिलः|

सञ्चारिणोऽरुणान् रूक्षानोष्ठौ ताम्रौ चलत्वचौ||

जिह्वा शीतासहा गुर्वी स्फुटिता कण्टाकाचिता|

विवृणोति च कृच्छ्रेण मुखं पाको मुखस्य सः| (A.H 21/ 58-59)

It is well described by Vagbhat that in Sarvasara Vyadhi a person would not able to a mouth completely. As the total fibrosis occurs elasticity of the oral mucosa becomes reduced and the person would have a very difficult opening the mouth and swallowing also. It’s a quite painful and the results are very poor.  Virtually it is irreversible pathology. But patient may some kind of relief with following prescription.

Treatment      – 1. Kaishora Guggulu

2.Gandhaka Rasayana

3.Manjishtadi Kwatha

  1. Tila taila Gandoosha

Tila taila gandoosha relives the symptoms and improves food intake.  Virtually there is no curative treatment anywhere else too. Treatment done is a palliative treatment. Submucus fibrosis is considered as precancerous condition, therefore be watchful for malignant pathology. It may require biopsy. Most important part is prevention, chewing habit should be completely stop.

Contact stomatitis

Very often cause is contact with cosmetics. As chemical comes in contact with body the lips and tongue also become inflamed. There is no specific description of a similar pathology in any of our ayurvedic texts but I would it considered as a variety of the hypersensitive reaction and treatment of course is one major reason that whatever that allergen should not be continued to be in contact.

Prescription- 1. Laghusoota Shekhara

  1. Kamadugha
  2. Manjishtadi kwatha

 

Leukoplakia

The exact causes are not known. Most of the time it is either physical or chemical irritation and it’s an essential pre-cancerous condition. When you see an ulcer in the oral cavity it’s quite important that the needs to be palpated and if you find some induration the leukoplakia has to be considered as one possible cause and the majority of these conditions may require biopsy even. In contemporary medicine there is no treatment.

But our point of view Sushrut has described these conditions similarly to the presentation-

वृत्तोन्नतो यः श्वयथुः सदाहः कण्ड्वन्वितोऽपाक्यमृदुर्गुरुश्च |

नाम्नैकवृन्दः परिकीर्तितोऽसौ व्याधिर्बलासक्षतजप्रसूतः ||

समुन्नतं वृत्तममन्ददाहं तीव्रज्वरं वृन्दमुदाहरन्ति |

तं चापि पित्तक्षतजप्रकोपाद्विद्यात् सतोदं पवनास्रजं तु  || (Su. Ni 16/55-56)

Palpable swelling which does not suppurate is considered as Vrinda or Ek Vrinda. When there are more Pittaja or Raktaja lakshanas it is to be considered as Vrinda. When there are more Kaphaja Lakshana it is considered Ekvrind. This condition cannot be reversed completely but patient would feel more comfortable after taking following treatment.  Follow up with biopsy if suggests malignancy then the outcome would be definitely poor.

Prescription– 1. Triphala Guggulu

  1. Gandhak Rasayana
  2. Khadirarishta
  3. Triphala Kwath gargling

Plummer Vinson syndrome- Pandu, Kshaya upadrava

It happens due to consequence of prolonged iron deficiency anaemia. Characteristic appearance will be a bald tongue and oral mucosa also will be quite bald or somewhat dry. Patient would have rare appreciation of taste.  Rarely a membrane formed the base also, which makes difficulty in swallowing could be other clinical presentation. These types of features were described in Ayurvedic text 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 tratment.

Prescripton- 1. Punarnavamandoora

  1. Chandraparbha
  2. Draksharishta

Oral carcinoma

Chelsia Q Sim, DDS, MSc is a member of the following medical societies: Academy of Laser Dentistry, American Academy of Oral and Maxillofacial Pathology, American Academy of Oral Medicine, American Association for Dental Research, American Dental Association, Singapore Dental Association

 

The incidence of carcinoma increasing worldwide now. Mostly it is due to consequences of submucous fibrosis resulting in malignancy or sometimes it could be the leukoplakia 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 patient has to be referred to a centre where either it could be surgery or may be radiation would be the preferred treatment & outcome would be very poor.

