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|title=Atisara Chikitsa

|title=Atisara Chikitsa

== Tattva Vimarsha (Fundamental Principles) ==

== Tattva Vimarsha (Fundamental Principles) ==

*''Atisara'' is caused by intake of heavy to digest, excessively hot and food that is incompatible to the body, impairment of ''agni'' and mind. The body reacts to expel out the incompatible material out of gut in the form of ''atisara''.  

*''Atisara'' is caused by intake of heavy to digest, excessively hot and food that is incompatible to the body, impairment of [[agni]] and mind. The body reacts to expel out the incompatible material out of gut in the form of ''atisara''.  

*There are five categories of etio-pathological factors for ''atisara'':

*There are five categories of etio-pathological factors for ''atisara'':

#Reduced ''agni'',  

#Reduced [[agni]],  

#Vitiated ''vata'' and its sub types ''samana'' and ''apana''.  

#Vitiated [[vata]] and its sub types ''samana'' and ''apana''.  

#Vitiated body fluids.  

#Vitiated body fluids.  

#Vitiated  ''purishavaha srotas'' (lower gastro-intestinal tract) and organs of excretion.  

#Vitiated  ''purishavaha srotas'' (lower gastro-intestinal tract) and organs of excretion.  

#Fear and grief (mental).

#Fear and grief (mental).

*Interaction of ''prakriti'' (basic constitution) and the diet and lifestyle of similar properties (as that of ''dosha prakriti'') makes the person susceptible for ''atisara''.   

*Interaction of [[Prakriti]] (basic constitution) and the diet and lifestyle of similar properties (as that of [[dosha]] [[Prakriti]]) makes the person susceptible for ''atisara''.   

*The exogenous factors like consumption of intoxicating beverages, exposure to '''krimi''' (bacteria and parasites), other diseases like ''shosha, jwara, arsha'' influence all the above factors and three ''dosha'' to cause ''sannipatik atisara'' (diarrhea) which includes bloody diarrhea.

*The exogenous factors like consumption of intoxicating beverages, exposure to '''krimi''' (bacteria and parasites), other diseases like ''shosha, jwara, arsha'' influence all the above factors and three [[dosha]] to cause ''sannipatik atisara'' (diarrhea) which includes bloody diarrhea.

*If spicy, hot, dry food in large quantity is ingested when ''agni'' is low, undigested food becomes waste product and ''samana vata'' sends it to excretory channels where ''apana vayu'' increases the motility of ''purishavaha srotas'' to excretes these large waste products, frequently.  

*If spicy, hot, dry food in large quantity is ingested when [[agni]] is low, undigested food becomes waste product and samana [[vata]] sends it to excretory channels where ''apana vayu'' increases the motility of ''purishavaha srotas'' to excretes these large waste products, frequently.  

*To fill this vacuum created by expulsion of wastes, the body fluids shift to the gut and get expelled out as ''atisara''/diarrhea causing dehydration.Thus after involvement of ''purishavaha srotasa'' ( lower GIT), ''udakavaha srotasa'' (body fluids) is also predominantly involved in pathogenesis of ''atisara''.  

*To fill this vacuum created by expulsion of wastes, the body fluids shift to the gut and get expelled out as ''atisara''/diarrhea causing dehydration.Thus after involvement of ''purishavaha srotasa'' ( lower GIT), ''udakavaha srotasa'' (body fluids) is also predominantly involved in pathogenesis of ''atisara''.  

*Fear and grief are two important mental factors leading to ''atisara''. The presentation and treatment of this ''atisara'' is similar to ''vata'' dominant ''atisara''. The fear shall be treated with ''harshana''(exhilaration) treatment and grief shall be treated with ''ashwasana'' (consolation) therapy.     

*Fear and grief are two important mental factors leading to ''atisara''. The presentation and treatment of this ''atisara'' is similar to [[vata]] dominant ''atisara''. The fear shall be treated with ''harshana''(exhilaration) treatment and grief shall be treated with ''ashwasana'' (consolation) therapy.     

*The endogenous ''atisara'' shall be treated after proper assessment of dominant ''dosha'', causative factors and pacifying factors,   

*The endogenous ''atisara'' shall be treated after proper assessment of dominant [[dosha]], causative factors and pacifying factors,   

*At the initial stage of ''atisara'' when undigested food is being expelled, ''stambhan'' (anti diarrheal treatment) is strictly contraindicated. If ''stambhana'' is given, it leads to various complications. Mild laxatives like ''haritaki'' shall be administered for evacuating the ''mala'' (accumulated undigested wastes). ''Deepana'' and ''pachana'' (stimulation of ''agni'' for digestion and metabolism) should be given with light nutritive liquid foods. After restoration of ''agni, stambhan'' is given and care should taken to keep ''vata'' balanced.

