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Line 1,563: + + + − + + + − + − 1. Hystorical origin of atisara+ − 2. Etiology of different types of atisara+ − 3. Signs and symptoms of atisara+ − 4. Curability and incurability of atisara+ − 5. Effective treatment for different stages of atisara [123].+ + − + + + − === ''Tattva Vimarsha'' ===+ + + + + + + + + + + + + + + + + + − • Atisara is caused by intake of heavy to digest, excessively hot and food that is incompatible to the body, impairement of agni and mind. The body reacts to expel out the incompatible material out of gut in the form of atisara. + − • There are five catgoroies of etiological factors for atisara, 1. reduced agni, 2. vitiated vata and its sub types samana and apana. 3.vitiated body fluids. 4. vitiated purishvaha srotus and organs of excretion. 5. fear and grief (metal). − • Interaction of prakruti (basic constitution) and the diet and lifestyle of similar properties (as that of dosha prakriti) makes the person susceptible for atisara. − • The exogenous factors like consumption of intoxicating beverages, exposure to krimi (bacteria and parasites), other diseases like shosha, jwara, arsha influence all the above factors and three dosha to cause sannipatic atisara (diarrhea) which includes bloody diahrrea. − • If spicy, hot, dry food in large quantity is ingested when agni is low, undigested food becomes waste product and samana vata sends it to excretory channels where apana vayu increases the motility of purishvaha srotus to excretes these large waste products, frequently. − • To fill this vaccum created by expulsion of wastes, the body fluids shift to the gut and get expelled out as atisara/diarrhea causing dehydration.Thus after involvement of purishavaha srotasa ( lower GIT), udakavaha srotasa (body fluids) is also predominantly involved in pathogenesis of atisara. − • Fear and grief are two important mental factors leading to atisara. The presentation and treatment of this atisara is similar to vata dominant atisara. The fear shall be treated with harshana(exhilaration) treatment and grief shall be treated with ashwasana (consolation) therapy. − • The endogenous atisara shall be treated after proper assessment of dominant dosha, causative factors and pacifying factors, − • At the initial stage of atisara when undigested food is being expelled, stambhan (anti diarrheal treatment) is strictly contraindicated. If stambhana is given, it leads to various complications. Mild laxatives like haritaki shall be administered for evacuating the mala (accumulated undigested wastes). Deepana and pachana (stimulation of agni for digestion and metabolism) should be given with light nutritive liquid foods. After restoration of agni, stambhan is given and care should taken to keep vata balanced. − • In case of prolapse of rectum, medicated ghee processed with sour herbs or anuvasana (unctuous enema) is prescribed. + − • Various states of atisara like that mixed with mucous, blood, associated with colic pain shall be treated with pichcha basti (mucilaginous enema). + − • When kapha gets reduced because of the above mentioned therapeutic measures, the vata is aggravated in its own location (colon). This aggravated vata must be immediately treated as it may cause instantaneous death.+ − • In case of sannipataja atisara, at first the aggravated vata shall be pacified followed by pitta and kapha. Alternatively, the most aggravated one should be controlled first followed by the treatment of the remaining two dosha.+ + − + + + + + + + + + + + + + + + + + + + + + + + + − Importance of agni in context of atisara:+ − त्रयो विकाराः प्रायेण ये परस्परहेतवः| − अर्शांसि चातिसारश्च ग्रहणीदोष एव च||२४४|| − एषामग्निबले हीने वृद्धिर्वृद्धे परिक्षयः| − तस्मादग्निबलं रक्ष्यमेषु त्रिषु विशेषतः||२४५|| − -Caraka chikitsā 14/244-245 − The three diseases viz. hemorrhoids, diarrhoea and Grahaṇí (digestive disorders) are interdependent in as much as one of them can cause the other. They get aggravated if there is reduction in the power of digestion and when the power of digestion is increased, they get cured. Therefore, agni should be specifically protected for these three ailments. Atisara manifests due to abnormal purishava srotas. − Therapeutic use of milk in atisara: − 1. When movement of flatus and stool is arrested, acute colic pain, patient voids blood and mucous- profuse quantity of milk should be given. − 2. In pittaja atisara-goat milk-for promotion of strength and complexion. − 3. In pittaja atisara, when dosha are excessively aggravated then cow’s milk should be given for laxation. − Milk is an emulsion or colloid of butter fat globules within a water-based fluid that contains dissolved carbohydrates and protein aggregates with minerals. Because it is produced as a food source for the young, all of its contents provide benefits for its growth. The principal requirements are energy (lipids, lactose, and protein), biosynthesis of non-essential amino acids supplied by proteins (essential amino acids and amino groups), essential fatty acids, vitamins and inorganic elements, and water. − Milk composition analysis, per 100 grams − Constituents Unit Cow+ − Goat+ − Sheep − Buffalo − Water g 87.8 88.9 83.0 81.1+ − Protein g 3.2 3.1 5.4 4.5+ − Fat g 3.9 3.5 6.0 8.0+ − ----Saturated fatty acids g 2.4 2.3 3.8 4.2+ − ----Monounsaturated fatty acids g 1.1 0.8 1.5 1.7+ − ----Polyunsaturated fatty acids g 0.1 0.1 0.3 0.2 − Carbohydrate (i.e the sugar form of Lactose) − g 4.8 4.4 5.1 4.9 − Cholesterol mg 14 10 11 8 − Calcium mg 120 100 170 195 − Energy kcal 66 60 95 110 − kJ 275 253 396 463 − The disease atisara may be correlated to diarrhoea.+ + + − Diarrhoea+ − 1. Gastroenterologists define diarrhoea as the passage of more than 200 g of stool daily, and measurement of stool volume is helpful in confirming this.+ − + − Acute diarrhoea+ − 1. This is extremely common and usually due to faecaloral transmission of bacteria, their toxins, viruses or parasites.+ − 2. Infective diarrhoea is usually short-lived and patients who present with a history of diarrhoea lasting more than 10 days rarely have an infective cause.