Changes

=== Introduction ===

=== Introduction ===

''Grahani'' and ''atisara'' - both manifest due to the vitiation of ''agni'' and share common features of impairment of digestion resulting in indigestion and loose motions. Therefore, this chapter should logically precede or succeed the chapter on ''grahani''. But it is described three chapters after that on ''grahani''. The reason for this unusual sequencing of these topics is that since ''pandu'' is a common symptom and sequelae of the malabsorption syndrome (''grahani''), the chapter on ''pandu'' follows ''grahani''. Now, dyspnea (''shwasa'') is a major symptom of ''pandu,'' and thus, follows the chapter on ''pandu''. Similarly, chapter on ''kasa'' (cough) follows  ''shwasa'' because of their relationship. That explains the sequencing of ''grahani'' and ''atisara'' in [[Charaka Samhita]].

''Grahani'' and ''atisara'' - both manifest due to the vitiation of ''agni'' and share common features of impairment of digestion resulting in indigestion and loose motions. Therefore, this chapter should logically precede or succeed the chapter on ''grahani''. But it is described three chapters after that on ''grahani''. The reason for this unusual sequencing of these topics is that since ''pandu'' is a common symptom and sequelae of the malabsorption syndrome (''grahani''), the chapter on ''pandu'' follows ''grahani''. Now, dyspnea (''shwasa'') is a major symptom of ''pandu,'' and thus, follows the chapter on ''pandu''. Similarly, chapter on ''kasa'' (cough) follows  ''shwasa'' because of their relationship. That explains the sequencing of ''grahani'' and ''atisara'' in [[Charak Samhita]].

Ayurveda considers ''atisara'' as a defense mechanism of the body to eject out any toxic material from it. Therefore, it is recommended that in ''amaja'' (or initial) state loose motions should not be checked. After evacuation of toxins from the body, fasting and digestive drugs are prescribed as a cure for milder forms of diarrhea. However, for other types of diarrhea, various preparations, diet and ''basti'' are advised. ''Picchabasti'' (mucilegue type of medicated enema) is prescribed particularly if blood accompanies the stool. Appropriate treatments for ulcer, suppuration of anus and prolapse of anus are dealt with, since these accompany the more complex forms of diarrhea.  

Ayurveda considers ''atisara'' as a defense mechanism of the body to eject out any toxic material from it. Therefore, it is recommended that in ''amaja'' (or initial) state loose motions should not be checked. After evacuation of toxins from the body, fasting and digestive drugs are prescribed as a cure for milder forms of diarrhea. However, for other types of diarrhea, various preparations, diet and ''basti'' are advised. ''Picchabasti'' (mucilegue type of medicated enema) is prescribed particularly if blood accompanies the stool. Appropriate treatments for ulcer, suppuration of anus and prolapse of anus are dealt with, since these accompany the more complex forms of diarrhea.  

*Depending upon the wholesomeness (''satmya'') of the patient, light food along with buttermilk or ''kanji'' (a sour drink), ''yavagu'' (thick gruel), ''tarpana'' (roasted flour of serials mixed with water), or alcoholic drink or honey should be given. Then gradually ''yavagu'' (thick gruel), ''vilepi'' (a sticky gruel), ''khanda'' (a sour appetiser), ''yusha'' (vegetable soup) and boiled rice mixed with meat soup which are prepared by adding digestive, stimulants and astringent (constipative) drugs should be given.  

*Depending upon the wholesomeness (''satmya'') of the patient, light food along with buttermilk or ''kanji'' (a sour drink), ''yavagu'' (thick gruel), ''tarpana'' (roasted flour of serials mixed with water), or alcoholic drink or honey should be given. Then gradually ''yavagu'' (thick gruel), ''vilepi'' (a sticky gruel), ''khanda'' (a sour appetiser), ''yusha'' (vegetable soup) and boiled rice mixed with meat soup which are prepared by adding digestive, stimulants and astringent (constipative) drugs should be given.  

