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<big>'''Principles of Diagnosis and Management of acid peptic diseases in Ayurveda'''</big>  

<big>'''Principles of Diagnosis and Management of acid peptic diseases in Ayurveda'''</big>  

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This article is based on the lecture delivered by Prof. H.M. Chandola, as part of Prof. M.S. Baghel Memorial Lecture Series on 09th April 2021.  

This article is based on the lecture delivered by Prof. H.M. Chandola, as part of Prof. M.S. Baghel Memorial Lecture Series on 09th April 2021.  

==Introduction==

==Introduction==

Acharya Sushruta’s definition of a “healthy person” (swastha) is the most widely accepted one in [[Ayurveda]].[Su. Sa. Sutra Sthana 15/41]

Acharya Sushruta’s definition of a “healthy person” (swastha) is the most widely accepted one in [[Ayurveda]].[Su. Sa. Sutra Sthana 15/41]

The physical components of health are listed as the three [[dosha]] - ([[vata]], [[pitta]] and [[kapha]]); the seven body tissues ([[dhatu]]); and the excretory functions([[mala]]). Digestive power([[agni]] is also added with due importance. It indicates that all kinds of “transformation processes”, essential for the maintenance of health are facilitated by the [[agni]] from gross to minute level.

The physical components of health are listed as the three [[dosha]] - ([[vata]], [[pitta]] and [[kapha]]); the seven body tissues ([[dhatu]]); and the excretory functions([[mala]]). Digestive power ([[agni]]) is also added with due importance. It indicates that all kinds of “transformation processes”, essential for the maintenance of health are facilitated by the [[agni]] from gross to minute level.

Apart from physical health, the pleasant state and harmony of sensual faculties ([[indriya]]), mind ([[manas]]) as well as spiritual awareness ([[atma]]) are also the essential criteria for health.  All these components are interrelated and can affect each other's state of well-being.

Apart from physical health, the pleasant state and harmony of sensual faculties ([[indriya]]), mind ([[manas]]) as well as spiritual awareness ([[atma]]) are also the essential criteria for health.  All these components are interrelated and can affect each other's state of well-being.

== Good health begins in the gut==

== Good health begins in the gut==

While explaining the concept of [[agni]], the main form of [[agni]] is called as the “jatharagni” (pachakagni) which refers to the digestive enzymes. There are five elemental enzymes (bhutagni) which are the micro-elemental converters, and also the seven corresponding tissue building enzymes (dhatwagni). The digestive enzymes (pachakagni) control the other two kinds of [[agni]] that are acting at the level of absorption and metabolism. The term “koshthagni” is used when it deals with the digestive process in the gastrointestinal tract (GIT).

While explaining the concept of [[agni]], the main form of [[agni]] is called as the “jatharagni” (pachakagni) which refers to the digestive enzymes. There are five elemental enzymes (bhutagni) which are the micro-elemental converters, and also the seven corresponding tissue building enzymes (dhatwagni). The digestive enzymes (pachakagni) control the other two kinds of [[agni]] that are acting at the level of absorption and metabolism. The term “koshthagni” is used when it deals with the digestive process in the gastrointestinal tract (GIT).

===Agni and patterns of digestion ===

==Agni and patterns of digestion ==

When the [[agni]] is in the balanced state, it is known as “samagni”. But when it is affected by three [[dosha]], it shows three pathological variations. If there is an excess of [[kapha]] [[dosha]], it lowers the power of [[agni]] and the condition is known as “mandagni” (slow digestion). When [[pitta]] is in excess form, the [[agni]] becomes “teekshnagni” (fast/quick digestion). It can digest anything and everything and when the food is not available, it starts digesting the tissue elements ([[dhatu]]). For example, in thyrotoxicosis the hyperactivity of the thyroid gland causes high basic metabolic rate (BMR) and cachexia develops.  

When the [[agni]] is in the balanced state, it is known as “samagni”. But when it is affected by three [[dosha]], it shows three pathological variations. If there is an excess of [[kapha]] [[dosha]], it lowers the power of [[agni]] and the condition is known as “mandagni” (slow digestion). When [[pitta]] is in excess form, the [[agni]] becomes “teekshnagni” (fast/quick digestion). It can digest anything and everything and when the food is not available, it starts digesting the tissue elements ([[dhatu]]). For example, in thyrotoxicosis the hyperactivity of the thyroid gland causes high basic metabolic rate (BMR) and cachexia develops.  