+ − + − Chronic or relapsing diarrhoea+ − 1. The most common cause is irritable bowel syndrome, which can present with increased frequency of defecation and loose, watery or pellety stools. + − 2. Diarrhoea rarely occurs at night and is most severe before and after breakfast.+ − 3. At other times the patient is constipated and there are other characteristic symptoms of irritable bowel syndrome. + − 4. The stool often contains mucus but never blood, and 24-hour stool volume is less than 200 g. + − 5. Chronic diarrhoea can be categorised as disease of the colon or small bowel, or malabsorption + − 6. Clinical presentation, examination of the stool, routine blood tests and imaging reveal diagnosis in many cases. + − 7. A series of negative investigations usually implies irritable bowel syndrome but some patients clearly have organic disease and need more extensive investigations.+ − Differential diagnosis:+ − Colonic Malabsorption Small bowel+ − Clinical features Blood and mucus Steatorrhoea Large-volume,watery stool+ − in stool + − Cramping Undigested food Abdominal bloating+ − lower abdominal in the stool Cramping mid- + − pain Weight loss and abdominal pain+ − nutritional + − disturbances+ − Some causes Inflammatory bowel Pancreatic VIPoma(endocrine tumor) disease + − Neoplasia Chronic pancreatitis Drug-induced+ − Ischaemia Cancer of pancreas NSAIDs+ − Irritable bowel Cystic fibrosis Aminosalicylates+ − syndrome + − Enteropathy Selective serotonin + − Coeliac disease re-uptake+ − Lymphoma inhibitors (SSRIs) + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + − Tropical sprue + − Lymphangiectasia + − Investigations Colonoscopy with Ultrasound, CT and Stool volume+ − biopsies MRCP + − Small bowel biopsy Gut hormone profile − Barium follow- Barium follow-through − through − − Acute diarrhoea and vomiting − 1. Acute diarrhoea, sometimes with vomiting, is the predominant symptom in infectious gastroenteritis − 2. Acute diarrhoea may also be a symptom of other infectious and non-infectious diseases − 3. Stress, whether psychological or physical, can also produce loose stools. − Causes of infectious gastroenteritis − Toxin in food: < 6 hours incubation − • Bacillus cereus • Clostridium spp. − • Staph. aureus enterotoxin − Bacterial: 12-72 hours incubation − • Vibrio cholerae • Salmonella − • Enterotoxigenic E. Coli • Shigella − • Campylobacter − • Shiga toxin-producing E. coli • Clostridium difficile − − • Enteroinvasive E. coli − Viral: short incubation − • Rotavirus • Norovirus − Protozoal: long incubation − • Giardiasis • Amoebic dysentery − • Cryptosporidium − • Isosporiasis i − • Microsporidiosis − Differential diagnosis of acute diarrhoea and vomiting+ − Infectious causes − • Gastroenteritis • Pelvic inflammatory disease − • C. difficile infection − • Acute diverticulitis • Meningococcaemia − • Sepsis − • Pneumonia (especially atypical disease) − • Malaria − Non-infectious causes − Gastrointestinal − • Inflammatory bowel • Overflow from constipation − disease • Bowel malignancy − Metabolic − • Diabetic ketoacidosis • Uraemia − • Neuroendocrine tumours − • Thyrotoxicosis releasing (e.g.) VIP or 5-HT − Drugs and toxins − • NSAIDs • Heavy metals − • Cytotoxic agents • Ciguatera fish poisoning − • Antibiotics − • Proton pump inhibitors • Scombrotoxic fish poisoning − • Dinoflagellates • Plant toxins − 1. The World Health Organization (WHO) estimates that there are more than 1000 million cases of acute diarrhoea annually in developing countries, with 3-4 million deaths, most often in infants and young children. − 2. In developed countries diarrhoea remains an important problem and the elderly are most vulnerable − 3. The majority of episodes are due to infections spread by the faecal-oral route and transmitted either on fomites, on contaminated hands, or in food or water. − 4. Measures such as the provision of clean drinking water, appropriate disposal of human and animal sewage, and simple principles of food hygiene all limit gastroenteritis. − Clinical features − 1. The history should include questioning about foods ingested, the duration and frequency of diarrhoea, the presence of blood or steatorrhoea, abdominal pain and tenesmus, and whether family or community members have been affected. − 2. Fever and bloody diarrhoea suggest an invasive, colitic, dysenteric process. − 3. Incubation periods of less than 18 hours suggest toxin-mediated food poisoning − − The clinical features of food-borne gastroenteritis depend on the pathogenic mechanisms involved. − 5. Some organisms (Bacillus cereus, Staph. aureus and Vibrio cholerae) elute exotoxins, which exert their major effects on the stomach and small bowel, and produce vomiting ; and/or so-called ‘secretory’ diarrhoea, which is watery ; diarrhoea without blood or faecal leucocytes. − • In general, the time from ingestion to the onset of symptoms is short and, other than dehydration, little systemic upset occurs. − 6. Other organisms, such as Shigella spp., Campylobacter spp. and enterohaemorrhagic E. coli (EHEC), may directly invade the mucosa of the small bowel or produce cytotoxins that cause mucosal ulceration, typically affecting the terminal small bowel and colon. − The incubation period is longer and more systemic upset occurs, with prolonged bloody diarrhoea. − 7. Salmonella spp. are capable of invading enterocytes, and of causing both a secretory response and invasive disease with systemic features. − • This is seen with Salmonella typhi and S. paratyphi (enteric fever), and, in the immunocompromised host, with non-typhoidal Salmonella spp. − Physical examination − 1. Examination includes assessment of the degree of dehydration − • Skin turgor − • Pulse and blood pressure measurement. − • The urine output and ongoing stool losses should be monitored. − Investigations+ − 1. Examination of Stool − A. Inspection of stool for blood − B. Microscopy -- leucocytes, and ova, cysts and parasites( if the history indicates former tropical residence or travel). − C. Stool culture should be performed, if possible. − Blood − 2. FBC − 3. Serum electrolytes indicate the degree of inflammation and dehydration. − 