Ingredients which are ''dipana'' (digestive stimulant) and ''grahi'' (constipating) are described in [[Charaka Samhita]] [[Sutra Sthana]] 4: 9 should be administered [23-25]

Ingredients which are ''dipana'' (digestive stimulant) and ''grahi'' (constipating) are described in [[Charak Samhita]] [[Sutra Sthana]] 4: 9 should be administered [23-25]

==== Treatment of ''vataja atisara'' ====

==== Treatment of ''vataja atisara'' ====

ityagnivēśakr̥tē tantrē carakapratisaṁskr̥tē cikitsāsthānē'tisāracikitsitaṁ nāmaikōnaviṁśō'dhyāyaḥ||19||  

ityagnivēśakr̥tē tantrē carakapratisaṁskr̥tē cikitsāsthānē'tisāracikitsitaṁ nāmaikōnaviṁśō'dhyāyaḥ||19||  

Thus, ends the nineteenth chapter of [[Chikitsa Sthana]] (section on the treatment of diseases) dealing with the treatment of ''atisara'' (diarrhea) in the work of Agnivesha as redacted by Charaka [19]

Thus, ends the nineteenth chapter of [[Chikitsa Sthana]] (section on the treatment of diseases) dealing with the treatment of ''atisara'' (diarrhea) in the work of Agnivesha as redacted by Charak [19]

=== ''Tattva Vimarsha'' ===

=== ''Tattva Vimarsha'' ===

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.

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 ====  

==== Chronic (or relapsing) diarrhea <ref>Patient Education: Chronic Diarrhea among adults, UptoDate

</ref> ====  

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.

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.

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 ====

==== Pathophysiological factors 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''.

==== Prevention of ''atisara'' ====

==== Prevention of ''atisara'' ====

===== ''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''

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  

! scope="col"| Type

Pitta and kapha dominant Kutaja kalpa 60 -120 mg Before meals two times Rice water with buttermilk

! scope="col"| Formulation

Raktaja Shatavaryadi kwatha 25 to 40 ml Empty stomach --

! scope="col"| Dose

Pravahika (dysentery) Isabgola seeds cold effusion with sugar 5-10 ml Morning and night two times --

! scope="col"| Time

Ahiphena kalpa 125-250 mg Morning and night two times Kutajavaleha

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

Kutaja parpati 250-1000 mg Empty stomach Honey  

Chronic Dhanya panchaka churna 10-25 grams Between meals Bilvavaleha  

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

Shatpala ghee 10-20 ml Before meals Buttermilk or hot water  

| ''Jatiphaladi–bhallataka guti''

Bilwadi tailam 10-20 grams Before meals Buttermilk  

| 60-120 mg

| Before meals, two times

| Buttermilk

| ''Sanjivani vati''

| 60-250 mg

| Before meals

| Buttermilk

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

| ''Kutaja kalpa''

| 60-120 mg

| Before meals, two times

| Ricewater with Buttermilk

|''Raktaja''

| ''Shatavaryadi kwatha''

| 25-40 ml

| Empty stomach

| ''-''

|-

|rowspan = "3"|''Pravahika''(dysentry)

| ''Isabgola'' seeds (cold effusion with sugar)

| 5-10 ml

| Morning and night, two times

| ''-''

|-

| ''Ahiphena kalpa''

| 125-250 mg

| Morning and night, two times

| ''Kutaja parpati''

| 250-1000 mg

| Empty stomach

| Honey

|rowspan = "3"|Chronic

| ''Dhanya panchaka churna''

| 10-25 mg

| Between meals

| ''Bilvavaleha''

| ''Shatpala ghee''

| 10-25 ml

| Before meals

| Buttermilk or hot water

| ''Bilwadi tailam''

| 10-25 grams

| Before meals

| Buttermilk

• Researches on atisara and medicines:

===== 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.   

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)(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.   

    

''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''.   

The conditions like ulcerative colitis, irritable bowel syndrome, acute diarrhoea are considered under the umbrella 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>

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 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:

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

In a study, ''vatasakadi'' syrup was observed 70 % effective in treatment of ''atisara'' in children as compared to ''bala-chaturbhadra'' syrup.<ref>Shah Kiran. A Comparative Study of Vatsakadi Syrup & Balachaturbhadra Syrup in Management Balatisara with reference to Diarrhea, Int. J. Ayu. Alt. Med., 2014; 2(1):28-33.</ref>

Note  

 

 

#Diarrhea due to mental factors: These patients need counseling along with therapeutic management of diarrhea as discussed above.

