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<div style='text-align:justify;'>Chronic diarrhoea is a feature of malabsorption, excessively rapid entry of chyme into the small or large intestine generates propulsive motor patterns leading to accelerated transit. Inflammation is associated with decreased mixing motor patterns, but increased propulsive motility including high amplitude propagated contractions.<ref name="ref5">Spiller R. Role of motility in chronic diarrhoea. Neurogastroenterol Motil. 2006 Dec;18(12):1045-55</ref> Hence treatment of inflammation and correcting the excessive abnormal peristalsis is the treatment principle in certain chronic diarrhoea mostly associated with irritable bowel syndrome, Crohn’s disease & ulcerative colitis. Contents in piccha basti have anti-inflammatory and antidiarrheal properties. Moreover, basti treatment itself can set in the reverse peristaltic waves, which can slow down the high amplitude propagated contractions in the colon. Basti has direct access to the colon and rectum, thus drugs used in basti can directly reach the site of inflammation or ulcers without any alteration due to gastric contents. The small intestine is the excretory organ for the pitta & colon for vata in natural course. But diseases associated with the intestine can hamper the pitta and vata excretion. Pitta is excreted through small intestine by virechana therapy and vata from colon by basti. This brings dosha from shakha and marma to koshtha. Thus inflammation to these organs makes the patient ineligible for panchakarma therapy. Koshtha has to be capable of excreting dosha. Thus, it is inevitable to treat and heal the gut (koshtha) on priority either by drug or by basti treatment. </div>
<div style='text-align:justify;'>Chronic diarrhoea is a feature of malabsorption, excessively rapid entry of chyme into the small or large intestine generates propulsive motor patterns leading to accelerated transit. Inflammation is associated with decreased mixing motor patterns, but increased propulsive motility including high amplitude propagated contractions.<ref name="ref5">Spiller R. Role of motility in chronic diarrhoea. Neurogastroenterol Motil. 2006 Dec;18(12):1045-55</ref> Hence treatment of inflammation and correcting the excessive abnormal peristalsis is the treatment principle in certain chronic diarrhoea mostly associated with irritable bowel syndrome, Crohn’s disease & ulcerative colitis. Contents in piccha basti have anti-inflammatory and antidiarrheal properties. Moreover, basti treatment itself can set in the reverse peristaltic waves, which can slow down the high amplitude propagated contractions in the colon. Basti has direct access to the colon and rectum, thus drugs used in basti can directly reach the site of inflammation or ulcers without any alteration due to gastric contents. The small intestine is the excretory organ for the pitta & colon for vata in natural course. But diseases associated with the intestine can hamper the pitta and vata excretion. Pitta is excreted through small intestine by virechana therapy and vata from colon by basti. This brings dosha from shakha and marma to koshtha. Thus inflammation to these organs makes the patient ineligible for panchakarma therapy. Koshtha has to be capable of excreting dosha. Thus, it is inevitable to treat and heal the gut (koshtha) on priority either by drug or by basti treatment. </div>
== Properties of commonly used drugs in piccha basti: ==
<div style='text-align:justify;'>Shalmali i.e. Salmalia malabarica (DC.) Schott & Endl is the primary and common ingredient in all the classical formulations of piccha basti. This herb is included in purishavirajaniya, shonitasthapana, vedanasthapana kashaya. [Cha. Sa. Sutra Sthana 4/46-50] Gum resin and stem of shalmali both are used to prepare piccha basti. It has antibacterial, antioxidant, anti-inflammatory, anti-carcinogenic, immunomodulatory, hypolipidemic, antihyperglycemic and analgesic properties.<ref name="ref6">https://www.easyayurveda.com/2012/10/03/shalmali-silk-cotton-tree-ayurveda-use-formulations-home-remedies/ cited on 1.10.2022</ref> It has specific activities such as anti-HIV activity & anti-Helicobacter pylori activity.<ref name="ref7">Sarita Karole*, Dr. Greindra Gautam, Dr. Shailsh Gupta, Pharmacognostic And Pharmacological Profile Of Bombax Ceiba, Asian Journal of Pharmaceutical Education and Research, 2017, 6(3): 16-27</ref> <br/>Tannins and gallic acids present in mocharasa acts as astringents which precipitate proteins that are helpful in restoring the damaged epithelial mucosal lining of the ulcerated mucosa.<ref name="ref8">Jagtap AG, Niphadkar PV, Phadke AS. Protective effect of aqueous extract of Bombax malabaricum DC on experimental models of inflammatory bowel disease in rats and mice. Indian J Exp Biol 2011;49:343-51</ref> A gum resin rich in starch contents, mocharasa forms a mucilaginous layer that protects the inflamed and damaged intestinal mucosa. <br/>Nyagrodha (Ficus bengalensis Linn.), Udumbara (Ficus racemosa Linn.), and Ashwattha (Ficus religiosa Linn.) are used in piccha basti formulation. These are contents of panchavalkala with wound healing properties.