4. In a malarious area, a blood film for malaria parasites should be obtained. − 5. Blood and urine cultures and a chest X-ray may identify alternative sites of infection, particularly if the clinical examination is suggestive of a syndrome other than gastroenteritis. − Foods associated with infectious illness including gastroenteritis + − Raw seafood − • Norovirus • Hepatitis A − • Vibrio spp. − Raw eggs − • Salmonella spp. − Undercooked meat or poultry − • Salmonella spp. • EHEC − • Campylobacterspp. • C. pertringens − Unpasteurised milk or juice − • Salmonella spp. • EHEC − • Campylobacterspp. • V, enterocolitica − Unpasfeurised soft cheeses − • Salmonella spp. • Y. enterocolitica − • Campylobacferspp. • L. Monocytogenes − • ETEC − Home-made canned goods − • botulinum − Raw hot dogs, pate − • L. Monocytogenes − Management + − Treatment: + − Infectious Diarrhea or Bacterial Food Poisoning+ − Empirical regimens for the treatment of traveler's diarrhea are + − 1. Clinical Syndrome+ − Watery diarrhea (no blood in stool, no fever), 1 or 2 unformed stools per day without distressing enteric symptoms+ − Treatment - Oral fluids (oral rehydration solution, Pedialyte, Lytren, or flavored mineral water) and saltine crackers + − + − Treatment - Bismuth subsalicylate (for adults): 30 mL or 2 tablets (262 mg/tablet) every 30 min for 8 doses; or loperamideb: 4 mg initially followed by 2 mg after passage of each unformed stool, not to exceed 8 tablets (16 mg) per day (prescription dose) or 4 caplets (8 mg) per day (over-the-counter dose); drugs can be taken for 2 days + − 3. Watery diarrhea (no blood in stool, no distressing abdominal pain, no fever), >2 unformed stools per day+ − Treatment- Antibacterial drugc plus (for adults) loperamideb (see dose above) + − 4. Dysentery (passage of bloody stools) or fever (>37.8°C)+ − Treatment- Antibacterial drug+ − 5. Vomiting, minimal diarrhea+ − Treatment- Bismuth subsalicylate (for adults; see dose above)+ − 6. Diarrhea in infants (<2 years old)+ − Treatment- 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+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + − 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 − 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 − 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. + − Effect of ayurveda medicines in chronic diarrhea and psycho somatic disease like irritable bowel syndrome needs further evaluation. + − Glossary+ − Ādikālē (आदिकाले): At the commencement of ancient time (Satya-yuga)+ − Anuvāsana Basti (अनुवासनबस्तिः): oily medicated enema − Asthāpana Basti (स्थापनबस्तिः): medicated enema with decoction − Atīsāracikitsitaṁ (अतीसारचिकित्सितं): treatment of diarrhoea − Candrakōpagatam (चन्द्रकोपगतम): coloured patches circular in shape like moon − Dadhighr̥tamajjatailavasākṣīravēsavārābham (दधिघृतमज्जतैलवसाक्षीरवेसवाराभम): looks like curd, ghee, bone-marrow, oil, muscle fat, milk and minced meat − Gauravādauṣṇyādasātmyatvāda (गौरवादौष्ण्यादसात्म्यत्वाद): due to heavy, hot & unwholesome − Grahnipradosa (ग्रहणीप्रदोषान्): grahani, sprue syndrome − Gudapākaṁ (गुदपाकं): suppuration of the anus − Gulma (गुल्म): localized growth in abdomen − Hāridra (हारिद्र): yellow colour like turmeric − Harita (हरित): green − Hutāgnihōtram (हुताग्निहोत्रम): oblations to the fire − Jāṅgalānāṁ (जाङ्गलानां): wild animals − Karburam (कर्बुरम): stool of variegated in colour − Kr̥tāhnikaṁ (कृताह्निकं): completion of daily worship − Kuṇapgandhyama (कुणपगन्ध्यम): smell like that of a dead body − Lakṣaṇa (लक्षण): signs and symptoms − Laṅghita (लङ्घित): undergone lighening therapy − Makṣikākāntaṁ (मक्षिकाकान्तं): stool attracts flies in excess − Māṁsadhāvanasannikāśaṁ (मांसधावनसन्निकाशं): appears like washing of meat − Maṇḍā (मण्डा): liquid portion of cooked rice − Māñjiṣṭha (माञ्जिष्ठ): reddish colour like of mnjistha − Matsyagandhi (मत्स्यगन्धि): smell like that raw fish − Mēcakābha (र्मेचकाभ): like tar coloured − Mēdōmāṁsōdakasannikāśaṁ (मेदोमांसोदकसन्निकाशं): like washing of fat or flesh − Muktanāla (मुक्तनाल): paralysed anus sphictor − Musti (मुष्टि): handful, fist − Nīla (नील): blue − Nimitta (निमित्त): cause − Niryūha (निर्यूह): decoction − Pañcavalkama (पञ्चवल्कम): bark of five plants viz. Nyagrodha, Udumbara, Ashvattha, Pārasa and plaksha − Patitagudavaliṁ (पतितगुदवलिं): prolapsed anal sphincters − Picchā-basti (पिच्छाबस्ति) medicated enema with mucilaginous drugs − Prāgutpatti (प्रागुत्पत्ति): origin − Prajānugrahārtham (प्रजानुग्रहार्थम): for wellbeing of humanity. − Pratyavarakālaṁ (प्रत्यवरकालं): age following performance of sacrifice by Daksa Prajapati − Pravāhikaḥ-(प्रवाहिकः): passing stool with spasmatic pain − Pūtipūyagandhyam (पूतिपूयगन्ध्यम): putrid smell or smell like undigested food − Samsarjanakrama (संसर्जन): gradual bringing from lighter to normal food after purification therapy − Srastapakvagudaṁ (स्रस्तपक्वगुदं): prolapsed and inflamed of the anus − Tarpaṇā (तर्पणा): roasted flour of cereals added with water − Upahatāgnī (उपहताग्नी): loss of the power of digestion − Upahatamanasāṁ (उपहतमनसां): afflicted mental equilibrium − Upaśamana (उपशमन): treatment − Varāhabhēdaḥsadr̥śa (वराहभेदःसदृश): white yellowish colour like of pig-fat − Vibaddha (विबद्ध): blocked − Yakr̥tkhaṇḍōpamaṁ (यकृत्खण्डोपमं): like piece of liver − Yamaka (यमक): mixture of two unctuous substances e.g. mixture of ghee and oil − Yavāgū (यवागू): thick gruel − Further reading: − 1. 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 − 2. Valiathan, M.S. (2009): Legacy of Charaka, Sushruta, Vagbhata, Orient Longman, Chennai. − 3. Sushruta. Sushruta Samhita. Volume III, Uttarasthana, translated by Prof. K.R. Srikatha Murthy, Varanasi, Chaukhambha Orientalia; 2005.p.223-250. − 4. Parameswarappa’s ĀyurvedÍya Vikriti Vijñāna and Roga Vijñāna by Dr. P.S. Byadgi. Volume II, pages-431-446 − 5. Davidson’s Principles of practice of medicine, 21th Ed. (2007) Ed. by Nicholas A. Boon., Nicki R. College, Brain R. Walker, Pub. Churchill Livingstone Elsevier, London Elsevier. Pages-302-304 − 6. 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 − 7. . 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.
