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→Vidhi Vimarsha
=== ''Vidhi Vimarsha'' ===
=== ''Vidhi Vimarsha'' ===
The disease ''atisara'' resembles the clinical condition of diarrhea and is defined as the passage of frequent, liquid stools (usually of more than 200 g of stool) daily. In the most severe instances of ''atisara'', incontinence is a commonly observed symptom. Diarrhea, among adults, could broadly be categorized as sudden onset(acute), or chronic diarrhea that could last for 14 days or more.
==== Acute (sudden onset) diarrhea ====
This is most common variant and in over 90% of cases is infectious, caused due to ingestion of contaminated food or water. Other causes may include drug induced especially antibiotics, diverticulitis, ischemia, radiation enterocholitis, food allergies or initial presentation of various gastrointestinal diseases.
==== Chronic (or relapsing) diarrhea ====
Defined as loose stools (occurring three or more times a day) that last for weeks. A most common variant is the Irritable Bowel Syndrome (IBS). Chronic diarrhea could be a symptom of an inflammatory bowel disease like Crohn's Disease, ulcerative colitis, malabsorption syndrome, metabolic or endocrine disorders, food allergies, laxative abuse, neoplasm, or reaction to certain medications.
Careful assessment of the patient's medical history, physical examination, CBC, electrolytes, stool and urine examination are initial tests advised to help assess the underlying causes. Further specialised investigations may be needed depending upon the condition of patient.
==== Pathophysiological factors of endogenous diarrhea ====
*Dosha: Vata dominant three dosha
*Dhatu (vitiated factors): Udaka (body fluid), Rasa dhatu
*Mala kriya affected: Purisha (defecation)
*Status of agni: Manda (poor)
*Origin of disease: Pakwashaya (large intestine)
*Sites of vitiation: large intestine
*Sites of clinical presentation: rectum and anus
*Srotasa involved: Purishavaha srotasa and udakavaha srotasa
*Type of samprapti: atipravritti (excess discharge)
==== Management protocol of endogenous diarrhea ====
===== Assessment of strength of patient =====
Excess dehydration in case of diarrhea can lead to serious complications. Hence the strength of the patient should be assessed first for severity of dehydration. This helps to design treatment protocol. Vital parameters including pulse rate, its volume, blood pressure, heart rate shall be examined.
===== 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''.
==== Prevention of ''atisara'' ====
===== ''Atisara'' can be prevented by following measures =====
#Avoiding causative factors
#Strengthening agni (digestive processes) by following dietary rules
#Observing body purification treatments as per prakriti and season
===== Current clinical management in Ayurveda practice =====
*'''Principles of treatment''': deepana, grahi, pachana, buttermilk
*'''Main drugs''': kutaja, ahiphena, bhanga, bhallataka, bilva
Type Formulation Dose Time Anupana
Vata and kapha dominant Jatiphaladi –bhallataka guti 60-120 mg Before meals two times Buttermilk
Sanjivani vati 60-250 mg Between meals Buttermilk
Pitta and kapha dominant Kutaja kalpa 60 -120 mg Before meals two times Rice water with buttermilk
Raktaja Shatavaryadi kwatha 25 to 40 ml Empty stomach --
Pravahika (dysentery) Isabgola seeds cold effusion with sugar 5-10 ml Morning and night two times --
Ahiphena kalpa 125-250 mg Morning and night two times Kutajavaleha
Kutaja parpati 250-1000 mg Empty stomach Honey
Chronic Dhanya panchaka churna 10-25 grams Between meals Bilvavaleha
Shatpala ghee 10-20 ml Before meals Buttermilk or hot water
Bilwadi tailam 10-20 grams Before meals Buttermilk
• Researches on atisara and medicines:
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.
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)(Charaka sutra 25/40). In an invitro study, sterile double dilution aqueous extract of Kutaja was found effective to inhibit growth of E. coli, staphylococcus aureus, salmonella Typhi. 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 diarrhoea.
The conditions like ulcerative colitis, irritable bowel syndrome, acute diarrhoea 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 udumbar kwatham combination of lodhra, musta, nagakeshara,mukta panchamruta rasa, kutaja ghana vati and udumbar kwatha basti. It also highlighted disease modifying effect and reduction in use of steroidal drugs in the patients.
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).
In another study, bilwadileha showed significant relief in management of irritable bowel syndrome.
In a study, vatasakadi syrup was observed 70 % effective in treatment of atisara in children as compared to bala-chaturbhdra syrup.
Management of exogenous diarrhoea/atisara:
1. Diarrhea due to mental factors: These patients need counseling along with therapeutic management of diarrhea as discussed above.
2. Infectious diarrhea or bacterial food poisoning: The practitioner/physician should proceed with the treatment of the disease with information obtained from the history, stool examination, and evaluation of dehydration severity.
3. Watery diarrhea usually indicates a defect in water absorption. However, there are other categories of watery diarrhea caused due to the dysregulation of intestinal function, endocrine dysfunction (including hypothyroidism), tumors (by obstructing bowel). Another category of watery diarrhea is idiopathic secretory diarrhea. These categories largely are termed chronic inflammatory diarrhea. Based on the result of examining the patient’s history thoroughly, the physician should prescribe a course of treatment as well as dietary regimen.
4. Fatty diarrhea, like watery diarrhea, indicates poor absorption of fat and other nutrients
5. Dysentery (passage of bloody stools) or fever (>37.8°C) should be treated with antibacterial drugs
6. Vomiting, minimal diarrhea should be treated with Bismuth subsalicylate.
7. Diarrhea in infants (<2 years old) should be treated with fluids and electrolytes (oral rehydration solution, pedialyte, lytren); continue feeding, especially with breast milk; seek medical attention for moderate dehydration, fever lasting >24 h, bloody stools, or diarrhea lasting more than several days
Note
Loperamide should not be used by patients with fever or dysentery because its use may prolong diarrhea in patients with infection due to Shigella or other invasive organisms.
Important guidelines and precautions for diarrhea management
The World Health Organization , beginning 2002, recommended a “reduced osmolarity/reduced-salt” Oral Rehydration Solution (ORS) to adequately rehydrate the patient, which is key to treating any case of diarrhea . The Centers for Disease Control and Prevention (CDC) considers rehydration as “the cornerstone of treatment of cholera”. CDC also recommends other treatment alternatives, based on recent studies in Bangladesh and other areas affected by cholera, such as zinc treatment . Severe cases need to take a recourse of antibiotics, though there are instances of resistance to tetracycline and other antimicrobial agents .
=== Research areas ===
=== Research areas ===