#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.

#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.<ref>Schiller Lawrence, Sellin Joseph, Pardi Darrell, Chronic Diarrhea:Diagnosis and Management, Clinical Gastroenterology and Hepatology, 2017, 15:182-193</ref>  

#Fatty diarrhea, like watery diarrhea, indicates poor absorption of fat and other nutrients

#Dysentery (passage of bloody stools) or fever (>37.8°C) should be treated with antibacterial drugs

#Vomiting, minimal diarrhea should be treated with Bismuth subsalicylate.  

#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.

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

==== 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 .

 

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.<ref>WHO Press Release, 8 May 2002, http://www.who.int/mediacentre/news/releases/release35/en/</ref> The Centers for Disease Control and Prevention (CDC) considers rehydration as “the cornerstone of treatment of cholera”.<ref>https://www.cdc.gov/cholera/treatment/rehydration-therapy.html</ref> CDC also recommends other treatment alternatives, based on recent studies in Bangladesh and other areas affected by cholera, such as zinc treatment.<ref>https://www.cdc.gov/cholera/treatment/zinc-treatment.html</ref> Severe cases need to take a recourse of antibiotics, though there are instances of resistance to tetracycline and other antimicrobial agents .<ref> https://www.cdc.gov/cholera/treatment/antibiotic-treatment.html</ref>

 

 

=== Research areas ===

==== Research Areas ====

Though there are many anti-diarheal and ant-dysentery medicines are available in conventional systems of medicine, the immediate stoppage of diarrhea may lead to complications as mentioned in the text. Therefore a survey study is needed to examine the prevalence of such complications caused by stoppage of diarrhea.  

*Though there are many anti-diarrheal and ant-dysentery medicines are available in conventional systems of medicine, the immediate stoppage of diarrhoea may lead to complications as mentioned in the text. Therefore a survey study is needed to examine the prevalence of such complications caused by stoppage of diarrhea.

*More researches are needed to study effect of Ayurveda medicines in chronic diarrhea and psycho somatic disease like irritable bowel syndrome.

=== Glossary ===

=== Glossary ===

=== Further reading ===

=== Further reading ===

   

   

#Charaka Samhita (700 BC) with English Translation and Critical exposition (Volume IV).  Sharma R.K. and Dash B., Chaukhambha Sanskrit Series Office, Varanasi.pages-202-242

#Charak Samhita (700 BC) with English Translation and Critical exposition (Volume IV).  Sharma R.K. and Dash B., Chaukhambha Sanskrit Series Office, Varanasi.pages-202-242

#Valiathan, M.S. (2009): Legacy of Charaka, Sushruta, Vagbhata, Orient Longman, Chennai.

#Valiathan, M.S. (2009): Legacy of Charak, Sushruta, Vagbhata, Orient Longman, Chennai.

#Sushruta.  Sushruta Samhita. Volume III, Uttarasthana,  translated by  Prof. K.R. Srikatha Murthy, Varanasi,  Chaukhambha Orientalia; 2005.p.223-250.

#Sushruta.  Sushruta Samhita. Volume III, Uttarasthana,  translated by  Prof. K.R. Srikatha Murthy, Varanasi,  Chaukhambha Orientalia; 2005.p.223-250.

#Parameswarappa’s ĀyurvedÍya Vikriti Vijñāna and Roga Vijñāna by Dr. P.S. Byadgi. Volume II, pages-431-446

#Parameswarappa’s ĀyurvedÍya Vikriti Vijñāna and Roga Vijñāna by Dr. P.S. Byadgi. Volume II, pages-431-446

#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, Chapter 128. Acute Infectious Diarrheal Diseases and Bacterial Food Poisoning  

#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, Chapter 128. Acute Infectious Diarrheal Diseases and Bacterial Food Poisoning  

#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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