Text replacement - "Ayurveda" to "Ayurveda"
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==([[Chikitsa Sthana]] Chapter 19, Chapter on the Management of diarrhea and associated disorders)==
==[[Chikitsa Sthana]] Chapter 19, Chapter on the Management of ''Atisara'' (diarrhea and associated disorders)==
=== Abstract ===
=== Abstract ===
The chapter on [[Atisara Chikitsa]] (management of diarrhea) traces the historical origin of the disorder since the Vedic period and attributes it to eating of heavy and hot foods specially meat products. There are six types of diarrhea, three of which are caused by single ''dosha'' (''vataja, pittaja'' and ''kaphaja'') while a fourth is caused by the combination of all the three ''doshas''. The fifth and sixth types are caused due to psychological factors such as fear and grief. Some of these variants could be further classified based on their constituents, e.g., ''vataja atisara'' (diarrhea caused due to ''vata dosha'') is further divided into ''amaja'' and ''niramaja atisara'' (with or without mucoid substances diarrhea) and it has been emphasized not to stop the lose motions in initial or ''ama'' stage.
The chapter on [[Atisara Chikitsa]] (management of diarrhea) traces the historical origin of the disorder since the Vedic period and attributes it to eating of heavy and hot foods specially meat products. There are six types of diarrhea, three of which are caused by single ''dosha'' (''vataja, pittaja'' and ''kaphaja'') while a fourth is caused by the combination of all the three ''doshas''. The fifth and sixth types are caused due to psychological factors such as fear and grief. Some of these variants could be further classified based on their constituents, e.g., ''vataja atisara'' (diarrhea caused due to ''vata dosha'') is further divided into ''ama'' and ''nirama atisara'' (with or without mucoid substances diarrhea) and it has been emphasized not to stop the lose motions in initial or ''ama'' stage.
The etiology, pathology, signs and symptoms of each of these six types of diarrhea, along with their prognosis have been detailed here.The principles of treatment and complications associated with diarrhea, such as bleeding, suppuration, ulceration and prolapsed anus are also described along with various measures to tackle the problems effectively.
The etiology, pathology, signs and symptoms of each of these six types of diarrhea, along with their prognosis have been detailed here.The principles of treatment and complications associated with diarrhea, such as bleeding, suppuration, ulceration and prolapsed anus are also described along with various measures to tackle the problems effectively.
''Sangrahi'' (astringent or anti-diarrheals) therapies are not advisable in the initial stage of the disease because of presence of ''ama'' inside the body. Instead, mild laxative should be given to eliminate the accumulated ''doshas''. Diarrhea should be allowed to continue and should not be stopped by constipating or bowel binding drugs. The patients shall be managed with light to digest, nutritive and liquid diet regimen which enhances power of ''agni'' as well as it helps to stop diarrhea.
''Sangrahi'' (astringent or anti-diarrheals) therapies are not advisable in the initial stage of the disease because of presence of ''ama'' inside the body. Instead, mild laxative should be given to eliminate the accumulated ''doshas''. Diarrhea should be allowed to continue and should not be stopped by constipating or bowel binding drugs. The patients shall be managed with light to digest, nutritive and liquid diet regimen which enhances power of ''agni'' as well as it helps to stop diarrhea.
'''Keywords''': ''atisara, diarrhea, amaja, niramaja, sangrahi'' treatment, ''pichcha basti''.
'''Keywords''': ''atisara, diarrhea, ama, nirama, sangrahi'' treatment, ''pichcha basti''.
=== 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.
''Atisara'' leads to the depletion of water and beneficial salts, causing dehydration in the body. This provokes ''vata'', and therefore requires taking special care of ''vata'', particularly if, the ''atisara'' is caused by all the three ''doshas''. Hydration of the body by means of oral administration of milk, buttermilk and various liquid preparations is advised. Goat’s milk is very useful in bloody diarrhea.
''Atisara'' leads to the depletion of water and beneficial salts, causing dehydration in the body. This provokes ''vata'', and therefore requires taking special care of ''vata'', particularly if, the ''atisara'' is caused by all the three ''doshas''. Hydration of the body by means of oral administration of milk, buttermilk and various liquid preparations is advised. Goat’s milk is very useful in bloody diarrhea.The treatment of cholera and other dehydrating diarrheal diseases was revolutionized by the promotion of oral rehydration solution (ORS), the efficacy of which depends on the fact that glucose-facilitated absorption of sodium and water in the small intestine remains intact in the presence of cholera toxin. Where indicated, appropriate antimicrobial agents can shorten the duration of illness from 3–4 days to 24–36 h, hence it should be started depending on the course of illness. Adequate prophylaxis measures should be taken to prevent the infectious diarrhoea.
