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|title=Grahani Chikitsa

|title=Grahani Chikitsa

|titlemode=append

|titlemode=append

|keywords=Digestion in Ayurveda, metabolism in Ayurveda, jatharagni, bhutagni, dhatvagni, grahani, grahanidosha, grahani roga, annavisha, atyagni, samashana, vishamashana, adhyashana

|keywords=Digestion in Ayurveda, metabolism in Ayurveda, jatharagni, bhutagni, dhatvagni, grahani, grahanidosha, grahani roga, annavisha, atyagni, samashana, vishamashana, adhyashana, Ayurveda, charak samhita, Indian system of medicine.

|description=Chikitsa Sthana Chapter 15. Management of Grahani (Diseases of digestion and metabolism)

|description=Chikitsa Sthana Chapter 15. Management of Grahani (Diseases of digestion and metabolism)

|image=http://www.carakasamhitaonline.com/mediawiki-1.32.1/resources/assets/ogimgs.jpg

|image=http://www.carakasamhitaonline.com/resources/assets/ogimgs.jpg

|image_alt=charak samhita

|image_alt=charak samhita

|type=article

|type=article

<big>'''[[Chikitsa Sthana]] Chapter 15. Management of Grahani (Diseases of digestion and metabolism) </big>'''

<big>'''[[Chikitsa Sthana]] Chapter 15. Management of Grahani (Diseases of digestion and metabolism) </big>'''

<big>'''Abstract </big>'''

<big>'''Abstract </big>'''

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== Introduction ==

== Introduction ==

Different theories of tissue nourishment as explained by the commentators play a crucial role in the entire process. The concept of ''upadhatu'' and ''dhatumala'' has also been dealt with. These descriptions are followed by the pathophysiology of ''grahanidosha'' syndrome and its management. This chapter underscores that the knowledge of physiology is crucial in understanding the pathophysiology and therapeutics of a disease.

Different theories of tissue nourishment as explained by the commentators play a crucial role in the entire process. The concept of ''upadhatu'' and ''dhatumala'' has also been dealt with. These descriptions are followed by the pathophysiology of ''grahanidosha'' syndrome and its management. This chapter underscores that the knowledge of physiology is crucial in understanding the pathophysiology and therapeutics of a disease.

Protection of ''agni'' is very essential in treatment of all diseases.(Chakrapani Ca.Ci.14/244-246 )''Arsha, atisara'' and ''grahanidosha'' are said to be ''paraspara hetu'' which means one disease becomes cause for another disease(Ca.Ci.14/244) e.g. in patients with chronic colitis, intestinal polyps are seen, in patients suffering from diarrhea colitis is observed. Therefore, one finds interrelation between these disorders and as explained earlier, special precaution should be taken with respect to ''agni bala''.  

Protection of ''agni'' is very essential in treatment of all diseases.[Chakrapani,Cha.Sa.[[ Chikitsa Sthana ]]14/244-246 ]''Arsha, atisara'' and ''grahanidosha'' are said to be ''paraspara hetu'' which means one disease becomes cause for another disease[Cha.Sa. [[ Chikitsa Sthana ]]14/244] e.g. in patients with chronic colitis, intestinal polyps are seen, in patients suffering from diarrhea colitis is observed. Therefore, one finds interrelation between these disorders and as explained earlier, special precaution should be taken with respect to ''agni bala''.  

Certain drugs like ''chitraka'' (Plumbago zeylanica), ''pippali'' (Piper longum), ''pippalimula'' (root of Piper longum), ''shunthi'' (Zingiber officinale), ''nagakesara, haridra, danti, duralabha, haritaki'' etc have been used in combinations with other drugs for the treatment of ''arsha'' considering the concept of ''agnibala vriddhi'' and ''vata anulomanam'' (facilitating passage of ''vata'') and the same drugs have been used in ''grahani chikitsa'' with the same concept. Charak explains that all the above three diseases are caused by ''agnimandya'' and if increase in ''agni'' is done then relief in the disease takes place. (Chakrapani  Ca.Ci.14/244-246)

Certain drugs like ''chitraka'' (Plumbago zeylanica), ''pippali'' (Piper longum), ''pippalimula'' (root of Piper longum), ''shunthi'' (Zingiber officinale), ''nagakesara, haridra, danti, duralabha, haritaki'' etc have been used in combinations with other drugs for the treatment of ''arsha'' considering the concept of ''agnibala vriddhi'' and ''vata anulomanam'' (facilitating passage of ''vata'') and the same drugs have been used in ''grahani chikitsa'' with the same concept. Charak explains that all the above three diseases are caused by ''agnimandya'' and if increase in ''agni'' is done then relief in the disease takes place. [Chakrapani  Cha.Sa.[[Chikitsa Sthana]] 14/244-246]

Further, ''vata'' is said to be ''agnisakha'' i.e. ''agnibala'' depends on ''vata''. ''Vatakshaya'' or ''prakopa'' results in ''agnimandya''. Therefore, ''anna, pana'' and ''ausadha'' which bring about ''vata anulomana'' are very useful in treatment of diseases like ''arsha'' and ''grahani dosha''.  