*At the initial stage of ''atisara'' when undigested food is being expelled, ''stambhan'' (anti diarrheal treatment) is strictly contraindicated. If ''stambhana'' is given, it leads to various complications. Mild laxatives like ''haritaki'' shall be administered for evacuating the [[mala]] (accumulated undigested wastes). [[Deepana]] and [[pachana]] (stimulation of [[agni]] for digestion and metabolism) should be given with light nutritive liquid foods. After restoration of [[agni]], [[stambhana]] is given and care should taken to keep [[vata]] balanced.

*In case of prolapse of rectum, medicated ghee processed with sour herbs or ''anuvasana'' (unctuous enema) is prescribed.   

*In case of prolapse of rectum, medicated ghee processed with sour herbs or ''anuvasana'' (unctuous enema) is prescribed.   

*Various states of ''atisara'' like that mixed with mucous, blood, associated with colic pain shall be treated with ''pichcha basti'' (mucilaginous enema).  

*Various states of ''atisara'' like that mixed with mucous, blood, associated with colic pain shall be treated with pichcha [[basti]] (mucilaginous enema).  

*When ''kapha'' gets reduced because of the above mentioned therapeutic measures, the ''vata'' is aggravated in its own location (colon). This aggravated ''vata'' must be immediately treated as it may cause instantaneous death.

*When [[kapha]] gets reduced because of the above mentioned therapeutic measures, the [[vata]] is aggravated in its own location (colon). This aggravated [[vata]] must be immediately treated as it may cause instantaneous death.

*In case of ''sannipataja atisara'', at first the aggravated ''vata'' shall be pacified followed by ''pitta'' and ''kapha''. Alternatively, the most aggravated one should be controlled first followed by the treatment of the remaining two ''dosha''.

*In case of ''sannipataja atisara'', at first the aggravated [[vata]] shall be pacified followed by [[pitta]] and [[kapha]]. Alternatively, the most aggravated one should be controlled first followed by the treatment of the remaining two [[dosha]].

== Vidhi Vimarsha (Applied Inferences ) ==

== Vidhi Vimarsha (Applied Inferences ) ==

=== Pathophysiological factors of endogenous diarrhea ===

=== Pathophysiological factors of endogenous diarrhea ===

*Dosha: Vata dominant three dosha  

* [[Dosha]]: [[Vata]] dominant three [[dosha]]

*Dhatu (vitiated factors): Udaka (body fluid), Rasa dhatu   

* [[Dhatu]] (vitiated factors): Udaka (body fluid), [[Rasa dhatu]]  

*Mala kriya affected: Purisha (defecation)  

* [[Mala]] kriya affected: [[Purisha]] (defecation)  

*Status of agni: Manda (poor)   

* Status of [[agni]]: Manda (poor)   

*Origin of disease: Pakwashaya (large intestine)  

* Origin of disease: Pakwashaya (large intestine)  

*Sites of vitiation: large intestine  

* Sites of vitiation: large intestine  

*Sites of clinical presentation: rectum and anus  

* Sites of clinical presentation: rectum and anus  

*Srotasa involved: Purishavaha srotasa and udakavaha srotasa  

* Srotasa involved: Purishavaha srotasa and udakavaha srotasa  

*Type of samprapti: atipravritti (excess discharge)  

* Type of samprapti: atipravritti (excess discharge)

=== Management protocol of endogenous diarrhea ===

=== Management protocol of endogenous diarrhea ===

==== Subjective and objective parameters ====

==== Subjective and objective parameters ====

Frequency of bowel more than three times a day with stool weight less than 200 grams with more watery content are considered as diarrhea. The quantity is less in ''vata'' dominance, medium in ''pitta'' dominance and more in ''kapha'' dominant. Frequency is more in ''vata'' dominance, medium in ''pitta'' dominance and less in ''kapha'' dominance. The consistency of stool also differs according to ''dosha'' dominance as described in the text. ''Purisha pariksha'' (stool examination) is researched further in view of frequency, consistency, smell, its specific gravity in water to determine the ''ama'' and ''nirama'' status of ''purisha''.