But if patient preferred our treatment only and there is virtually no other possibility. I may use prescription would be Kachnaar guggulu and Aarogayavardhani vati as palliative treatment.  Identification of this condition is important one. Oral lesions which are very fragile and indurated swelling need to be diagnosed at early stage.

Denture Stomatitis

A person who uses denture for a long time, either it is due to improper denture shape or due to an unhygienic condition patient may having 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 be reviewed it should be modified either the position of the denture or may be 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 be a dark blackish colour appearance and the patient would always be complaining of non-appreciation of the taste and intolerance to mild 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 the history of chemotherapy being used.

A symptomatic relief can be achieved by Tila tail gandusha and Kamdugha rasa

helps in reducing trouble to patient to 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 it not requires any specific treatment and the best of the 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 best remedy. If patient requires any treatment, I would be preferring Avipathikara choorna/ Hingvasthaka choorana 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 taste of food at all is a typical presentation. A patient may have pain in chest or upper part of the abdomen which is what we often say is a gastritis-like condition suggesting involvement of lower part of gastrointestinal tract. It could be like a burning sensation or heaviness in the chest area.  These are symptoms that can be seen in Arochak 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)
  1. Progressive unintentional weight loss
  2. Progressive dyspepsia
  3. Persistent vomiting
  4. Iron deficiency anaemia
  5. 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

Article· Literature Review in Gastroenterology Clinics of North America 36(3):649-64, xi-x · October 2007

Below guideline is issued by the gasteroenterology clinics of North America & its 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

(Reference 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 nasuea/ 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 over counter drug. Person who take Proton pump inhibitor regularly tend to have rebound symptoms.In this condition my specific treatment would be Arogyvardhini, Kamadugha and Avipathikara . In absence of Proton pump inhibitor (PPI) intake, my prescription would be Soota shekhara Rasa, Godanti and Avipathikara considering 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

 Condition in which gastric emptying abnormality will consider this as Ajeerna. Contemporary method of classifying   either delayed gastric emptying and accelerated gastric emptying or normal emptying period.  Delayed or accelerated gastric emptying can be assessed clinically based on symptoms of patients. If patient complains of heaviness in stomach after consumption of food, having distension and stools is not passed up to quantity suggest delayed emptying. In case of accelerated  emptying patient would have more pain after intake of food and  passage of either frequent or liquid stool. In case of normal gastric emptying bowel movements are normal and patient would not have appetite.

अजीर्णमामं विष्टब्धं विदग्धं च यदीरितम् |

विसूच्यलसकौ तस्माद्भवेच्चापि विलम्बिका |(Su.Ut56/3)

From Ayurvedic point of view Ajeerna is classied mainly it under the same head, Vishtabdhajeerna (Delayed gastric emptying), Vidagdha where patient may have more burning sensation, faster movement of bowels and digestion is not poor, Visuchi is other way where patient may have diarrhea like symptoms. Alasaka is patient would be having more distension of abdomen. Vilambika is exactly what is mentioned as delayed gastric emptying.  Ajeerna classification of Ayurveda are much more detailed than 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 passed 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.   Burning sensation increased frequency of stool passing, appearance of systemic symptoms like thirst, rarely dehydration-like conditions. Many times symptoms are related with stess 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 which is mentioned, the text is what we see that after conception the food the patient will feel that the food neither moves up or down, He may have urge for defecation but doesn’t pass. He may have a raging but he is not able to vomit and there will be some discomfort continuously. 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)

And the basic important issue is you always have to have a proper diet. Proper diet in the sense to the limit which is required physiologically is consumed then you’ll never have this disease. Only those who do not follow that regimen they tend to develop these complications and their system would be affected. This guideline is very important to prevent these conditions.

Chardi

A issue of controversy whether chardi is considered as a diseases or a symptom of other diseases. So, if you have plenty of conditions where vomiting can be presented as a symptom of other diseases then patient has to be assessed thoroughly. Only when you do not find any definite underlying pathology, we will consider that as a chardi vyadhi.  And Sushrut also mentioned same thing, the causes of the chardi could be huge, it could be physical, psychological or it could be due to other systemic condition.

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 its not a complete list, just a common condition or general guideline .

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 – history of consuming odd food for a day or two.  Characteristically vomiting become less frequent once stomach is emptied. Often patient may also have diarrhoea. There  could be low degree of toxicity like fever. My prescription would be Agnitundi, and Anandabhairava followed by light diet like khichadi. Patient would respond to this medicine very well unless patient would not have dehydration. In case of dehydration fluid supplement may be required.