=== Sanskrit Text, Transliteration and English Translation ===
=== Sanskrit Text, Transliteration and English Translation ===
अपिचशोणितादीन्धातूनतिप्रकृष्टं[१]दूषयन्तोधातुदोषस्वभावकृतानतीसारवर्णानुपदर्शयन्ति |
अपिचशोणितादीन्धातूनतिप्रकृष्टं[१]दूषयन्तोधातुदोषस्वभावकृतानतीसारवर्णानुपदर्शयन्ति |
तत्रशोणितादिषुधातुष्वतिप्रदुष्टेषुहारिद्रहरितनीलमाञ्जिष्ठमांसधावनसन्निकाशंरक्तंकृष्णंश्वेतंवराहभेदःसदृशमनुबद्धवेदनमवेदनंवासमासव्यत्यासादुपवेश्यतेशकृद्ग्रथितमामंसकृत्, सकृदपिपक्वमनतिक्षीणमांसशोणितबलोमन्दाग्निर्विहतमुखरसश्च; तादृशमातुरंकृच्छ्रसाध्यंविद्यात् |
तत्रशोणितादिषुधातुष्वतिप्रदुष्टेषुहारिद्रहरितनीलमाञ्जिष्ठमांसधावनसन्निकाशंरक्तंकृष्णंश्वेतंवराहभेदःसदृशमनुबद्धवेदनमवेदनंवासमासव्यत्यासादुपवेश्यतेशकृद्ग्रथितमामंसकृत्, सकृदपिपक्वमनतिक्षीणमांसशोणितबलोमन्दाग्निर्विहतमुखरसश्च; तादृशमातुरंकृच्छ्रसाध्यंविद्यात् |
एभिर्वर्णैरतिसार्यमाणंसोपद्रवमातुरमसाध्योऽयमितिप्रत्याचक्षीत; तद्यथा- पक्वशोणिताभं[२]यकृत्खण्डोपमंमेदोमांसोदकसन्निकाशंदधिघृतमज्जतैलवसाक्षीरवेसवाराभमतिनीलमतिरक्तमतिकृष्णमुदकमिवाच्छंपुनर्मेचकाभमतिस्निग्धंहरितनीलकषायवर्णंकर्बुरमाविलंपिच्छिलंतन्तुमदामंचन्द्रकोपगतमतिकुणपपूतिपूयगन्ध्यामाममत्स्यगन्धिमक्षिकाकान्तं[३]कुथितबहुधातुस्रावमल्पपुरीषमपुरीषंवाऽतिसार्यमाणंतृष्णादाहज्वरभ्रमतमकहिक्काश्वासानुबन्धमतिवेदनमवेदनंवास्रस्तपक्वगुदंपतितगुदवलिंमुक्तनालमतिक्षीणबलमांसशोणितंसर्वपर्वास्थिशूलिनमरोचकारतिप्रलापसम्मोहपरीतंसहसोपरतविकारमतिसारिणमचिकित्स्यंविद्यात्; इतिसन्निपातातिसारः ||९||
एभिर्वर्णैरतिसार्यमाणंसोपद्रवमातुरमसाध्योऽयमितिप्रत्याचक्षीत; तद्यथा- पक्वशोणिताभं[२]यकृत्खण्डोपमंमेदोमांसोदकसन्निकाशंदधिघृतमज्जतैलवसाक्षीरवेसवाराभमतिनीलमतिरक्तमतिकृष्णमुदकमिवाच्छंपुनर्मेचकाभमतिस्निग्धं
हरितनीलकषायवर्णंकर्बुरमाविलंपिच्छिलंतन्तुमदामंचन्द्रकोपगतमतिकुणपपूतिपूयगन्ध्यामाममत्स्यगन्धिमक्षिकाकान्तं[३]कुथितबहुधातुस्रावमल्पपुरीषमपुरीषंवाऽतिसार्यमाणं
तृष्णादाहज्वरभ्रमतमकहिक्काश्वासानुबन्धमतिवेदनमवेदनंवास्रस्तपक्वगुदंपतितगुदवलिंमुक्तनालमतिक्षीणबलमांसशोणितं
सर्वपर्वास्थिशूलिनमरोचकारतिप्रलापसम्मोहपरीतंसहसोपरतविकारमतिसारिणमचिकित्स्यंविद्यात्; इतिसन्निपातातिसारः ||९||
api ca śōṇitādīn dhātūnatiprakr̥ṣṭaṁ [1] dūṣayantō dhātudōṣasvabhāvakr̥tānatīsāravarṇānupadarśayanti|
api ca śōṇitādīn dhātūnatiprakr̥ṣṭaṁ [1] dūṣayantō dhātudōṣasvabhāvakr̥tānatīsāravarṇānupadarśayanti|
tatra śōṇitādiṣu dhātuṣvatipraduṣṭēṣu hāridraharitanīlamāñjiṣṭhamāṁsadhāvanasannikāśaṁ raktaṁkr̥ṣṇaṁ śvētaṁ varāhabhēdaḥsadr̥śamanubaddhavēdanamavēdanaṁ vā samāsavyatyāsādupavēśyatēśakr̥d grathitamāmaṁ sakr̥t, sakr̥dapi pakvamanatikṣīṇamāṁsaśōṇitabalō mandāgnirvihatamukharasaśca;tādr̥śamāturaṁ kr̥cchrasādhyaṁ vidyāt|
tatra śōṇitādiṣu dhātuṣvatipraduṣṭēṣu hāridraharitanīlamāñjiṣṭhamāṁsadhāvanasannikāśaṁ raktaṁkr̥ṣṇaṁ śvētaṁ varāhabhēdaḥsadr̥śamanubaddhavēdanamavēdanaṁ vā samāsavyatyāsādupavēśyatēśakr̥d grathitamāmaṁ sakr̥t, sakr̥dapi
pakvamanatikṣīṇamāṁsaśōṇitabalō mandāgnirvihatamukharasaśca;tādr̥śamāturaṁ kr̥cchrasādhyaṁ vidyāt|
ēbhirvarṇairatisāryamāṇaṁ sōpadravamāturamasādhyō'yamiti pratyācakṣīta; tadyathā- pakvaśōṇitābhaṁ[2] yakr̥tkhaṇḍōpamaṁ mēdōmāṁsōdakasannikāśaṁdadhighr̥tamajjatailavasākṣīravēsavārābhamatinīlamatiraktamatikr̥ṣṇamudakamivācchaṁpunarmēcakābhamatisnigdhaṁ haritanīlakaṣāyavarṇaṁ karburamāvilaṁ picchilaṁ tantumadāmaṁcandrakōpagatamatikuṇapapūtipūyagandhyāmāmamatsyagandhi makṣikākāntaṁ [3]kuthitabahudhātusrāvamalpapurīṣamapurīṣaṁ vā'tisāryamāṇaṁtr̥ṣṇādāhajvarabhramatamakahikkāśvāsānubandhamativēdanamavēdanaṁ vā srastapakvagudaṁpatitagudavaliṁ muktanālamatikṣīṇabalamāṁsaśōṇitaṁsarvaparvāsthiśūlinamarōcakāratipralāpasammōhaparītaṁ sahasōparatavikāramatisāriṇamacikitsyaṁvidyāt; iti sannipātātisāraḥ||9||
ēbhirvarṇairatisāryamāṇaṁ sōpadravamāturamasādhyō'yamiti pratyācakṣīta; tadyathā- pakvaśōṇitābhaṁ[2] yakr̥tkhaṇḍōpamaṁ mēdōmāṁsōdakasannikāśaṁdadhighr̥tamajjatailavasākṣīravēsavārābhamatinīlamatiraktamatikr̥ṣṇamudakamivācchaṁpunarmēcakābhamatisnigdhaṁ haritanīlakaṣāyavarṇaṁ karburamāvilaṁ picchilaṁ tantumadāmaṁcandrakōpagatamatikuṇapapūtipūyagandhyāmāmamatsyagandhi makṣikākāntaṁ [3]kuthitabahudhātusrāvamalpapurīṣamapurīṣaṁ vā'tisāryamāṇaṁtr̥ṣṇādāhajvarabhramatamakahikkāśvāsānubandhamativēdanamavēdanaṁ vā srastapakvagudaṁpatitagudavaliṁ muktanālamatikṣīṇabalamāṁsaśōṇitaṁsarvaparvāsthiśūlinamarōcakāratipralāpasammōhaparītaṁ sahasōparatavikāramatisāriṇamacikitsyaṁvidyāt; iti sannipātātisāraḥ||9||
Such a patient should be rejected for the treatment (as it is incurable). [9]
Such a patient should be rejected for the treatment (as it is incurable). [9]
==== Principles of treatment ====
==== Guidelines for starting treatment ====
तमसाध्यतामसम्प्राप्तंचिकित्सेद्यथाप्रधानोपक्रमेणहेतूपशयदोषविशेषपरीक्षयाचेति ||१०||
तमसाध्यतामसम्प्राप्तंचिकित्सेद्यथाप्रधानोपक्रमेणहेतूपशयदोषविशेषपरीक्षयाचेति ||१०||