Frequency of bowel more than three times a day with stool weight less than 200 grams with more watery content are considered as diarrhea. The quantity is less in [[vata]] dominance, medium in [[pitta]] dominance and more in [[kapha]] dominant. Frequency is more in [[vata]] dominance, medium in [[pitta]] dominance and less in [[kapha]] dominance. The consistency of stool also differs according to [[dosha]] dominance as described in the text.[[Purisha]] pariksha (stool examination) is researched further in view of frequency, consistency, smell, its specific gravity in water to determine the ''ama'' and ''nirama'' status of [[purisha]].

[[File:Atisara.png]]

[[File:Atisara.png]]

==== ''Atisara'' can be prevented by following measures ====

==== ''Atisara'' can be prevented by following measures ====

#Avoiding causative factors  

#Avoiding causative factors  

#Strengthening ''agni'' (digestive processes) by following dietary rules

#Strengthening [[agni]] (digestive processes) by following dietary rules

#Observing body purification treatments as per ''prakriti'' and season

#Observing body purification treatments as per [[Prakriti]] and season

==== Current clinical management in [[Ayurveda]] practice ====

==== Current clinical management in [[Ayurveda]] practice ====

*'''Principles of treatment''': ''deepana, grahi, pachana,'' buttermilk  

*'''Principles of treatment''': [[deepana]], grahi, [[pachana]], buttermilk  

*'''Main drugs''': ''kutaja, ahiphena, bhanga, bhallataka, bilva''

*'''Main drugs''': ''kutaja, ahiphena, bhanga, bhallataka, bilva''

! scope="col"| ''Anupana''

! scope="col"| ''Anupana''

|-

|-

| rowspan="2"|''Vata'' and ''kapha'' dominant

| rowspan="2"|[[Vata]] and [[kapha]] dominant

| ''Jatiphaladi–bhallataka guti''  

| ''Jatiphaladi–bhallataka guti''  

| 60-120 mg

| 60-120 mg

| Buttermilk

| Buttermilk

|-

|-

|''Pitta'' and ''kapha'' dominant

|[[Pitta]] and [[kapha]] dominant

| ''Kutaja kalpa''  

| ''Kutaja kalpa''  

| 60-120 mg

| 60-120 mg

| Ricewater with Buttermilk

| Ricewater with Buttermilk

|-

|-

|''Raktaja''

|[[Rakta]]ja

| ''Shatavaryadi kwatha''  

| ''Shatavaryadi kwatha''  

| 25-40 ml

| 25-40 ml

A combination of ''musta'' (cyperus rotundus), ''ativisha'' (aconitum heterophyllum), ''kutaja'' (holarrhena antidysenterica), ''chitraka'' (plumbago zeylanica) and ''bilva'' (Aegle marmelos) was found effective in management of ''atisara''.<ref>Sridhar B.N., Gopakumar K., Jaya N. Mustadi yoga-A new preparation for treatment of atisara. Aryavaidyan,10(4).May-July 1997;222-225. </ref>  

A combination of ''musta'' (cyperus rotundus), ''ativisha'' (aconitum heterophyllum), ''kutaja'' (holarrhena antidysenterica), ''chitraka'' (plumbago zeylanica) and ''bilva'' (Aegle marmelos) was found effective in management of ''atisara''.<ref>Sridhar B.N., Gopakumar K., Jaya N. Mustadi yoga-A new preparation for treatment of atisara. Aryavaidyan,10(4).May-July 1997;222-225. </ref>  

    

    

''Kutaja'' is widely used and first preferred drug in management of ''atisara''. It is mainly indicated in conditions of vitiated ''kapha-pitta'' and as a ''sangrahi'' (styptic) and ''shoshana'' (absorbent)(Charak sutra 25/40). In an in-vitro study, sterile double dilution aqueous extract of ''kutaja'' was found effective to inhibit growth of  E. coli, staphylococcus aureus, salmonella Typhi.<ref>Shrivastava Niraj, Saxena Varsha. Antibacterial activity of Kutaja(Holarrhena antidysenterica Linn.) in childhood diarrhea:-In vitro study. The Pharma Innovation Journal 2015;4(4):97-99 .</ref> Thus ''kutaja'' can be used for all purpose in management of ''atisara''.   

''Kutaja'' is widely used and first preferred drug in management of ''atisara''. It is mainly indicated in conditions of vitiated [[kapha]]-[[pitta]] and as a ''sangrahi'' (styptic) and ''shoshana'' (absorbent)(Charak sutra 25/40). In an in-vitro study, sterile double dilution aqueous extract of ''kutaja'' was found effective to inhibit growth of  E. coli, staphylococcus aureus, salmonella Typhi.<ref>Shrivastava Niraj, Saxena Varsha. Antibacterial activity of Kutaja(Holarrhena antidysenterica Linn.) in childhood diarrhea:-In vitro study. The Pharma Innovation Journal 2015;4(4):97-99 .</ref> Thus ''kutaja'' can be used for all purpose in management of ''atisara''.   