Gastritis– Burning sensation and irritation in stomach would be present. The typical characteristic would be, the moment person consume food   there will be vomiting and pain in upper abdomen may be present. My prescription would be Sootashekhara, Kamadugha, occasionally we add Godanti ,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

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 ark

  1. 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.

  1. Agnitundi vati ( more discomfort and less appetite)
  2. 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 –

  1. Obstructive pathologies

Pyloric stenosis

Intestinal obstruction

  1. 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.

My clinical experience in appendicitis is described below in graphical diagram-

These are changes that occurred during the course of my practice. The graph represents reduced incidence of surgery over a period of time.

Cholecystitis         

It’s also a Pittaja shoola variety. General guidelines for every calculous cholecystitis is treated with the surgery.  Nowadays every case of gall bladder pathology is treated with gall  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 if a person has a acalculous cholecystitis and the person has come in an acute state an antibiotic regime may be necessary and then recurrence can be effectively prevented by a 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 choice of treatment may be surgery, otherwise in case of acalculous cholecystitis where no stone is present surgery is not required.

The calculus cholecystitis with acute presentation often may require surgery and surgery is the choice because the course is unpredictable.

Asymptomatic cholelithiasis/ bilary sludge, large number of patients with this condition, no clinical evidence only confirm by ultrasonography so in that condition my prescription would be always preferred to nonsurgical management and if it is a large single stone that usually a cholesterol stone we can give a drug like Arogyavardhini and Kumari asava for prolonged duration like three to four months can help in complete resolution. But in multiple small stones there is a one risk is that stone may migrate in common bile duct obstruction and patient get obstructive jaundice which require essentially surgical treatment. So, the choice has to be that patient has to be educated about that risk.

Pancreatitis    

Acute pancreatitis is a definitely medical emergency and we need to give large amounts of intravenous fluids and antibiotics are necessary. I don’t think that only ayurvedic treatment would be enough to manage.

But for chronic recurrent pancreatitis, contemporary medicine system doesn’t have any satisfactory solution whereas treatment like Arogyavardhini, Angitundi, Kumari asava is typical Pittaja Shoola chikitsa or if the patient has episodes of fever during that Mritunjaya rasa can be prescribed and gives a more reliable results way and the only thing is the treatment duration may have to be prolonged. It can be managed considering Pittaja shola management.

  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 pass 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 rescription 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 its affects the nourishment, produces any of systemic symptoms like Karshya, genral 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/ genral debility

Genral 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.

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 in our status.

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

  1. 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.

  1. 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.

Dyssynergia 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.

Rao/62af34c7a6bc2f087d6e3fb3ea391fbb7a887a7b/figure/0

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 have 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 dis synergia 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

Effect of biofeedback therapy on anorectal physiologicalparameters 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

Ajeerna – Malabsorption (unspecified) ICD code K90.9

It always related to food issues again, which are mention such as –

The special variety of Ajeerna, which is mentioned in Samhitas where is always related to food issues again

माधुर्यमन्नं गतमामसञ्ज्ञं विदग्धसञ्ज्ञं गतमम्लभावम् |

किञ्चिद्विपक्वं, भृशतोदशूलं विष्टब्धमानद्धविरुद्धवातम् ||५०२||

उद्गारशुद्धावपि भक्तकाङ्क्षा न जायते हृद्गुरुता च यस्य |

रसावशेषेण तु सप्रसेकं चतुर्थमेतत् प्रवदन्त्यजीर्णम् ||५०३||

मूर्च्छा प्रलापो वमथुः प्रसेकः सदनं भ्रमः |

उपद्रवा भवन्त्येते मरणं चाप्यजीर्णतः ||५०४||

तत्रामे लङ्घनं कार्यं, विदग्धे वमनं हितम् |

विष्टब्धे स्वेदनं पथ्यं, रसशेषे शयीत च ||५०५||

वामयेदाशु तं तस्मादुष्णेन लवणाम्बुना |

कार्यं वाऽनशनं तावद्यावन्न प्रकृतिं भजेत् ||५०६||

लघुकायमतश्चैनं लङ्घनैः समुपाचरेत् |

यावन्न प्रकृतिस्थः स्याद्दोषतः प्राणतस्तथा ||५०७|| (Su.Ut 46/502-507)

Basic treatment involves  ‘Langhana’.