Further, ''vata'' is said to be ''agnisakha'' i.e. ''agnibala'' depends on ''vata''. ''Vatakshaya'' or ''prakopa'' results in ''agnimandya''. Therefore, ''anna, pana'' and ''ausadha'' which bring about ''vata anulomana'' are very useful in treatment of diseases like ''arsha'' and ''grahani dosha''.  

''Vata anulomanam'' means to facilitate the ''gati'' (motion) of ''vata'' downwards to anus. Among five types of ''vata, samana'' and ''apana'' have major role in diseases like ''arsha, atisara'' and ''grahanidosha''. Obstruction to movement of ''vata'' (''avarudha gati'') or diarrhea (''atisaraṇa'') leads to ''agni kshaya''. ''Avarudha gati'' is the cause for ''vibandha'' (constipation), ''malavibandha'' (obstruction to feces) along with ''pravahana'' (urge to defecate) which increases the intra-lumen pressure leading to incompetency of valves in rectal veins leading to their varicosity which causes hemorrhoids where as ''atisarana'' (diarrhea) causes increased motility of intestine. Hence ''vata anulomanam'' should not be understood as ''virechana'' or laxation but regularization of ''vata gati'' so that there is no ''avarodha'' or ''atisarana''. The same concept of ''vata anulomana'' is also mentioned in [[Grahani Chikitsa]].(Ca.Ci.14/247)

''Vata anulomanam'' means to facilitate the ''gati'' (motion) of ''vata'' downwards to anus. Among five types of ''vata, samana'' and ''apana'' have major role in diseases like ''arsha, atisara'' and ''grahanidosha''. Obstruction to movement of ''vata'' (''avarudha gati'') or diarrhea (''atisaraṇa'') leads to ''agni kshaya''. ''Avarudha gati'' is the cause for ''vibandha'' (constipation), ''malavibandha'' (obstruction to feces) along with ''pravahana'' (urge to defecate) which increases the intra-lumen pressure leading to incompetency of valves in rectal veins leading to their varicosity which causes hemorrhoids where as ''atisarana'' (diarrhea) causes increased motility of intestine. Hence ''vata anulomanam'' should not be understood as ''virechana'' or laxation but regularization of ''vata gati'' so that there is no ''avarodha'' or ''atisarana''. The same concept of ''vata anulomana'' is also mentioned in [[Grahani Chikitsa]].[Cha.Sa. [[Chikitsa Sthana]] 14/247]

Therefore, the line of treatment used in ''arsha'' with regard to ''agni bala'' and ''vata anulomanam'' is basically similar to that of ''grahanidosha'' hence Charak has explained [[Grahani Chikitsa]] after [[Arsha Chikitsa]].( Chakrapani  Ca.Ci.15/1) Charak could have restricted the name of chapter to [[Grahani Chikitsa]] i.e. treatment of the ''avayava grahani'' whereas he has increased the scope of chapter by using the word ''grahanidosha''.(Chakrapani  Ca.Ci.15/1).

Therefore, the line of treatment used in ''arsha'' with regard to ''agni bala'' and ''vata anulomanam'' is basically similar to that of ''grahanidosha'' hence Charak has explained [[Grahani Chikitsa]] after [[Arsha Chikitsa]].[Chakrapani  Cha.Sa.[[Chikitsa Sthana]]15/1] Charak could have restricted the name of chapter to [[Grahani Chikitsa]] i.e. treatment of the ''avayava grahani'' whereas he has increased the scope of chapter by using the word ''grahanidosha''.[Chakrapani, Cha.Sa. [[Chikitsa Sthana]] 15/1].

