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Introduction

According to the Ayurveda, Agnimandya (indigestion) is the root cause of all the diseases.[1] The main Nidana of Agnimandya is faulty dietary habits such as Adhyashana, Vishamashana, and wrong behavioural patterns such as Vegadharana leads to vitiation of all Doshas. Classical signs and symptoms of the disease entity described under the heading of Amlapitta, like heart burn, abdominal pain,sour-bitter belching, reflexes of food taken, nausea, loss of appetite etc. has become a very common cause of hospital visits worldwide. [2] In Brihatrayees, Amlapitta was not considered or grouped under any specific disease, but the symptoms are mentioned. In Laghutrayees description regarding Nidana, Samprapti and Laxanas are available. [3] The above symptoms of Amlapitta as explained in Ayurveda, are nearer clinical entity with symptoms of Hyperacidity mentioned in modern science. [4] Hyperacidity refers to a set of symptoms caused by animbalance between the acid secreting mechanism of the stomach and proximal intestine and the protective mechanisms that ensure their safety. Kashyapa is the first person who mentioned Amlapitta as a separate disease entity. Not only vivid description of Amlapitta with its treatment has been mentioned. but suggestion to change the place for peace of mind in case where medicine does not work has also given. In main treatment of Amlapitta is As the disease is pittashamna, shodhana treatment When patient cannot be well managed with oral medications ‘Panchakarma procedures’ like Vamana (emesis) or virechana (purgation) either is needed should be given. In chronic cases Basti (medicated enema) is also indicated.[5]

Nirukti: [6] -The ‘Amlapitta’ is composed of word Amla and Pitta. The term Amla has been used as an epithet to Pitta. Though, the Amla has been said a natural property of Pitta along with Katu-Rasa according to Charaka. Sushruta has enlisted Katu as its original rasa and mentioned that when Pitta becomes Vidagdha then it changes into Amla. Shrikanthadatta in his commentary on the relevant chapter has defined that Amlapitta is a condition where excessive secretion of Amla Guna Pitta takes place causing vidahyadi conditions.

Definition: Chakrapani has defined Amlapitta as Amlapitta is a condition in which Amla Guna of Pitta is increased. According to Kashyapa, Vidagdha Annarasa staying in Aamashaya attains Shuktata and produces Amlapitta. [7] Commentator of Madhava Nidana, Srikanthadatta and Vijayarakshita[8]  said that Means the condition of pitta in which udriktata of Amla guna along with vidaha is noticed should be called as Amlapitta. In Madhava Nidana, it is defined as[9]  disease condition in which there is avipaka, klama, utklesha, tiktodgara, amlodgar, gaurava, hriddaha, kanthadaha and aruchi are seen is supposed to be Amlapitta.

Types: According to Gati of Pitta Madhava Nidana has described two types of Amlapitta i.e.

1. Urdhavaga Amlapitta
2. Adhoga Amlapitta

Acharya Kashyapa and Madhava both have divided Amlapitta according to involvement of Doshas as below.

Kashyapa                                                 

1. Vatika                                       
2. Paittika
3. Shleshmika                          
4. Shleshmapitta

Nidana of Amlapitta[10] [11] 

Aharaja Hetu : The first and the foremost group of etiological factors of Amlapitta may be considered as the dietary factors. Under this group the intake of food against the code of dietetics i.e. Ahara Vidhi Vidhana and Ahara Vidhi Viseshayatana is included. Various types of incompatible substances, excess use of Pitta aggravating factors like Katu, Amla, Vidahi, kullath as in diet etc., Bharjitanna and untimely consumption of food are the factors against the dietetic code and they directly disturb the Pitta equilibrium.

Viharaja Hetu (Habit Factors): To keep the health undisturbed one is required to follow the healthy code of habits. He requires to have regular habits of defaecation, to eat properly and to sleep in time. He is not to suppose the natural urges, maintaining the equilibrium of the body constituents and by that obviously, he would maintain good health and proper functioning of the body. If this instructions are not followed regular, the whole functioning of the body will be disturbed and in long run, they will cause the disturbance of the equilibrium of Pitta and digestion which ultimately will lead to Amlapitta.

Manasika Hetu (Psychological Factors) : Psychology also playing a great role in maintaining the health . On the other hand an abnormal psychology, in terms of anger, anxiety, greediness etc. would affect the physiology of digestion. Either there would be a lesser secretion of the digestive juice or secreted at improper time and sometimes it may be secreted in excessive quantity. All these conditions lead to indigestion which ultimately gives rise to Amlapitta. The modern science have established that acid Gastritis is nothing else but is the syndrome resulting from stress and strain which shows the important role of psychogenic factors in the production of Amlapitta.

Agantuja hetu (Miscellaneous Factors): Allied factors can be taken under this factor. Under this group constant and excessive consumption of alcohol, tobacco, beverages, smoking or other irritant substances etc. are taken. These substances cause a local irritation in the stomach which in turn secretes more gastric juice. Kashyapa, Harita, Madhavakara have described the etiological factors of Amlapitta, but the list in Kashyapa smhita is very small. Madhavakara has given few etiological factors which are mainly having properties of pitta aggravation. Kashyapa has mentioned such etiological factors of Amlapitta, which are Kapha Prakopaka – this thing shows his inclination towards the role of Kapha as main cause of Amlapitta.