Irritable Bowel Syndrome (Rome IV classification)

 

The current classification of the IBS, which I considered as a variety of Ajeerna, they are mainly categorized as –

IBS -D (diarrhoea predominant)

IBS -C (constipation predominant)

IBS -M (mixed diarrhoea and constipation)

IBS -U (unclassified; the symptoms cannot be categorized into one of the above three subtypes)

# This has a relevance to what Charaka has categorized the varieties like Vidagdha (diarrhoea prominent), Vishtabadh(constipation predominant)  etc.

And important is when the patient has any of those alarming signs like weight loss, iron deficiency anaemia, family history of certain organic GI illnesses then you need to thoroughly investigate rest of the conditions they can manage on the same lines of the Shokaja atisara.

Gut Brain Axis

Thakur AK, Shakya A. Husain GM, Emerald M. Kumar V (2014) Gut-Microbiota and Mental Health: Current and Future Perspectives. J Pharmacol Clin Toxicol 2(1):1016.

A large number of patients who have a neurological symptom, psychological symptoms/disorders, abnormal behaviours, anxiety, the basic cause could be in the abdomen. This is now  identified issue like a abnormality of the bowel. The presence of the bowel mucosa, these bacterial colonies would affect the site and many of those psychiatric conditions or the neurological conditions.

This is a very recently identified concept in the conemporary system whereas in ancient system has specified like –

Anna, which is one which makes it. So, the relationship of food and bowel movements in relation to the whole personality. And it is the new development from the contemporary point of view but this well known in text. So, hope of your personality, your activity, is dependent upon type of food which you consume and now we your gut brain axis but it is Satavik, Rajasik, and Tamasa Aahar rasa where you have the personality reflected.

This was a well-known and a strength of ayurveda and if we follow this regime of diet like Satvik Aahar and may avoid a Tamasik Aahar rasa that would be best of thing to prevent any of the diseases and maintain a hygiene .

Faecal Transplant

 

Mayer EA, Tillisch K, Gupta A. Gut/brain axis and the microbiota. J Clin Invest. 2015 Mar;125(3) 926-938. doi:10.1172/jci76304. PMID: 25689247; PMCID: PMC4362231.

One of the choices for chronic Clostridium infection is faecal transplant.

FDA released discretionary enforcement guidance in 2013. And large number of patients are being now treated with in USA but not in India. So, transplanting a healthy person’s gut organism it’s not really faces but the organism are separated from the faecal matter and transplanted into a person who has a very chronic infection. This has become a pattern of the treatment now. So, in the contemporary science to the important of the diet and food and that the possibility of a transplanting a healthy person’s organism to other has become may be the latest of the treatment.

Arshas

अर्शोतिसारग्रहणीविकाराः

प्रायेण चान्योन्यनिदानभूताः|

सन्नेऽनले सन्ति, न सन्ति दीप्ते,

रक्षेदतस्तेषु विशेषतोऽग्निम्||१६४||(A.H.Chi 8/164)

From ayurvedic point of view that Agni is be protected and if there is a agnimandhya or Agni is effected, it can produced a large number of condition like Arsha, Grahani, etc.

I also refer as this Arsha as Annavaha strotas dhusti.

From the basic approach management point, Vataja Arsha presents the feature of fissure and most of the time its accompanies type – I dyssynergia.

तत्र मारुतात् परिशुष्कारुणविवर्णानि विषममध्यानि कदम्बपुष्पतुण्डिकेरीनाडीमुकुलसूचीमुखाकृतीनि च भवन्ति; तैरुपद्रुतः सशूलं संहतमुपवेश्यते कटीपृष्ठपार्श्वमेढ्रगुदनाभिप्रदेशेषु चास्य वेदना भवन्ति, गुल्माष्ठीलाप्लीहोदराणि चास्य तन्निमित्तान्येव भवन्ति, कृष्णत्वङ्नखनयनदशनवदनमूत्रपुरीषश्च पुरुषो भवति ||(Su. Ni.2/10)

Typical presentation of Vataja Arsha

  1. Fissure/wound, tag like appearance
  2. Constipation
  3. Pain

Management

# if you have managed type I dyssynergia effectively, this can be prevented.

If patient has fissure treat Agnimandya more specifically.