There is always an inter-relationship between ''avayava'' (organ) and ''avayavi'' (part of organ) or ''ashraya''(seat) and ''ashrayi'' (seated). Either of the one has an impact on the other, hence if ''grahaniavayava'' is in normal state then ''agni'' the ''avayavi'' functions normally and vice versa also holds true, whereas if ''dusti'' of ''grahani'' takes place ''agni vaishamyata'' (imbalance) is seen e.g. ileitis, wherein digestion is hampered. ''Grahani'' is the seat for ''jatharagni''. (Ca.Ci.15 /56) ''Agni'' is responsible for ''ayu'' (longevity of life), ''varna'' (complexion), ''bala'' (strength), ''svasthya'' (health), ''utsaha'' (enthusiasm), ''upachaya'' (proper metabolism), ''prabha'' (glow) and ''oja'' (core energy). ''Prakrita agni'' (normal digestive power) is essential for long and healthy life while, vitiated ''agni'' is responsible for ''roga avastha''(disease).(Ca. Ci. 15/3-4)

There is always an inter-relationship between ''avayava'' (organ) and ''avayavi'' (part of organ) or ''ashraya''(seat) and ''ashrayi'' (seated). Either of the one has an impact on the other, hence if ''grahaniavayava'' is in normal state then ''agni'' the ''avayavi'' functions normally and vice versa also holds true, whereas if ''dusti'' of ''grahani'' takes place ''agni vaishamyata'' (imbalance) is seen e.g. ileitis, wherein digestion is hampered. ''Grahani'' is the seat for ''jatharagni''. [Cha.Sa.[[Chikitsa Sthana]] 15 /56] ''Agni'' is responsible for ''ayu'' (longevity of life), ''varna'' (complexion), ''bala'' (strength), ''svasthya'' (health), ''utsaha'' (enthusiasm), ''upachaya'' (proper metabolism), ''prabha'' (glow) and ''oja'' (core energy). ''Prakrita agni'' (normal digestive power) is essential for long and healthy life while, vitiated ''agni'' is responsible for ''roga avastha''(disease).[Cha. Sa. [[Chikitsa Sthana]] 15/3-4]

In this chapter, Charak describes formation of body tissues in detail with the role of ''ahara'' which is supplied continuously to maintain homeostasis. ''Vyana vata'' is promoter of ''rasa raktadi'' circulation.( Ca. Ci. 15/36) It transports ''rasa raktadi drava'' ''dhatu'' throughout body continuously and as per metabolic demand. This explanation shows that closed circulation in human was known to Charak.

In this chapter, Charak describes formation of body tissues in detail with the role of ''ahara'' which is supplied continuously to maintain homeostasis. ''Vyana vata'' is promoter of ''rasa raktadi'' circulation.[ Cha. Sa. [[Chikitsa Sthana]] 15/36] It transports ''rasa raktadi drava'' ''dhatu'' throughout body continuously and as per metabolic demand. This explanation shows that closed circulation in human was known to Charak.

''Grahani'' is prime place where digestion and absorption of ''ahara rasa'' takes place. ''Ahara rasa'' provides nutrition for the ''rasadi sapta dhatu'', along-with three ''sharirika dosha'' and three ''manasika dosha''. Nourishment of ''sattva, raja'' and ''tama'' is influenced by ''sattvika, rajasika'' and ''tamasika ahara''. ''Tamasika'' and ''rajasika ahara'' suppresses ''sattva guna'' thereby causing ''alpa sattva'' in individual, a common predisposing factor of psychiatric disorders for e.g. ''alpa sattva'' as mentioned in ''unmada'' (Ca. Ci. 9/5)In ''vataja grahanivyadhishanka'' (feeling of suffering from disease) manifests in patients with ''alpa sattva''.  

''Grahani'' is prime place where digestion and absorption of ''ahara rasa'' takes place. ''Ahara rasa'' provides nutrition for the ''rasadi sapta dhatu'', along-with three ''sharirika dosha'' and three ''manasika dosha''. Nourishment of ''sattva, raja'' and ''tama'' is influenced by ''sattvika, rajasika'' and ''tamasika ahara''. ''Tamasika'' and ''rajasika ahara'' suppresses ''sattva guna'' thereby causing ''alpa sattva'' in individual, a common predisposing factor of psychiatric disorders for e.g. ''alpa sattva'' as mentioned in ''unmada'' [Cha.Sa [[Chikitsa Sthana]] 9/5] In ''vataja grahanivyadhishanka'' (feeling of suffering from disease) manifests in patients with ''alpa sattva''.  

Homeostasis at cellular level and gross level is maintained by ''vata, pitta'' and ''kapha'' in which digestive and metabolic contributions are due to ''agni''. This chapter has been dedicated to ''agni'' to understand the manner in which it gets vitiated by ''dosha'' and accordingly the line of treatment for the ''agni dosha'' is explained. As the functions of ''agni'' take place in ''grahani'' hence disease related to ''grahani'' has been given the name.

Homeostasis at cellular level and gross level is maintained by ''vata, pitta'' and ''kapha'' in which digestive and metabolic contributions are due to ''agni''. This chapter has been dedicated to ''agni'' to understand the manner in which it gets vitiated by ''dosha'' and accordingly the line of treatment for the ''agni dosha'' is explained. As the functions of ''agni'' take place in ''grahani'' hence disease related to ''grahani'' has been given the name.