Three recipes of ''pramathya'' which are useful in the treatment of diarrhea are as follow:
Three recipes of ''pramathya'' which are useful in the treatment of diarrhea are as follow:
*Decoction of pippali, nāgara, dhānyaka, bhutika, abhayā and vachā for vataja atisara
*Decoction of ''pippali, nagara, dhanyaka, bhutika, abhaya'' and ''vacha'' for ''vataja atisara''
*Decoction of hrivera, bhadra-mustā, bilva, nāgara and dhānyaka for pittaja atisara)
*Decoction of ''hrivera, bhadra-musta, bilva, nagara'' and ''dhanyaka'' for ''pittaja atisara'')
*Decoction of prasniparni, svadamstrā, samanga and kantakarika for kaphaja atisara
*Decoction of ''prashniparni, svadamstra, samanga'' and ''kantakarika'' for ''kaphaja atisara''
*Decoction of vachā and prativisha for vataja atisara
*Decoction of ''vacha'' and ''prativisha'' for ''vataja atisara''
*Decoction of Mustā and parpataka for pittaja atisara
*Decoction of ''musta'' and ''parpataka'' for ''pittaja atisara''
*Decoction of hrivera and sringavera for kaphaja atisara
*Decoction of ''hrivera'' and ''sringavera'' for ''kaphaja atisara''
[Note: Decoction should be prepared as per the procedure described for ''sandanga-paniya'' in C.S.Ci.3-145.] [20-22]
[Note: Decoction should be prepared as per the procedure described for ''sandanga-paniya'' in C.S.Ci.3-145.] [20-22]
==== Diet and drinks for ''atisara'' patient ====
==== Diet and drinks for ''atisara'' patient ====
*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'' ====
If there is prolapse of rectum and colic pain, and if the diarrhea is free from ''ama'', then the patient should be given medicated ghee prepared with sour drugs or ''anuvasana'' (unctuous enema). [42]
If there is prolapse of rectum and colic pain, and if the diarrhea is free from ''ama'', then the patient should be given medicated ghee prepared with sour drugs or ''anuvasana'' (unctuous enema). [42]
==== ''Changerighritam'' ====
==== ''Changeri ghritam'' ====
चाङ्गेरीकोलदध्यम्लनागरक्षारसंयुतम् |
चाङ्गेरीकोलदध्यम्लनागरक्षारसंयुतम् |
Ghee should be cooked with the juice of ''changeri'', decoction of ''kola'' and sour curd, and the paste of ''nagara'' and ''kshara'' (alkali preparation). Intake of this medicated ghee cures ailments caused by prolapse of rectum. Thus, ends the description of ''changeri-ghrita'' [43].
Ghee should be cooked with the juice of ''changeri'', decoction of ''kola'' and sour curd, and the paste of ''nagara'' and ''kshara'' (alkali preparation). Intake of this medicated ghee cures ailments caused by prolapse of rectum. Thus, ends the description of ''changeri-ghrita'' [43].
==== ''Chavyadighritam'' ====
==== ''Chavyadi ghritam'' ====
सचव्यपिप्पलीमूलंसव्योषविडदाडिमम् |
सचव्यपिप्पलीमूलंसव्योषविडदाडिमम् |
तत्रश्लोकः-
तत्रश्लोकः-
प्रागुत्पत्तिनिमित्तानिलक्षणंसाध्यतानच |
प्रागुत्पत्तिनिमित्तानिलक्षणंसाध्यतानच |
क्रियाचावस्थिकीसिद्धानिर्दिष्टाह्यतिसारिणाम् ||१२३||
क्रियाचावस्थिकीसिद्धानिर्दिष्टाह्यतिसारिणाम् ||१२३||
tatra ślōkaḥ-
tatra ślōkaḥ-
prāgutpattinimittāni lakṣaṇaṁ sādhyatā na ca|
prāgutpattinimittāni lakṣaṇaṁ sādhyatā na ca|
kriyā cāvasthikī siddhā nirdiṣṭā hyatisāriṇām||123||
kriyā cāvasthikī siddhā nirdiṣṭā hyatisāriṇām||123||
tatra shlokaH-
tatra shlokaH-
prAgutpattinimittAni lakShaNaM sAdhyatA na ca|
prAgutpattinimittAni lakShaNaM sAdhyatA na ca|
kriyA cAvasthikI siddhA nirdiShTA hyatisAriNAm||123||
kriyA cAvasthikI siddhA nirdiShTA hyatisAriNAm||123||
In this chapter, the following topics in respect of the patient suffering from atisara (diarrhoea) are described:
In this chapter, the following topics in respect of the patient suffering from ''atisara'' (diarrhea) are described:
*Historical origin of ''atisara''
*Etiology of different types of ''atisara''
*Signs and symptoms of ''atisara''
*Curability and incurability of ''atisara''
*Effective treatment for different stages of ''atisara'' [123].
इत्यग्निवेशकृतेतन्त्रेचरकप्रतिसंस्कृतेचिकित्सास्थानेऽतिसारचिकित्सितंनामैकोनविंशोऽध्यायः ||१९||
इत्यग्निवेशकृतेतन्त्रेचरकप्रतिसंस्कृतेचिकित्सास्थानेऽतिसारचिकित्सितंनामैकोनविंशोऽध्यायः ||१९||
ityagnivēśakr̥tē tantrē carakapratisaṁskr̥tē cikitsāsthānē'tisāracikitsitaṁ nāmaikōnaviṁśō'dhyāyaḥ||19||
ityagnivēśakr̥tē tantrē carakapratisaṁskr̥tē cikitsāsthānē'tisāracikitsitaṁ nāmaikōnaviṁśō'dhyāyaḥ||19||
Thus, ends the nineteenth chapter of Cikitsa-sthana (section on the treatment of diseases) dealing with the treatment of atisara (diarrhoea) 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'' / Fundamental Principles===
*''Atisara'' is caused by intake of heavy to digest, excessively hot and food that is incompatible to the body, impairment of ''agni'' and mind. The body reacts to expel out the incompatible material out of gut in the form of ''atisara''.
*There are five categories of etio-pathological factors for ''atisara'':
#Reduced ''agni'',
#Vitiated ''vata'' and its sub types ''samana'' and ''apana''.
#Vitiated body fluids.
#Vitiated ''purishavaha srotas'' (lower gastro-intestinal tract) and organs of excretion.
