Lecture Note: Anna Vaha Srotas – GIT Disorders .. Clinical Experience (Part-5)

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Anna Vaha Srotas – GIT Disorders
Clinical Experience

Part-5

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

Ajeerna – Malabsorption (unspecified) ICD code K90.9(1.36)

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

The specific 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
A large number of patients experiencing neurological symptoms, psychological disorders, abnormal behaviors, and anxiety may find the root cause in the abdomen. This issue has now been identified as an abnormality of the bowel. The presence of bacterial colonies in bowel mucosa could affect various sites and contribute to many psychiatric or neurological conditions. These conditions can be managed through a better diet and improved bowel movements.

(For further details readers may refer, 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.)

This is a very recently identified concept in the contemporary 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
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.

(For further details readers may refer,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.)

Arshas

अर्शोतिसारग्रहणीविकाराः
प्रायेण चान्योन्यनिदानभूताः|

सन्नेऽनले सन्ति, न सन्ति दीप्ते,
रक्षेदतस्तेषु विशेषतोऽग्निम्||
(A.H.Chi 8/164)

From ayurvedic point of view that Agni is be protected and if there is a Agnimandhya or Agni is affected, it can produce a large number of conditions 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.

Prescription includes-

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 ||
(Su. Ni.2/13)

And once the patient has developed this presentation my prescription would be –

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  ||
(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 guidelines also align with this approach, recommending conservative management for grades one to three. Surgery is suggested only in advanced conditions where either medical treatment fails or specific complications, such as a prolapsed or thrombosed mass, are present. The majority of conditions need to be treated medically. (For more details readers may refer, 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 common error observed in clinical practice is the tendency of many physicians to miss proctitis, often misdiagnosing it as haemorrhoids. The usual management for haemorrhoids may be harmful in cases of proctitis. Patients presenting with rectal bleeding or a rectal mass need not always have 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, as mentioned in Sushrut. The patient typically presents with pain before and after defecation, usually without constipation, increased stool frequency, and a prolonged medical history. Upon examination, areas of inflammation and mucosal congestion are visible. In such conditions, it is advisable not to pursue any interventional treatment, as it may exacerbate the patient’s symptoms. 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, Arogyavardhini 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 an 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 Agnimandya are mentioned in Sushruta.

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

But unfortunately, the fast food or junk food market is increasing or it is becoming popular and the predicted 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. Interventions such as a low-salt diet have a protective effect on all-cause mortality, while omega-3 fatty acids are protective against myocardial infarction and cardiovascular disease. Folic acid is also considered protective against stroke. However, the combination of calcium and vitamin D is deemed harmful in the context of stroke risk. Other interventions have no significant effect. The result is so called health promoting substances are harmful or no effect except low salt diet, omega 3 fatty acid and folic acid. And that’s another important issue. So, they need to be avoided.

 (For more details interested readers may refer 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 have to 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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