Secondly, ''pandu roga'' is due to ''alpata'' of ''raktaposhaka sara bhaga'' (Chakrapani Ca. Ci. 16/3-7) and, one of the main causes of this ''alpata'' is mal-digestion and mal-absorption which takes place in ''grahani''. It is well known fact, that various contributory factors for blood formation have their absorption in gastrointestinal tract such as folic acid, vitamin B12, iron, etc which if not absorbed causes anemia this is the reason why Charak has placed this chapter in between ''arsha'' and ''pandu roga''.

Secondly, ''pandu roga'' is due to ''alpata'' of ''raktaposhaka sara bhaga'' [Chakrapani, Cha. Sa. [[Chikitsa Sthana]] 16/3-7] and, one of the main causes of this ''alpata'' is mal-digestion and mal-absorption which takes place in ''grahani''. It is well known fact, that various contributory factors for blood formation have their absorption in gastrointestinal tract such as folic acid, vitamin B12, iron, etc which if not absorbed causes anemia this is the reason why Charak has placed this chapter in between ''arsha'' and ''pandu roga''.

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== Sanskrit Text, Transliteration and English Translation ==

== Sanskrit Text, Transliteration and English Translation ==

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In patients with ''vataja grahani'' after ascertaining that ''ama'' is digested, medicated ghee starting with very minimum quantity prepared from ''deepaneeya gana'' be administered [Ca.Su.4/9/6]- [77]

In patients with ''vataja grahani'' after ascertaining that ''ama'' is digested, medicated ghee starting with very minimum quantity prepared from ''deepaneeya gana'' be administered [Cha.Sa.[[Sutra Sthana ]]4/9/6]- [77]

=== ''Niruha basti'' ===

=== ''Niruha basti'' ===

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''Tikta ghrita'' as mentioned in [[Kushtha Chikitsa]] [Ca.Ci.7/140-150] may also be prescribed in ''pittaja grahani'' [128]

''Tikta ghrita'' as mentioned in [[Kushtha Chikitsa]] [Cha. Sa. [[Chikitsa Sthana]] 7/140-150] may also be prescribed in ''pittaja grahani'' [128]

=== ''Nagaradya churna'' ===

=== ''Nagaradya churna'' ===

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''Satpala ghrita'' (Ca.Ci. 5/147-148) and ''bhallataka ghrita'' (Ca.Ci.5/143-146) as explained in [[Gulma Chikitsa]] may also be administered [170]

''Satpala ghrita'' [Cha.Sa. [[Chikitsa Sthana]]. 5/147-148] and ''bhallataka ghrita'' [Cha.Sa.[[ Chikitsa Sthana ]]5/143-146] as explained in [[Gulma Chikitsa]] may also be administered [170]

=== ''Ksharaghrita'' ===

=== ''Ksharaghrita'' ===

''Accha pitta'' is ‘liquid’ in nature, released in the duodenum and can be correlated with bile.  

''Accha pitta'' is ‘liquid’ in nature, released in the duodenum and can be correlated with bile.  

''Pachaka pitta'' has the functional site between ''amashaya'' (stomach) and ''pakvashaya'' (colon), which is indicative of small intestine. It is composed of five ''mahabhutas'' but the ''agni mahabhuta'' is predominant; and hence, it becomes devoid of fluidity and therefore is also known as ''agni''. It splits the food into sāra (nutritive) and ''kitta'' (non-nutritive) portions. (Ashtanga Hridaya, Sutra Sthana, 12/10-12).

''Pachaka pitta'' has the functional site between ''amashaya'' (stomach) and ''pakvashaya'' (colon), which is indicative of small intestine. It is composed of five ''mahabhutas'' but the ''agni mahabhuta'' is predominant; and hence, it becomes devoid of fluidity and therefore is also known as ''agni''. It splits the food into sāra (nutritive) and ''kitta'' (non-nutritive) portions.<ref>Vagbhata. Sutra Sthana, Cha.12 Doshabhediya Adhyaya verse 10-12. In: Harishastri Paradkar Vaidya, Editors. Ashtanga Hridayam. 1st ed. Varanasi: Krishnadas Academy;2000.p.4.</ref>

''Sara'' of the food is the minutest fraction (''parama sukshma''). This portion reaches the heart in the form of ''ahara rasa''. From the heart, it then gets re-distributed into 24 pulsatile vessels to be carried into the whole body. (Sushruta Samhita, Sutra Sthana, 14/3)

''Sara'' of the food is the minutest fraction (''parama sukshma''). This portion reaches the heart in the form of ''ahara rasa''. From the heart, it then gets re-distributed into 24 pulsatile vessels to be carried into the whole body.<ref>Sushruta. Sutra Sthana, Cha.14 Shonitavarnaniya Adhyaya verse 3. In: Jadavaji Trikamji Aacharya, Editors. Sushruta Samhita. 8th ed. Varanasi: Chaukhambha Orientalia;2005. p.1</ref>

The portion that reaches the colon is the one that is designated as ''kitta''. During the third stage of digestion, there occurs the solidification of fecal matter and formation of certain pungent gases such as ammonia, methane, hydrogen sulfide etc. The term ''pakva'' in this context indicates ''pakva mala''; not ''pakva ahara'' (Verse 9-11).