When the [[agni]] is affected by vitiated [[vata]], it becomes “vishamagni” (irregular digestion). As [[vata]] has catalytic action (“yogavahi”), if it interacts with [[kapha]], it will enhance the activity of [[kapha]] and if it interacts with [[pitta]], it enhances the activities of [[pitta]].

When the [[agni]] is affected by vitiated [[vata]], it becomes “vishamagni” (irregular digestion). As [[vata]] has catalytic action (“yogavahi”), if it interacts with [[kapha]], it will enhance the activity of [[kapha]] and if it interacts with [[pitta]], it enhances the activities of [[pitta]].

Acid peptic disorders include many conditions whose pathophysiology is directly related to the damage caused by acid and peptic activity of gastric secretions. It includes gastroesophageal reflux disease, peptic ulcer (gastric and duodenal), and stress-related mucosal injury. In all these conditions, mucosal erosions or ulcerations arise when the caustic effects of aggressive factors overwhelm the defensive factors of the gastrointestinal mucosa.

Acid peptic disorders include many conditions whose pathophysiology is directly related to the damage caused by acid and peptic activity of gastric secretions. It includes gastroesophageal reflux disease, peptic ulcer (gastric and duodenal), and stress-related mucosal injury. In all these conditions, mucosal erosions or ulcerations arise when the caustic effects of aggressive factors overwhelm the defensive factors of the gastrointestinal mucosa.

==Aggressive and Defensive Factors==

==Aggressive and defensive Factors==

Here, the aggressive factors represent the acid, pepsin, bile salts, drugs (NSAIDs), and H. pylori and the defensive factors are represented by mucus, bicarbonate layer, proper blood flow, cell renewal prostaglandins, and phospholipids.

Here, the aggressive factors represent the acid, pepsin, bile salts, drugs (NSAIDs), and H. pylori and the defensive factors are represented by mucus, bicarbonate layer, proper blood flow, cell renewal prostaglandins, and phospholipids.

Improper dietary habits cause vitiation of [[agni]], which leads to the process of fermentation of food material and ultimately it forms the toxic material called “amavisha”. It leads to “indigestion” (ajeerna) by vitiating the [[dosha]]. Continuous indulgence in improper diet and erratic lifestyle aggravates [[pitta]] [[dosha]]. This leads to an acute condition of “vidagdhajirna”. This is converted into different acid-peptic disorders like gastritis, gastro-oesophageal reflux disease(amlapitta), duodenal ulcer (parinama shula), gastric ulcer(annadrava shula) etc.

Improper dietary habits cause vitiation of [[agni]], which leads to the process of fermentation of food material and ultimately it forms the toxic material called “amavisha”. It leads to “indigestion” (ajeerna) by vitiating the [[dosha]]. Continuous indulgence in improper diet and erratic lifestyle aggravates [[pitta]] [[dosha]]. This leads to an acute condition of “vidagdhajirna”. This is converted into different acid-peptic disorders like gastritis, gastro-oesophageal reflux disease(amlapitta), duodenal ulcer (parinama shula), gastric ulcer(annadrava shula) etc.

===Vidagdhajeerna and Amlapitta===

===Vidagdhajeerna and Amlapitta===

The clinical diagnosis of “vidagdhajeerna” is based on the symptoms like sour eructation, burning sensation, giddiness, thirst, and sweating.

The clinical diagnosis of “vidagdhajeerna” is based on the symptoms like sour eructation, burning sensation, giddiness, thirst, and sweating.  

In case of “amlapitta”, the symptoms are indigestion, nausea, sour/bitter eructation, burning sensation in oesophagus, epigastric region, anorexia, and abdominal heaviness.

In case of “amlapitta”, the symptoms are indigestion, nausea, sour/bitter eructation, burning sensation in oesophagus, epigastric region, anorexia, and abdominal heaviness.

Many of the clinical researches on “amlapitta” had revealed that hyperacidity might not be an essential finding in all the patients with the symptoms of “amlapitta”. Many of them can be normosecretors. Some may be hyper secretors as in the case of “hyperchlorhydria” and some may even be hypo-secretors as in the case of hypochlorhydria.

Many of the clinical researches on “amlapitta” had revealed that hyperacidity might not be an essential finding in all the patients with the symptoms of “amlapitta”. Many of them can be normosecretors. Some may be hyper secretors as in the case of “hyperchlorhydria” and some may even be hypo-secretors as in the case of hypochlorhydria.

In its advanced stage, there is progression from chronic superficial gastritis to chronic atrophic gastritis characterized by mucosal atrophy and metaplasia of intestinal or pseudopyrloric type.