Gandhaka rasayana

Kankayani vati

Avipathikar

Pittaja Arshas

Pitaja Arshas characteristic where the mass tends to get prolapse easily and once it gets collapsed it gets blocked, it doesn’t get reduced. And this is what we see in case of type 2 dyssynergia typically.

In this condition more bleeding, initially it will be bleeding you may not see the masses initially but once the masses come out, they tend to remain flashed out and they become painful.

Management

Gandhaka rasayana

Kamdugha

Avipathikara

Whereas the Raktaja Arshas you will have a strangulation and which is often seen in type 3 dyssynergia.

रक्तजानि न्यग्रोधप्ररोहविद्रुमकाकणन्तिकाफलसदृशानि पित्तलक्षणानि च, यदाऽवगाढपुरीषप्रपीडितानि भवन्ति तदाऽत्यर्थंदुष्टमनल्पमसृक्सहसा विसृजन्ति,तस्यचातिप्रवृत्तौ शोणितातियोगोपद्रवा भवन्ति ||१३||||(Su. Ni.2/13)

And once the patient has developed this presentation my prescription is –

Gandhaka rasayana

Kamadugha

Usheerasava/Draksharishta

श्लेष्मजानि श्वेतानि महामूलानि स्थिराणि वृत्तानि स्निग्धानि पाण्डूनि करीरपनसास्थिगोस्तनाकाराणि, न भिद्यन्ते न स्रवन्ति कण्डूबहुलानि च भवन्ति; तैरुपद्रुतः सश्लेष्माणमनल्पं मांसधावनप्रकाशमतिसार्यते, शोफशीतज्वरारोचकाविपाकशिरोगौरवाणि चास्य तन्निमित्तान्येव भवन्ति, शुक्लत्वङ्नखनयनदशनवदनमूत्रपुरीषश्च पुरुषो भवति ||१२|| (||(Su. Ni.2/12)

The third degree prolapse the patient would have usually the type 4 or the tone is reduced that could be a mass prolapsed and a persistent maximum mass which doesn’t get strangulated easily.

And in that condition my prescription would be –

Gandhaka rasayana

Chitrakadi vati

Manibhadra leha

# Surgery is an option

Sahaja Arshas is typical of either intestinal polyposis where essentially the surgical management is required where the patient would have systemic symptoms of anaemia.

Management of the Arshas according to ayurveda is divided into four categories.

चतुर्विधोऽर्शसां साधनोपायः |

तद्यथा- भेषजं क्षारोऽग्निः शस्त्रमिति |

तत्र, अचिरकालजातान्यल्पदोषलिङ्गोपद्रवाणि भेषजसाध्यानि, मृदुप्रसृतावगाढान्युच्छ्रितानि क्षारेण, कर्कशस्थिरपृथुकठिनान्यग्निना, तनुमूलान्युच्छ्रितानि क्लेदवन्ति च शस्त्रेण | (||(Su. Chi.6/3)

Modern guideline also is according to the same like only in grade one to grade three you can have a conservative management. Surgery is in one suggested only in the advanced conditions where either the medical treatment fails or there are some specific complications like prolapsed mass or thrombosed mass so majority of condition need to be treated medically.

Lohsiriwat V. Treatment of hemorrhoids: A coloproctologist’s view. World J Gastroenterol. 2015 Aug;21(31) 9245-9252. doi:10.3748/wjg. v21.i31.9245. PMID: 26309351; PMCID: PMC4541377.

One of common errors which are done by in the clinical practice, many of the physicians they miss the proctitis and they may diagnosis as a haemorrhoids and the usual management of haemorrhoids would be harmful.

Patient present with the bleeding per rectum or mass in the rectum need not always be haemorrhoids.

पित्तातिसारी यो मर्त्यः पित्तलान्यतिषेवते |

पित्तं प्रदुष्टं तस्याशु रक्तातीसारमावहेत् ||

ज्वरं शूलं तृषां दाहं गुदपाकं च दारुणम् |   (Su.Ut 40/116-117)

Proctitis is a complication of Gudapaka which is mention in Sushrut where patient presentation would be pain before and after defecation, mostly non constipation, frequency of stool increased, and patient would have a prolonged history and when you do the examination you can see that areas of the inflammation, mucosal congestion is seen and, in such conditions, never do any interventional treatment because any intervention producing more trouble to the patient. My choice of treatment would be

Gandhaka rasayana

Anandbhairava

Avipathikar choorna is better choice.