The portion that reaches the colon is the one that is designated as ''kitta''. During the third stage of digestion, there occurs the solidification of fecal matter and formation of certain pungent gases such as ammonia, methane, hydrogen sulfide etc. The term ''pakva'' in this context indicates ''pakva mala''; not ''pakva ahara'' (Verse 9-11).

=== Causes of ''grahani'' disorder ===

=== Causes of ''grahani'' disorder ===

''Abhojana'' (starvation) leads to increase in ''vata'' and in turn ''agnimandya''.(Ca.Vi/ 2/7) Starvation and protein malnutrition disrupts the normal indigenous gastrointestinal tract micro-flora and impairs host antibacterial defenses. Both starvation and protein malnutrition increases the cecal levels of gram negative enteric bacilli and decrease the level of lactobacillus and promote growth of anaerobes that in turn disturb the gut flora. Gut flora also known as gut microbiome has a unique role in digestion and absorption. Once the gut microbiome gets vitiated it leads to indigestion and malabsorption.

''Abhojana'' (starvation) leads to increase in ''vata'' and in turn ''agnimandya''.[Cha. Sa. [[Vimana Sthana]] 2/7] Starvation and protein malnutrition disrupts the normal indigenous gastrointestinal tract micro-flora and impairs host antibacterial defenses. Both starvation and protein malnutrition increases the cecal levels of gram negative enteric bacilli and decrease the level of lactobacillus and promote growth of anaerobes that in turn disturb the gut flora. Gut flora also known as gut microbiome has a unique role in digestion and absorption. Once the gut microbiome gets vitiated it leads to indigestion and malabsorption.

''Atibhojana'' (excessive intake) causes provocation of all the ''dosha'' and thereby causing ''agnimandya''. Protein rich diet or fat laden diet or excessive diet takes longer time for emptying of stomach. Longer stay of food explains increase of acidic pH. Therefore, whenever such chyme enters the duodenum the liver and pancreas need to increase secretion of alkali pH. Repeated, such dietary habits lead to indigestion. Further increase of alkali pH causes reduced transit time in small intestine leading to the symptoms like diarrhea.  Diet which is ''atiguru'' (heavy) and indulging ''vishamashana''( irregular food habit) will have similar effect. ''Atiruksha ahara'' or  diet has low protein value. Protein malnutrition leads to decrease of enzyme secretion as proteins are the building blocks of enzymes. ''Asatmya desha, kala, ritu'' only explain the dietary changes which dramatically alter the balance of bacteria in the gut on daily basis. Research shows that these fluctuations could lead to various digestive and absorptive problems. ''Dushita bhojana'' or contaminated food reacts directly with intestinal flora disturbing their quantitative and qualitative growth causing indigestion. Intake of unctuous substances in ''sama pitta'' condition leads to ''grahani dosha'' and various other disorders.( Ca. Su 13/76 ) Emaciation due to disease also has its own impact on digestion. ''Mandagni'' is a causative factor for all diseases but if patient continuously indulges in ''apathya'' then complications may increase or the prognosis turns bad.  

''Atibhojana'' (excessive intake) causes provocation of all the ''dosha'' and thereby causing ''agnimandya''. Protein rich diet or fat laden diet or excessive diet takes longer time for emptying of stomach. Longer stay of food explains increase of acidic pH. Therefore, whenever such chyme enters the duodenum the liver and pancreas need to increase secretion of alkali pH. Repeated, such dietary habits lead to indigestion. Further increase of alkali pH causes reduced transit time in small intestine leading to the symptoms like diarrhea.  Diet which is ''atiguru'' (heavy) and indulging ''vishamashana''( irregular food habit) will have similar effect. ''Atiruksha ahara'' or  diet has low protein value. Protein malnutrition leads to decrease of enzyme secretion as proteins are the building blocks of enzymes. ''Asatmya desha, kala, ritu'' only explain the dietary changes which dramatically alter the balance of bacteria in the gut on daily basis. Research shows that these fluctuations could lead to various digestive and absorptive problems. ''Dushita bhojana'' or contaminated food reacts directly with intestinal flora disturbing their quantitative and qualitative growth causing indigestion. Intake of unctuous substances in ''sama pitta'' condition leads to ''grahani dosha'' and various other disorders.[ Cha. Sa. [[Sutra Sthana]] 13/76] Emaciation due to disease also has its own impact on digestion. ''Mandagni'' is a causative factor for all diseases but if patient continuously indulges in ''apathya'' then complications may increase or the prognosis turns bad.  