<ref name="ref9">Dhurve, V., & Dudhamal, T. (2020, September 29). Wound healing potential of three forms of Panchavalkala in post-operative fistula wounds- Case Series. International Journal of AYUSH Case Reports, 4(3), 189-197.</ref> It also possesses antimicrobial and anticancer properties.<ref name="ref10">Aphale S, Pandita S, Raina P, Mishra J N, Kaul-Ghanekar R. Phytochemical standardization of panchavalkala: An ayurvedic formulation and evaluation of its anticancer activity in cervical cancer cell lines. Phcog Mag 2018;14:554-60</ref> Manjishtha (Rubia cordifolia L.), chandana (Santalum album L.), utpala (Nymphaea stellata Willd), madhuka (Glycyrrhiza glabra Linn.) used in piccha basti are cold in nature and pacify pitta dosha, which is vital for the reduction of inflammation. Badara (Ziziphus mauritiana Lamk)<ref name="ref11">https://www.iafaforallergy.com/herbs-a-to-z/badara-ziziphus-jujuba/ cited on 25.09.2022</ref>, nagabala (Sida Veronicaefolia)<ref name="ref12">https://www.easyayurveda.com/2012/10/03/nagabala-full-ayurvedic-details-usage-health-benefits-formulation/#properties cited on 25.09.2022</ref>, shleshmataka<ref name="ref13"> https://www.easyayurveda.com/2016/12/21/lasoda-cordia-dichotoma-shleshmataka/ cited on 25.09.2022</ref> (Cordia dichotoma G.Forsk.) are also helpful for pacifying pitta dosha and checking to bleed. Rakta basti (enema with fresh blood) is beneficial formulation that significantly improves hemoglobin level.<ref name="ref14">Abhijit Dinkarrao Shekhar, Role of Raktabasti In Pandu (Mycrocytic Hypocromic Anemia), World Journal Of Pharmaceutical And Medical Research, 2017,3(5), 146-151</ref> The use of rakta in basti formulation may be useful to overcome the anemia caused by blood loss through the colonic bleeding. Due to antibacterial and healing properties, pichha basti can be well deployed in fissure in ano. Piccha basti probably removes the accumulated secretions in the fissure bed, promotes healing and reduces secondary infection too. <br/>Honey and ghee together relieve the wound's warmth showing anti-inflammatory actions.<ref name="ref15">Charde MS, Fulzele SV, Satturwar PM, et al. Wound healing and anti-inflammatory potential of madhu-ghrita. Indian J Pharm Sci. 2006;68:26–31.</ref> Ghrita is a well-known remedy for vitiated pitta. Research has proven the wound-healing potential<ref name="ref16">Subrahmanyam M. Topical application of honey for burn wound treatment – an overview. Ann Burns Fire Disasters. 2007;20:137–140.</ref> of honey and its inhibitory effect on most strains of pathogenic bacteria. Also, the increase in resistant bacterial species has stressed using natural antibacterial agents.<ref name="ref17">Cooper RA, Molan PC, Harding KG (1999) Antibacterial activity of honey against strains of Staphylococcus aureus from infected wounds. J Roy Soc Med 283–285</ref> </div>
== Clinical indications of piccha basti: ==
<ol><li>Ulcerative colitis</li>
<li>Irritable bowel syndrome</li>
<li>Crohn’s disease</li>
<li>Chronic diarrhoea</li>
<li>Colorectal cancer</li>
<li>Bleeding piles</li>
<li>Celiac disease</li>
<li>Dysentery</li>
<li>Drug induced colitis</li>
<li>Enteropathic arthritis</li>
<li>Fissure in ano</li></ol>
== Further reading: ==
Following research works have been done to study effect of piccha basti as treatment modality.
<ol style='text-align:justify;'><li>Sharma P, Kajaria D. Efficacy of Piccha Basti and immune enhancer medicines in the management of ulcerative colitis. Indian Journal of Ayurveda integrative Medicine 2022; 3:41-6</li>
<li>Daberao, M. Role Of Piccha Basti In The Management Of Celiac Disease W.S.R To Grahani: A Review. IJ-RIM 2020, 4.</li>
<li>Sankal, Gurdipsingh and Behera (2018): Clinical Study on role of Piccna Basti in management of chronic colitis. Journal of Ayurveda Physicians and Surgeons July 2018 Volume 5(3) : 77</li>
<li>Dabas R, Gupta S, Kar AC. Picchabasti and Nilotpaladi yoga in the management of Ulcerative colitis. J AyuCaRe 2017;1(2): 10-15</li>
<li>Lovekrishna Pal Singh Rathore and Lakshman Singh, World Journal of Pharmaceutical Research, 2021, 10(13): 1290-1296</li>
<li>Bhausaheb A. Patange, Clinical Efficacy Of Piccha Basti Inparikartika (Fissure-In-Ano), Aayushi International Interdisciplinary Research Journal (AIIRJ), 2019, 6(12): 38-43</li>
<li>Dr. Aparna K., & Dr. Ananta S Desai. (2020). Ayurvedic management of Enteropathic arthritis : A Case Study. Journal of Ayurveda and Integrated Medical Sciences, 5(05), 501-504.</li>
<li>Pankaj Kumar, Sumit Kumar, Ragini Kumari, & Vijay Bahadur Singh. (2022). Ayurvedic Management of Ulcerative Colitis: A Case Study. International Journal of Ayurveda and Pharma Research, 10(6), 45-48.</li>
<li>Jha Shailesh Arunkumar, Pallavi A. Hegde, & M. M. Salimath. (2022). Lateral Fissure-In-Ano - A Case Study. Journal of Ayurveda and Integrated Medical Sciences, 6(6), 291 - 295.</li>
<li>Varsakiya JN, Goyal M, Kathad D, Kumari R. Efficacy of Ayurveda modalities in the management Raktaja pravahika (ulcerative colitis): A case report. J Ayurveda Case Rep 2021;4:115-20</li></ol>
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