In its advanced stage, there is progression from chronic superficial gastritis to chronic atrophic gastritis characterized by mucosal atrophy and metaplasia of intestinal or pseudopyrloric type.

'''Principle of treatment of chronic gastritis'''

=== '''Principle of treatment of chronic gastritis''' ===

 

For treating the chronic gastritis, the principle of treatment of “[[vata]]-[[pitta]] dominant gulma” is recommended. It includes protecting the [[kapha]], which is the defensive factor. Here, the measures to reduce the penetrating power (tikshnatva) of [[pitta]] should be administered, followed by healing or soothing type of medicines (ropana chikitsa). The combination of Glycyrrhiza Glabra (madhuyashti), Asparagus racemosus (shatavari), Phyllanthus emblica (amalaki) with ghee and honey is best for healing action. Drugs with bitter (tikta) or sweet (madhura) tastes (rasa) are preferable here. Ghee or milk preparation processed with these kind of drugs are also advisable.  

For treating the chronic gastritis, the principle of treatment of “[[vata]]-[[pitta]] dominant gulma” is recommended. It includes protecting the [[kapha]], which is the defensive factor. Here, the measures to reduce the penetrating power (tikshnatva) of [[pitta]] should be administered, followed by healing or soothing type of medicines (ropana chikitsa). The combination of Glycyrrhiza Glabra (madhuyashti), Asparagus racemosus (shatavari), Phyllanthus emblica (amalaki) with ghee and honey is best for healing action. Drugs with bitter (tikta) or sweet (madhura) tastes (rasa) are preferable here. Ghee or milk preparation processed with these kind of drugs are also advisable.  

Formulations like avipattikara churna, sitopaladi churna, yashtitriphala churna, dadimadi ghrita, shatavari ghrita, guduchyadi ghrita, ashwagandha mahatiktam ghritam are effective in this condition.

Formulations like avipattikara churna, sitopaladi churna, yashtitriphala churna, dadimadi ghrita, shatavari ghrita, guduchyadi ghrita, ashwagandha mahatiktam ghritam are effective in this condition.

=== Gastro-esophageal reflux disease (GERD) ===

== Gastro-esophageal reflux disease (GERD) ==

Due to decreased tone of lower oesophageal sphincter, the gastric contents get regurgitated frequently into the oesophagus. It causes damage to the mucous membrane of oesophagus and lead to esophagitis.The risk factors for this condition include obesity, fat-rich diet, caffeine, alcohol, smoking, and the symptoms are heartburn, regurgitation, and dysphagia. It can be diagnosed on the basis of clinical symptoms, 24 hour pH monitoring, endoscopy, and biopsy.

Due to decreased tone of lower oesophageal sphincter, the gastric contents get regurgitated frequently into the oesophagus. It causes damage to the mucous membrane of oesophagus and lead to esophagitis.The risk factors for this condition include obesity, fat-rich diet, caffeine, alcohol, smoking, and the symptoms are heartburn, regurgitation, and dysphagia. It can be diagnosed on the basis of clinical symptoms, 24 hour pH monitoring, endoscopy, and biopsy.

The main thing is the modification of dietary and personal habits. It is better to avoid hot and spicy foods, excessive use of pungent, sour, and salty food, fried items, curd, mustard, and sour fruits in the diet. It is recommended to avoid alcohol consumption, smoking, and regular intake of coffee.

The main thing is the modification of dietary and personal habits. It is better to avoid hot and spicy foods, excessive use of pungent, sour, and salty food, fried items, curd, mustard, and sour fruits in the diet. It is recommended to avoid alcohol consumption, smoking, and regular intake of coffee.

==Peptic ulcer==

== Peptic ulcer ==

It includes both gastric ulcer and duodenal ulcer formed due to the imbalance of aggressive factor and defensive factor as discussed earlier.

It includes both gastric ulcer and duodenal ulcer formed due to the imbalance of aggressive factor and defensive factor as discussed earlier.

Eating worsens the symptoms of gastric ulcer and improves the symptoms of duodenal ulcer.  Hunger pain is observed in duodenal ulcer. The diagnosis is based on endoscopy. For detection of H. pylori, “rapid urease test” or “clo test” is performed. Biopsy is done to exclude possibility of cancer. In the management, high dose of proton pump inhibitors is given in conventional medicine.