Suppression of manifested natural urges may have impact on nervous system resulting in effect  either on enzymatic secretion or on the hormonal secretion.These factors have role in digestion and absorption as may be understood in case of ''adhovata'' (accumulation of ''vata'' in rectum and pelvic region) and ''purisha vegadharana'' (suppression of urge of defecation), wherein regular urge suppression disturbs the intestinal pro-kinetic movement.( Ca. Su. 7/ 6,8,12) Disturbed pro-kinesia increases the transit time leading to the change in pH which further has its impact on electrolytes and enzymatic secretion leading to reduced digestive power (''agnimandya'').  

Suppression of manifested natural urges may have impact on nervous system resulting in effect  either on enzymatic secretion or on the hormonal secretion.These factors have role in digestion and absorption as may be understood in case of ''adhovata'' (accumulation of ''vata'' in rectum and pelvic region) and ''purisha vegadharana'' (suppression of urge of defecation), wherein regular urge suppression disturbs the intestinal pro-kinetic movement.[Cha. Sa. [[Sutra Sthana ]] 7/ 6,8,12] Disturbed pro-kinesia increases the transit time leading to the change in pH which further has its impact on electrolytes and enzymatic secretion leading to reduced digestive power (''agnimandya'').  

Further ''kshudha vegadharana'' (avoiding sense of hunger) effect will be similar to ''abhojana'' (not eating). It may also be noted that repeated ''kshudha vegadharana''  leads to atrophy of the stomach which further weakens the perception of hunger which is controlled by the percentage of the stomach that remains empty similar to the explanation given by Charak that excessive fasting leads to diminution in ''agni''.(Ca.Su.22/37) ''Trishna vegadharana'' (avoiding thirst) leads to reduced fluid balance in the body.  

Further ''kshudha vegadharana'' (avoiding sense of hunger) effect will be similar to ''abhojana'' (not eating). It may also be noted that repeated ''kshudha vegadharana''  leads to atrophy of the stomach which further weakens the perception of hunger which is controlled by the percentage of the stomach that remains empty similar to the explanation given by Charak that excessive fasting leads to diminution in ''agni''.[Cha.Sa. [[Sutra Sthana]] 22/37] ''Trishna vegadharana'' (avoiding thirst) leads to reduced fluid balance in the body.  

Nearly seven liters of water is secreted during various gastrointestinal secretions. Reduced water intake in long term will reduce gastrointestinal secretion leading to impaired digestion.  

Nearly seven liters of water is secreted during various gastrointestinal secretions. Reduced water intake in long term will reduce gastrointestinal secretion leading to impaired digestion.  

Exogenous and endogenous factors vitiate the doṣha which when associated with ama produce either local or systemic disorders.  

Exogenous and endogenous factors vitiate the doṣha which when associated with ama produce either local or systemic disorders.  

''Tridosha'' play role in impairing immunity and depending on the dominance of a particular ''dosha'' they are classified as ''vataja, pittaka'' and ''kaphaja'' disorders.(Ca. Su. 28/7)

''Tridosha'' play role in impairing immunity and depending on the dominance of a particular ''dosha'' they are classified as ''vataja, pittaka'' and ''kaphaja'' disorders.[Cha.Sa. [[Sutra Sthana]] 28/7]

=== Equilibrium of ''agni'' ===

=== Equilibrium of ''agni'' ===

''Timira'' (blurred vision) results from vitamin A malabsorption and anemia.

''Timira'' (blurred vision) results from vitamin A malabsorption and anemia.

Tinnitus is a symptom also found in ''Pandu'' (anemia)(Ca. Ci. 15/61), which is observed due to malabsorption of essential elements like vitamin B12.

Tinnitus is a symptom also found in ''Pandu'' (anemia)[Cha. Sa. [[Chikitsa Sthana]] 15/61], which is observed due to malabsorption of essential elements like vitamin B12.

Pain in flanks, thigh, pelvis, cervical area occurs due to calcium and Vitamin D malabsorption. Pain is also contributed by protein deficiency due to low nutritional diet, osteoporosis, anemia and decrease lactic acid neutralization due to reduce peripheral circulation.  