#Fear and grief (mental).
*Interaction of ''prakriti'' (basic constitution) and the diet and lifestyle of similar properties (as that of ''dosha prakriti'') makes the person susceptible for ''atisara''.
*The exogenous factors like consumption of intoxicating beverages, exposure to '''krimi''' (bacteria and parasites), other diseases like ''shosha, jwara, arsha'' influence all the above factors and three ''dosha'' to cause ''sannipatik atisara'' (diarrhea) which includes bloody diarrhea.
*If spicy, hot, dry food in large quantity is ingested when ''agni'' is low, undigested food becomes waste product and ''samana vata'' sends it to excretory channels where ''apana vayu'' increases the motility of ''purishavaha srotas'' to excretes these large waste products, frequently.
*To fill this vacuum created by expulsion of wastes, the body fluids shift to the gut and get expelled out as ''atisara''/diarrhea causing dehydration.Thus after involvement of ''purishavaha srotasa'' ( lower GIT), ''udakavaha srotasa'' (body fluids) is also predominantly involved in pathogenesis of ''atisara''.
*Fear and grief are two important mental factors leading to ''atisara''. The presentation and treatment of this ''atisara'' is similar to ''vata'' dominant ''atisara''. The fear shall be treated with ''harshana''(exhilaration) treatment and grief shall be treated with ''ashwasana'' (consolation) therapy.
*The endogenous ''atisara'' shall be treated after proper assessment of dominant ''dosha'', causative factors and pacifying factors,
*At the initial stage of ''atisara'' when undigested food is being expelled, ''stambhan'' (anti diarrheal treatment) is strictly contraindicated. If ''stambhana'' is given, it leads to various complications. Mild laxatives like ''haritaki'' shall be administered for evacuating the ''mala'' (accumulated undigested wastes). ''Deepana'' and ''pachana'' (stimulation of ''agni'' for digestion and metabolism) should be given with light nutritive liquid foods. After restoration of ''agni, stambhan'' is given and care should taken to keep ''vata'' balanced.
*In case of prolapse of rectum, medicated ghee processed with sour herbs or ''anuvasana'' (unctuous enema) is prescribed.
*Various states of ''atisara'' like that mixed with mucous, blood, associated with colic pain shall be treated with ''pichcha basti'' (mucilaginous enema).
*When ''kapha'' gets reduced because of the above mentioned therapeutic measures, the ''vata'' is aggravated in its own location (colon). This aggravated ''vata'' must be immediately treated as it may cause instantaneous death.
*In case of ''sannipataja atisara'', at first the aggravated ''vata'' shall be pacified followed by ''pitta'' and ''kapha''. Alternatively, the most aggravated one should be controlled first followed by the treatment of the remaining two ''dosha''.
=== ''Vidhi Vimarsha'' / Applied Inferences===
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.
=== ''Vidhi Vimarsha'' ===
==== Chronic (or relapsing) diarrhea <ref>Patient Education: Chronic Diarrhea among adults, UptoDate
(https://www.uptodate.com/contents/chronic-diarrhea-in-adults-beyond-the-basics?topicRef=4021&source=see_link)
</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.
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''.
[[File:Atisara.png]]
==== 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''
{| class="wikitable"
|-
2. The most severe symptom in many patients is urgency of defecation, and faecal incontinence is a common event in acute and chronic diarrhoeal illnesses.
! scope="col"| Type
! scope="col"| Formulation
! scope="col"| Dose
! scope="col"| Time
3. A variety of drugs, including antibiotics, cytotoxic drugs, PPIs and NSAIDs, may be responsible for acute diarrhoea.
! scope="col"| ''Anupana''
|-
| rowspan="2"|''Vata'' and ''kapha'' dominant
| ''Jatiphaladi–bhallataka guti''
| 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
| ''kutajavaleha''
|-
| ''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 =====
A combination of ''musta'' (cyperus rotundus), ''ativisha'' (aconitum heterophyllum), ''kutaja'' (holarrhena antidysenterica), ''chitraka'' (plumbago zeylanica) and ''bilva'' (Aegle marmelos) was found effective in management of ''atisara''.<ref>Sridhar B.N., Gopakumar K., Jaya N. Mustadi yoga-A new preparation for treatment of atisara. Aryavaidyan,10(4).May-July 1997;222-225. </ref>
''Kutaja'' is widely used and first preferred drug in management of ''atisara''. It is mainly indicated in conditions of vitiated ''kapha-pitta'' and as a ''sangrahi'' (styptic) and ''shoshana'' (absorbent)(Charak sutra 25/40). In an in-vitro study, sterile double dilution aqueous extract of ''kutaja'' was found effective to inhibit growth of E. coli, staphylococcus aureus, salmonella Typhi.<ref>Shrivastava Niraj, Saxena Varsha. Antibacterial activity of Kutaja(Holarrhena antidysenterica Linn.) in childhood diarrhea:-In vitro study. The Pharma Innovation Journal 2015;4(4):97-99 .</ref> Thus ''kutaja'' can be used for all purpose in management of ''atisara''.
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>
4. Incubation period longer than 5 days suggests diarrhoea caused by protozoa or helminths.
The conditions like ulcerative colitis, irritable bowel syndrome, acute diarrhea are considered under the umbrella of ''atisara''.
In a study on 43 patients of ulcerative colitis, Patel M.V.et.al observed 80% reduction in signs and symptoms of ulcerative colitis by Ayurvedic treatment. The treatment included ''udumbara kwatha'' combination of ''lodhra, musta, nagakeshara,mukta panchamrita rasa, kutaja ghana vati'' and ''udumbara kwatha basti''. It also highlighted disease modifying effect and reduction in use of steroidal drugs in the patients. <ref>Patel M.V.,Patel K.B., Gupta S.N. Effects of Ayurvedic treatment on forty three patients of ulcerative colitis. AYU,Oct-Dec 2010,31(4), 478-481.</ref>
A study found that a combination of ''nagarmotha'' (Cyperus rotundus L.), ''indrayava'' (Holarrhena antidysenterica (L.) Wall.), ''nagakeshara'' (Mesua ferrea L.), ''madhuyashti'' (Glycyrrhiza glabra L.), and ''amalaki'' (Emblica officinalis Gaertn.) powders, along with ''dadimashtaka choorna, shankha bhasma, mustarista'' and ''dhanyapanchaka kvatha'' showed significant response in case of ''pravahika'' (irritable bowel syndrome). <ref>Pooja BA, Bhatted S. Ayurvedic management of Pravahika – A case report. Ayu 2015;36:410-2. </ref>
In another study, ''bilwadileha'' showed significant relief in management of irritable bowel syndrome. <ref>Tiwari R, Pandya DH, Baghel MS. Clinical evaluation of Bilvadileha in the management of irritable bowel syndrome. AYU [serial online] 2013 [cited 2018 Jun 12];34:368-72. Available from: http://www.ayujournal.org/text.asp?2013/34/4/368/127717</ref>
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>
==== Management of exogenous diarrhea/''atisara'' ====
2. Watery diarrhea (no blood in stool, no fever), 1 or 2 unformed stools per day with distressing enteric symptoms
#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.