Eating worsens the symptoms of gastric ulcer and improves the symptoms of duodenal ulcer.  Hunger pain is observed in duodenal ulcer. The diagnosis is based on endoscopy. For detection of H. pylori, “rapid urease test” or “clo test” is performed. Biopsy is done to exclude possibility of cancer. In the management, high dose of proton pump inhibitors is given in conventional medicine.

In case of peptic ulcer, rice, bean, salt, sour food articles, and condiments should be avoided. Milk, banana, and coconut water are advisable.

In case of peptic ulcer, rice, bean, salt, sour food articles, and condiments should be avoided. Milk, banana, and coconut water are advisable.

'''Principles of treatment of peptic ulcer'''

=== '''Principles of treatment of peptic ulcer''' ===

 

As the first line of treatment, drugs having predominantly bitter taste (tikta rasa) and inducing dryness(ruksha) are used.

As the first line of treatment, drugs having predominantly bitter taste (tikta rasa) and inducing dryness(ruksha) are used.

In a research work on duodenal ulcer(parinama shula) by Antony Jose & H.M.Chandola(2004), a formulation called “Akshadi churna” [a combination of Terminalia chebula (haritaki) , Terminalia bellirica(bibhitaki) , Phyllanthus emblica (amalaki)  and Piper longum(pippali)][ Chakradatta  27/6] along with ghee preparation called “medhya rasayana ghrita”[a combination of Convolvulus pluricaulis(shankhapushpi) , Centella asiatica(mandukaparni), Glycyrrhiza Glabra (yashtimadhu)  and Tinospora cordifolia (guduchi) ] were used. It showed better results than administering only Akshadi churna. Significant difference was observed in the parameters of Brief Psychiatry Rating Scale. This shows the importance of dealing with the psychic component in this disease.

In a research work on duodenal ulcer(parinama shula) by Antony Jose & H.M.Chandola(2004), a formulation called “Akshadi churna” [a combination of Terminalia chebula (haritaki) , Terminalia bellirica(bibhitaki) , Phyllanthus emblica (amalaki)  and Piper longum(pippali)][ Chakradatta  27/6] along with ghee preparation called “medhya rasayana ghrita”[a combination of Convolvulus pluricaulis(shankhapushpi) , Centella asiatica(mandukaparni), Glycyrrhiza Glabra (yashtimadhu)  and Tinospora cordifolia (guduchi) ] were used. It showed better results than administering only Akshadi churna. Significant difference was observed in the parameters of Brief Psychiatry Rating Scale. This shows the importance of dealing with the psychic component in this disease.

===Inflammatory bowel Diseases (IBD)===

==Inflammatory bowel Diseases (IBD)==

This includes two idiopathic bowel diseases having many similarities but distinctive morphological appearance.

This includes two idiopathic bowel diseases having many similarities but distinctive morphological appearance.

Symptoms like the elimination of faecal matter mixed with blood and mucous, having offensive smell are observed with weight loss in patients.These conditions  are mentioned in the contexts of raktatisara, tridoshaja atisara and shokaja atisara. These symptoms are similar to IBD.  

Symptoms like the elimination of faecal matter mixed with blood and mucous, having offensive smell are observed with weight loss in patients.These conditions  are mentioned in the contexts of raktatisara, tridoshaja atisara and shokaja atisara. These symptoms are similar to IBD.  

'''Principle of treatment for ulcerative colitis'''

=== '''Principle of treatment for ulcerative colitis''' ===

 

The treatment protocols of “pittatisara” or “raktatisara”, “[[pitta]]-[[kapha]] grahani chikitsa”, “jirna pravahika chikitsa”, “adhoga raktapitta chikitsa” are adopted here. Anti-inflammatory (pakahara and shophahara) and anthelminthic (krimighna) treatments are preferred in cases of ulcerative colitis. Drugs having bitter (tikta) or sweet (madhura) taste, with healing (ropana) property, in the form of medicated milk are recommended here.  

The treatment protocols of “pittatisara” or “raktatisara”, “[[pitta]]-[[kapha]] grahani chikitsa”, “jirna pravahika chikitsa”, “adhoga raktapitta chikitsa” are adopted here. Anti-inflammatory (pakahara and shophahara) and anthelminthic (krimighna) treatments are preferred in cases of ulcerative colitis. Drugs having bitter (tikta) or sweet (madhura) taste, with healing (ropana) property, in the form of medicated milk are recommended here.  

In Ayurvedic parlance, it can be interpreted under the following clinical conditions.