Pain in flanks, thigh, pelvis, cervical area occurs due to calcium and Vitamin D malabsorption. Pain is also contributed by protein deficiency due to low nutritional diet, osteoporosis, anemia and decrease lactic acid neutralization due to reduce peripheral circulation.  

Indigestion causes depletion of beneficial gut bacteria thus breakdown in the balance between the putative protective and harmful intestinal bacteria leads to chronic inflammation.  

Indigestion causes depletion of beneficial gut bacteria thus breakdown in the balance between the putative protective and harmful intestinal bacteria leads to chronic inflammation.  

Antigenic nature of endogenous factors can be understood when helpful bacteria and ''ushna, teekshna guna'' of ''kapha'' trigger inflammatory response leading to autoimmune pathogenesis.

Antigenic nature of endogenous factors can be understood when helpful bacteria and ''ushna, teekshna guna'' of [[pitta dosha]] trigger inflammatory response leading to autoimmune pathogenesis.

In case of hypersecretion of gastrin in gastrinoma (Zollingers – Ellison Syndrome) stimulate the parietal cells of the stomach to secrete acid to their maximal capacity and increase the parietal cell mass three to six fold. The acid output may be so great that it reaches the upper small intestine reducing the luminal pH to two or less.

In case of hypersecretion of gastrin in gastrinoma (Zollingers – Ellison Syndrome) stimulate the parietal cells of the stomach to secrete acid to their maximal capacity and increase the parietal cell mass three to six fold. The acid output may be so great that it reaches the upper small intestine reducing the luminal pH to two or less.

Bile acids are not present in the diet but are synthesized in the liver by a series of enzymatic steps that also include cholesterol catabolism. Bile acids are either primary or secondary. Primary bile acids are synthesized in the liver from cholesterol and secondary bile acids are synthesized from primary bile acids in the intestine by colonic bacterial enzymes. Bile acids are primarily absorbed by active, sodium dependent process that is located exclusively in the ileum; secondly bile acids can also be absorbed to a lesser extent by non carrier mediated transport processes in the jejunum, ileum and colon. Conjugated bile acids that enter the colon are de-conjugated by colonic bacterial enzyme to unconjugated bile acids and are rapidly absorbed. Colonic bacterial enzymes also dehydroxylate bile acids to secondary bile acids, thus if exogenous factors like diet as discussed above disturb the colonic bacterial growth than bile acids are not absorbed. A decrease in the amount of bile acids returning to the liver from the intestine is associated with an increase in bile acids synthesis/cholesterol catabolism, which helps keep bile acid pool size relatively constant. Defects in any of the steps of the enterohepatic circulation of bile acids can result in decrease in duodenal concentration of conjugated bile acids as a result steatorrhea. Thus steatorrhea can be caused by abnormalities in bile acid synthesis and excretion, their physical state in the intestinal lumen and reabsorption. The bile gives the yellowish nature to the stools  (Verse 66).

Bile acids are not present in the diet but are synthesized in the liver by a series of enzymatic steps that also include cholesterol catabolism. Bile acids are either primary or secondary. Primary bile acids are synthesized in the liver from cholesterol and secondary bile acids are synthesized from primary bile acids in the intestine by colonic bacterial enzymes. Bile acids are primarily absorbed by active, sodium dependent process that is located exclusively in the ileum; secondly bile acids can also be absorbed to a lesser extent by non carrier mediated transport processes in the jejunum, ileum and colon. Conjugated bile acids that enter the colon are de-conjugated by colonic bacterial enzyme to unconjugated bile acids and are rapidly absorbed. Colonic bacterial enzymes also dehydroxylate bile acids to secondary bile acids, thus if exogenous factors like diet as discussed above disturb the colonic bacterial growth than bile acids are not absorbed. A decrease in the amount of bile acids returning to the liver from the intestine is associated with an increase in bile acids synthesis/cholesterol catabolism, which helps keep bile acid pool size relatively constant. Defects in any of the steps of the enterohepatic circulation of bile acids can result in decrease in duodenal concentration of conjugated bile acids as a result steatorrhea. Thus steatorrhea can be caused by abnormalities in bile acid synthesis and excretion, their physical state in the intestinal lumen and reabsorption. The bile gives the yellowish nature to the stools  (Verse 66).