Worm Infestations

In text large number of varieties of worm described but from the practical point of view pinworms and roundworms effectively managed with the ayurvedic medicines. And I have a doubt in hookworm case is our medicine is useful or not because number of patients with that problem is lesser where I practice but in pinworm and roundworm ayurvedic treatment is much better than contemporary medicine.

श्वेताः सूक्ष्मास्तुदन्त्येते गुदं प्रतिसरन्ति च |

तेषामेवापरे पुच्छैः पृथवश्च भवन्ति हि ||९||

शूलाग्निमान्द्यपाण्डुत्वविष्टम्भबलसङ्क्षयाः |

प्रसेकारुचिहृद्रोगविड्भेदास्तु पुरीषजैः ||१०||

रक्ता गण्डूपदा दीर्घा गुदकण्डूनिपातिनः |

शूलाटोपशकृद्भेदपक्तिनाशकराश्च ते ||११|| |   (Su.Ut 54/9-11)

Prescription

Krimikuthara rasa

Gandhaka rasayana

Vidangarishta usually for 4 days and then to prevent the further growth

Arogyavardhina and Kumari asava as prakriti Vighata Chikitsa.

If necessary, it can be repeated after a month and two or three courses of four days would be effective.

 

Concept of Sushrut Annavaha srotas –

अन्नवहे द्वे, तयोर्मूलमामाशयोऽन्नवाहिन्यश्च धमन्यः, तत्र विद्धस्याध्मानं शूलोऽन्नद्वेषश्छर्दिः पिपासाऽऽन्ध्यं  मरणं च;(Su.Sha 9/12)

We need to identify the function of the gastrointestinal tract in the two ways like first part is consumption of food reaching up to the stomach where the food is consumed and retained, and the next part is a absorptive area.

Effects of Junk Food

A large number of patients the diseases are produced by the junk food. Every system of body could be affected due to the junk food, and it is well known. The basic causes for Agnimandhya are mentioned in Sushruta.

शुष्कं विरुद्धं विष्टम्भि वह्निव्यापदमावहेत् ||४९८|| (Su,Su 46/498)

s-of-fast-food.html

But unfortunately, the fast food or junk food market is increasing or it is becoming popular and the predicted this junk food market in 2024 will be quite alarming.

Another study which I felt like it would be relevant as another common cause for most the abnormalities and malfunctioning of the G.I.T. are consumption of unnecessary health promoting substances vitamins, tonics and so on. and it has become a habit of almost every patient would having any of these.

A large number of studies is done on over 992,129 participates healthy persons and 227 trails all over the world and this was analysed, published & the result are so called health promoting substances are harmful or no effect. And that’s another important issue. So they needs to be avoided.

Khan SU, Khan MU, Riaz H, et al. Effects of nutritional supplements and dietary interventions on cardiovascular outcomes. Ann Intern Med. 2019;171:190-198.

Hence, the carry home points are if you take care of the food, follow the regimes of the consumption of the food and the food in terms of given below sloka-

तत्र खल्विमान्यष्टावाहारविधिविशेषायतनानि भवन्ति; तद्यथा- प्रकृतिकरणसंयोगराशिदेशकालोपयोगसंस्थोपयोक्त्रष्टमानि (भवन्ति)||(Ch.Vi 1/21)

And the pattern of food consumption in terms of –

तत्रेदमाहारविधिविधानमरोगाणामातुराणां चापि केषाञ्चित् काले प्रकृत्यैव हिततमं भुञ्जानानां भवति- उष्णं, स्निग्धं, मात्रावत्, जीर्णे वीर्याविरुद्धम्, इष्टे देशे, इष्टसर्वोपकरणं, नातिद्रुतं, नातिविलम्बितम्, अजल्पन्, अहसन्, तन्मना भुञ्जीत, आत्मानमभिसमीक्ष्य सम्यक्||(Ch.Vi 1/24)

And these are the important assets, we must ensure, that culture is re-established and that would be helping the society quite significantly. Because careful assessment of the food and careful consumption of food can prevent the diseases and can help in a maintenance of the health of the society.

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