In Ayurvedic parlance, it can be interpreted under the following clinical conditions.

a.Atisara [Cha. Sa. [[Chikitsa Sthana]] 19, Su. Sa. Uttara Tantra. 40 ]

a. Atisara [Cha. Sa. [[Chikitsa Sthana]] 19, Su. Sa. Uttara Tantra. 40 ]

b.Grahani [Cha. Sa. [[Chikitsa Sthana]].15, Su. Sa.Uttara Tantra 40,  A. Hr. Nidana Sthana 8]

b. Grahani [Cha. Sa. [[Chikitsa Sthana]].15, Su. Sa.Uttara Tantra 40,  A. Hr. Nidana Sthana 8]

c.Pravahika [Cha.Sa. [[Chikitsa Sthana]] 19]

c. Pravahika [Cha.Sa. [[Chikitsa Sthana]] 19]

d.Pakvashayagata vata [Cha. Sa. [[Chikitsa Sthana]] 28 /28-29]

d. Pakvashayagata vata [Cha. Sa. [[Chikitsa Sthana]] 28 /28-29]

Among these conditions, symptoms of [[vata]] predominant [[grahani]] show more resemblance with IBS. Poor digestion, hyperacidity, roughness in the body and flatulence during and after digestion are observed in this condition. The patient frequently passes stool with difficulty. The consistency of faecal matter is liquid mixed with hard stool, associated with sound and frothiness. [Cha. Sa. [[Chikitsa Sthana]]15/6-10]  

Among these conditions, symptoms of [[vata]] predominant [[grahani]] show more resemblance with IBS. Poor digestion, hyperacidity, roughness in the body and flatulence during and after digestion are observed in this condition. The patient frequently passes stool with difficulty. The consistency of faecal matter is liquid mixed with hard stool, associated with sound and frothiness. [Cha. Sa. [[Chikitsa Sthana]]15/6-10]  

Dietary modifications including more dietary fibers, psycho-social therapies, drugs like anticholinergics, antidepressants, antidiarrheals, anxiolytics and those acting on serotonin receptors are being used in the management of IBS. Probiotics have a greater role to enhance or support the bacterial flora in the gut.  

Dietary modifications including more dietary fibers, psycho-social therapies, drugs like anticholinergics, antidepressants, antidiarrheals, anxiolytics and those acting on serotonin receptors are being used in the management of IBS. Probiotics have a greater role to enhance or support the bacterial flora in the gut.  

'''Principles of treatment of IBS'''

=== '''Principles of treatment of IBS''' ===

 

The treatment principles of vataja grahani, atisara and pakwashayagata [[vata]] are used in the management of IBS. The psychological health component is taken care of by therapies like the pouring of liquid medicines like oil, medicated butter milk etc on the forehead (shirodhara/ takradhara) and anointment of medicated paste on scalp(shirolepa).  

The treatment principles of vataja grahani, atisara and pakwashayagata [[vata]] are used in the management of IBS. The psychological health component is taken care of by therapies like the pouring of liquid medicines like oil, medicated butter milk etc on the forehead (shirodhara/ takradhara) and anointment of medicated paste on scalp(shirolepa).  

In a clinical study on IBS, by Raksha Mer & H. M. Chandola (2004), the effect of kutajadi avaleha alone and kutajadi avaleha along with medhyarasayana ghrita was compared. Better results were observed in the combined group. This shows the importance of addressing the psychological component in the treatment protocol.

In a clinical study on IBS, by Raksha Mer & H. M. Chandola (2004), the effect of kutajadi avaleha alone and kutajadi avaleha along with medhyarasayana ghrita was compared. Better results were observed in the combined group. This shows the importance of addressing the psychological component in the treatment protocol.

==Butter milk - the best medicine for gut related disorders==

====Butter milk - the best medicine for gut related disorders====

Buttermilk has an astringent taste (kashaya rasa) and hot potency (ushna virya). It increases the digestive power ([[deepana]]) and absorbs fluid from the stool (grahi). It decreases aggravated [[kapha]] and rectifies the digestive process. It’s sweet and sour taste do not provoke [[vata]]. Its property of “madhura vipaka”, does not cause the aggravation of [[pitta]]. So, it is best to keep the balance of all the three [[dosha]] in gut.

Buttermilk has an astringent taste (kashaya rasa) and hot potency (ushna virya). It increases the digestive power ([[deepana]]) and absorbs fluid from the stool (grahi). It decreases aggravated [[kapha]] and rectifies the digestive process. It’s sweet and sour taste do not provoke [[vata]]. Its property of “madhura vipaka”, does not cause the aggravation of [[pitta]]. So, it is best to keep the balance of all the three [[dosha]] in gut.