''Guru, snigdha'' and ''seeta ahara'' is dominated by ''prithvi'' and ''jala mahabhuta'', these qualities help in reducing the impact of ''agni mahabhuta'' thus causing ''jatharagni mandyata'' resulting in indigestion leading to formation ''ama''. Such ''ama'' is responsible for ''dosha prakopa''.(Madhukoshatika Ma. Ni. Jwara adhyaya/2)

''Guru, snigdha'' and ''seeta ahara'' is dominated by ''prithvi'' and ''jala mahabhuta'', these qualities help in reducing the impact of ''agni mahabhuta'' thus causing ''jatharagni mandyata'' resulting in indigestion leading to formation ''ama''. Such ''ama'' is responsible for ''dosha prakopa''.<ref> Madhavakara. Madhava Nidanam (Roga vinischaya) Chap 2, jwara Adhyaya, Translated from Sanskrit by K. R. Srikantha Murthy. 8th ed. Varanasi: Chaukhambha orientalia;2007.pp--</ref>

''Klinna''(moist), ''guru, pishtanna''(malt), ''abhishyandi''(which increases secretions) ''ahara''(food) and ''adhyashana''(over eating) are source for extra calories. Fast foods are defined as any food that contributes little or no nutrient values to the diet, but instead provides excess calories and fat. Common foods include salted snack foods, gum, sweet desserts, fried fast foods, carbonated beverages and candy.

''Klinna''(moist), ''guru, pishtanna''(malt), ''abhishyandi''(which increases secretions) ''ahara''(food) and ''adhyashana''(over eating) are source for extra calories. Fast foods are defined as any food that contributes little or no nutrient values to the diet, but instead provides excess calories and fat. Common foods include salted snack foods, gum, sweet desserts, fried fast foods, carbonated beverages and candy.

Further research shows that incase of uncontrolled growth of gut microbiome, flushing of gut reduces both psycho-somatic symptoms. ''Shodhana'' therapy not only flushes the vitiated gut microbiome but also flushes out the substrata due to which growth of microbiome is controlled (Verse 73-74).

Further research shows that incase of uncontrolled growth of gut microbiome, flushing of gut reduces both psycho-somatic symptoms. ''Shodhana'' therapy not only flushes the vitiated gut microbiome but also flushes out the substrata due to which growth of microbiome is controlled (Verse 73-74).

''Kshara'' has been advised along with ''tilvaka sneha; kshara'' has alkaline pH. In duodenum and small intestine, enzymes with alkaline pH are secreted. ''Ushna, teekshna'' and ''laghu guna'' help in digestion. ''Kledayati ado paschata visoshayati''(Ca. Vi. 1/17 ) i.e. secretion are first increased and later on absorbed is very essential in ''grahani dosha''. Both these actions help in secretion of digestive enzymes thereby increasing ''agni'' and by absorption correct the malabsorption. Therefore use of ''kshara'' is more in ''grahani dosha'' and ''gulma'' (Verse 79).

''Kshara'' has been advised along with ''tilvaka sneha; kshara'' has alkaline pH. In duodenum and small intestine, enzymes with alkaline pH are secreted. ''Ushna, teekshna'' and ''laghu guna'' help in digestion. ''Kledayati ado paschata visoshayati''[Cha.Sa.[[ Vimana Sthana]] 1/17 ] i.e. secretion are first increased and later on absorbed is very essential in ''grahani dosha''. Both these actions help in secretion of digestive enzymes thereby increasing ''agni'' and by absorption correct the malabsorption. Therefore use of ''kshara'' is more in ''grahani dosha'' and ''gulma'' (Verse 79).

''Aranala''(a fermented preparation), ''dadhimanda''(curd whey) or ''sauviraka'' are all fermented liquids. Fermented liquids contain probiotic organisms. Probiotic foods are produced by chemical action of lactic acid, bacteria, yeast or combination of both. These useful microorganisms help in breaking down carbohydrates, sugars making them easily digestible. Probiotics improves absorption of nutrients; improve synthesis of vitamins, essential fatty acids and enhance nutritional qualities of food grains. Fermented foods increase the absorption of vital minerals from gastrointestinal tract thus preventing mineral deficiencies and also treat the diarrhea. It explains the role of helpful gut microbiome (Verse 82-86). Use of fermented products explains the concept of gut microbiome and use of ''kshara'' and ''amla'' drug for maintaining pH (Verse 88-93).

''Aranala''(a fermented preparation), ''dadhimanda''(curd whey) or ''sauviraka'' are all fermented liquids. Fermented liquids contain probiotic organisms. Probiotic foods are produced by chemical action of lactic acid, bacteria, yeast or combination of both. These useful microorganisms help in breaking down carbohydrates, sugars making them easily digestible. Probiotics improves absorption of nutrients; improve synthesis of vitamins, essential fatty acids and enhance nutritional qualities of food grains. Fermented foods increase the absorption of vital minerals from gastrointestinal tract thus preventing mineral deficiencies and also treat the diarrhea. It explains the role of helpful gut microbiome (Verse 82-86). Use of fermented products explains the concept of gut microbiome and use of ''kshara'' and ''amla'' drug for maintaining pH (Verse 88-93).