Nitin Salve and Debendranath Mishra studied the botanical identification of plants described in text Madhava chikitsa for the treatment of diarrhea.<ref>Nitin Salve, Debendranath Mishra. Botanical identification of plants described in text Madhava chikitsa for the treatment of diarrhoea. Anc Sci Life.2016 Apr-Jun:35(4):195-200 </ref>  

Nitin Salve and Debendranath Mishra studied the botanical identification of plants described in text Madhava chikitsa for the treatment of diarrhea.<ref>Nitin Salve, Debendranath Mishra. Botanical identification of plants described in text Madhava chikitsa for the treatment of diarrhoea. Anc Sci Life.2016 Apr-Jun:35(4):195-200 </ref>  

The conditions like ulcerative colitis, irritable bowel syndrome, acute diarrhea are considered under the umbrella of ''atisara''.

The conditions like ulcerative colitis, irritable bowel syndrome, acute diarrhea are considered under the umbrella of ''atisara''.

In a study on 43 patients of ulcerative colitis, Patel M.V.et.al observed 80% reduction in signs and symptoms of ulcerative colitis by Ayurvedic treatment. The treatment included ''udumbara kwatha'' combination of ''lodhra, musta, nagakeshara,mukta panchamrita rasa, kutaja ghana vati'' and ''udumbara kwatha basti''. It also highlighted disease modifying effect and reduction in use of steroidal drugs in the patients. <ref>Patel M.V.,Patel K.B., Gupta S.N. Effects of Ayurvedic treatment on forty three patients of ulcerative colitis. AYU,Oct-Dec 2010,31(4), 478-481.</ref>  

In a study on 43 patients of ulcerative colitis, Patel M.V.et.al observed 80% reduction in signs and symptoms of ulcerative colitis by Ayurvedic treatment. The treatment included ''udumbara kwatha'' combination of ''lodhra, musta, nagakeshara,mukta panchamrita rasa, kutaja ghana vati'' and udumbara kwatha [[basti]]. It also highlighted disease modifying effect and reduction in use of steroidal drugs in the patients. <ref>Patel M.V.,Patel K.B., Gupta S.N. Effects of Ayurvedic treatment on forty three patients of ulcerative colitis. AYU,Oct-Dec 2010,31(4), 478-481.</ref>  

A study found that a combination of ''nagarmotha'' (Cyperus rotundus L.), ''indrayava'' (Holarrhena antidysenterica (L.) Wall.), ''nagakeshara'' (Mesua ferrea L.), ''madhuyashti'' (Glycyrrhiza glabra L.), and ''amalaki'' (Emblica officinalis Gaertn.) powders,  along with ''dadimashtaka choorna, shankha bhasma, mustarista'' and ''dhanyapanchaka kvatha'' showed significant response in case of ''pravahika'' (irritable bowel syndrome). <ref>Pooja BA, Bhatted S. Ayurvedic management of Pravahika – A case report. Ayu 2015;36:410-2.  </ref>  

A study found that a combination of ''nagarmotha'' (Cyperus rotundus L.), ''indrayava'' (Holarrhena antidysenterica (L.) Wall.), ''nagakeshara'' (Mesua ferrea L.), ''madhuyashti'' (Glycyrrhiza glabra L.), and ''amalaki'' (Emblica officinalis Gaertn.) powders,  along with ''dadimashtaka choorna, shankha bhasma, mustarista'' and ''dhanyapanchaka kvatha'' showed significant response in case of ''pravahika'' (irritable bowel syndrome). <ref>Pooja BA, Bhatted S. Ayurvedic management of Pravahika – A case report. Ayu 2015;36:410-2.  </ref>  

#Harrison’s principles of internal medicine 17th Ed. (2008) Ed. by  Fauci Kasper D.L., A.S., Longo D.L., Braunwal Eugene, Hauser S.J., Jameson J.L.. Joseph Loscalzo., Pub. MacGraw-Hill USA, Vol.-2, Chapter 338.

#Harrison’s principles of internal medicine 17th Ed. (2008) Ed. by  Fauci Kasper D.L., A.S., Longo D.L., Braunwal Eugene, Hauser S.J., Jameson J.L.. Joseph Loscalzo., Pub. MacGraw-Hill USA, Vol.-2, Chapter 338.

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== References ==

== References ==