==== 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.<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>
==== List of research on review of ''atisara'' ====
#Uikey R, Kar AC. A review on Purisha Pariksha in [[Ayurveda]]. AYU [serial online] 2015 [cited 2018 Jun 12];36:125-9. Available from: http://www.ayujournal.org/text.asp?2015/36/2/125/175536
#Patil Dhiraj, Babel Sadhana, Chitte Sanjay. Atisaar (Diarrhea): A Review based on [[Ayurveda]] and modern perspective. WJPMR, 2017,3(7), 227-229 available from http://www.wjpmr.com/ downloaded on 12/06/2018
#S Durgalakshmi, Pious Uthara Anu, Ajantha. An Overview on Nidana Panchaka of Atisara (Diarrhea). IAMJ: Volume 3(8); August. 2015 available from http://www.iamj.in/current_issue/images/upload/2419_2425.pdf downloaded on 12/06/2018
==== Research Areas ====
*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.
*The rehydrating effect of ''pramathya'' (decoctions), ''peya'' (liquid gruel), sour processing media like ''dadima, changeri,'' buttermilk used in the treatment of ''atisara'' need to be investigated further.
*More researches are needed to study effect of [[Ayurveda]] medicines in chronic diarrhea and psycho somatic disease like irritable bowel syndrome.
=== Glossary ===
#Ādikālē (आदिकाले): At the commencement of ancient time (Satya-yuga)
#Anuvāsana Basti (अनुवासनबस्तिः): oily medicated enema
#Asthāpana Basti (स्थापनबस्तिः): medicated enema with decoction
#Atīsāracikitsitaṁ (अतीसारचिकित्सितं): treatment of diarrhoea
#Candrakōpagatam (चन्द्रकोपगतम): coloured patches circular in shape like moon
#Dadhighr̥tamajjatailavasākṣīravēsavārābham (दधिघृतमज्जतैलवसाक्षीरवेसवाराभम): looks like curd, ghee, bone-marrow, oil, muscle fat, milk and minced meat
#Gauravādauṣṇyādasātmyatvāda (गौरवादौष्ण्यादसात्म्यत्वाद): due to heavy, hot & unwholesome
#Grahnipradosa (ग्रहणीप्रदोषान्): grahani, sprue syndrome
#Gudapākaṁ (गुदपाकं): suppuration of the anus
#Gulma (गुल्म): localized growth in abdomen
#Hāridra (हारिद्र): yellow colour like turmeric
#Harita (हरित): green
#Hutāgnihōtram (हुताग्निहोत्रम): oblations to the fire
#Jāṅgalānāṁ (जाङ्गलानां): wild animals
#Karburam (कर्बुरम): stool of variegated in colour
#Kr̥tāhnikaṁ (कृताह्निकं): completion of daily worship
#Kuṇapgandhyama (कुणपगन्ध्यम): smell like that of a dead body
#Lakṣaṇa (लक्षण): signs and symptoms
#Laṅghita (लङ्घित): undergone lighening therapy
#Makṣikākāntaṁ (मक्षिकाकान्तं): stool attracts flies in excess
#Māṁsadhāvanasannikāśaṁ (मांसधावनसन्निकाशं): appears like washing of meat
#Maṇḍā (मण्डा): liquid portion of cooked rice
#Māñjiṣṭha (माञ्जिष्ठ): reddish colour like of mnjistha
#Matsyagandhi (मत्स्यगन्धि): smell like that raw fish
#Mēcakābha (र्मेचकाभ): like tar coloured
#Mēdōmāṁsōdakasannikāśaṁ (मेदोमांसोदकसन्निकाशं): like washing of fat or flesh
#Muktanāla (मुक्तनाल): paralysed anus sphictor
#Musti (मुष्टि): handful, fist
#Nīla (नील): blue
#Nimitta (निमित्त): cause
#Niryūha (निर्यूह): decoction
#Pañcavalkama (पञ्चवल्कम): bark of five plants viz. Nyagrodha, Udumbara, Ashvattha, Pārasa and plaksha
#Patitagudavaliṁ (पतितगुदवलिं): prolapsed anal sphincters
#Picchā-basti (पिच्छाबस्ति) medicated enema with mucilaginous drugs
#Prāgutpatti (प्रागुत्पत्ति): origin
#Prajānugrahārtham (प्रजानुग्रहार्थम): for wellbeing of humanity.
#Pratyavarakālaṁ (प्रत्यवरकालं): age following performance of sacrifice by Daksa Prajapati
#Pravāhikaḥ-(प्रवाहिकः): passing stool with spasmatic pain
#Pūtipūyagandhyam (पूतिपूयगन्ध्यम): putrid smell or smell like undigested food
#Samsarjanakrama (संसर्जन): gradual bringing from lighter to normal food after purification therapy
#Srastapakvagudaṁ (स्रस्तपक्वगुदं): prolapsed and inflamed of the anus
#Tarpaṇā (तर्पणा): roasted flour of cereals added with water
#Upahatāgnī (उपहताग्नी): loss of the power of digestion
#Upahatamanasāṁ (उपहतमनसां): afflicted mental equilibrium
#Upaśamana (उपशमन): treatment
#Varāhabhēdaḥsadr̥śa (वराहभेदःसदृश): white yellowish colour like of pig-fat
#Vibaddha (विबद्ध): blocked
#Yakr̥tkhaṇḍōpamaṁ (यकृत्खण्डोपमं): like piece of liver
#Yamaka (यमक): mixture of two unctuous substances e.g. mixture of ghee and oil
#Yavāgū (यवागू): thick gruel
=== Further reading ===
#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 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.
#Parameswarappa’s ĀyurvedÍya Vikriti Vijñāna and Roga Vijñāna by Dr. P.S. Byadgi. Volume II, pages-431-446
#Davidson’s Principles of practice of medicine, 21th Ed. (2007) Ed. by Nicholas A. Boon., Nicki R. College, Brain R. Walker, Pub. Churchill Livingstone Elsevier, London Elsevier. Pages-302-304
#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.
=== Reference ===
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