SAMRAPTI OF AMLAPITTA: [12] 

Samprapti means description of pathological process, which takes place in a person due to nidana sevana. It helps to understand the manifestation of clinical features and it also has importance in chikitsa. The Aacharya has stated that samprapti vighatanameva chikitsa, that is, reversal of pathogenesis is the chikitsa.

Nidan sevena which result in Agnidusti, Pitta Prakopa and produce prominent 2nd stage of Avasthapaka. Agni dusti leads to Rasadusti and Produces Suktas?mlat?. Due to Raktadusti, abnormal pitta production occurs, as pitta is the mala of Rakta Simultaneously Suktamlata aggravates pitta on digestive system. This ?mapitta (Premature Pitta) produces Amlodagara, Daha etc. Symptoms and it further produces the amlapitta. Due to nidana seven pitta prakopa may occur & this prakupitta pitta mixes with sanchit pitta and it leads to Amlodagara, Daha etc. symptoms. And it result in Amlapitta. If nidans are Amlarasa Pradhan, Prominent 2nd stage of avasthapaka takes place which leads to increase pittodirana [Own Properties Ati Usnata /titiksnata]. This ?mapitta (Premature Pitta) Produces Amlodagara, Dahu etc. are developed.

Acharya Kashyapa explained the samprapti of Amplapitta in detail. Due to nidana sevana doshas become prakupita.These prakupita doshas lead to agnidushti which results in jatharagnimandya. Even after jatharagnimandya if person continues with nidana sevana then the consumed aahara attains vidagdhata.This vidagdha amarasa stays in amashaya for long time and due to this prolong stasis in amashaya it undergoes shuktapaka (amlatwa). In this condition whatever the food consumed gets vidagdha and later shuktatwa by dushita pitta. This condition is called as Amlapitta. One slimily is given by the Aacharya Kashyapa for easy understanding of the samprapti i.e., if we pour milk in a vessel containing curd, soon after milk gets converted into curd. In the same way when Rasadhatu is amlayukta, then anything consumed gets converted into vidagdha and shuktata[13]   Madhavakara explains the samprapti of Amlapitta as, the pitta becomes sanchita due to Swa Prakopaka Nidanas. This sanchita pitta further attains vidagdhata due to consuming the viruddha, dustha, amla, vidahi, pitta prakopaka ahara, pana and kala(Varsha & Sharad) etc. Then this dushita pitta leads to manifestation of symptoms like hritkanthadaha, avipaka, klama, utklesha, tikta amlodgara, gourava, aruchi, chardi etc[14] 

Samprapti Ghataka Of Amlapitta :

1. Udabhava   -Amashaya and Pittadharakala
2.  Sanchaya    - From Pittadharakata to Shleshmadharakala of Amashaya and Pachyamanashaya
3.  Adhisthana- Adhoamashaya
4.  Dosha            - Pachaka Pitta, Samna Vayu, Kledaka Kapha
5.  Dushya         - Ahara Rasa
6.  Agnimandaya- Jatharagnimandhaya
7.  Ama- Jatharagnimandya Janya Ama
8.  Swabhava- Chirakari
9.  Vayadhi        - Amashayottha
10.  Rogamarga-Abhayantara Rogamarga
11.  Paradhanata- Pitta Dosha Pradhanya

Table no. 1 Correlation between Hyperacidity and Amlapitta

CHIKITSA SUTRA:

Ayurveda has 3 basics of Chikitsa regarding any type of disease.

Nidana Parivarjana[15] : Removal of alleviating factors of Ahara and Vihara which are responsible for causation of the disease. It is to be advised to patient to avoid such type etiological factors which are responsible for the manifestation of disease.

Apakarshana[16]: Kashyapa has described Vamana as the first line of treatment followed by Langhana and Laghu Bhojana. Kashyapa opines that just like a tree with its trunk and branches is destroyed by striking blow at its root. As per Chakradatta, Yogaratnakara, the second line of treatment is to carry out Mrudu Virechana. The next regimen consists of Administration of Anuvasana followed by Asthapan in the chronically afflicted patients. Drugs used for Vamana are Lavanambu, Sukhosna Dugdha, Ikshurasa, Madhudaka or Tiktadravyas and for Virechana Triphala, Trayamana, Katuki, Rohini and Trivrit. According to Bhavaprakasha decoction of Patola, Nimba, and Madanaphala with Saindhava Lavana should be used for Vamana. Nishotha churna and Amalaki are prescribed for Virechana. Yogaratnakara added Raktamokshana as tool if Amlapitta is not cured by Vamana and Virechana.

Prakritivighat[17] : Prakritivighata refers to the use of drugs which suppress the Dosha; such treatment is termed as Samana therapy. Kashyapa opines that, after Vamana if the doshas persist, the physician should resort to Samana Chikitsa with the aid of Laghu, Bhojana, Samana and Pachana Aushadhi. It is forbidden by Acharyas to give Drava Aushadhi if the doshas are in condition of Utklesha; because if Vamana is not done the Drava Aushadhi will not be metabolized. When the Dosha Utklesha has reduced with the help of Ahara and Vihara, physician can give, Ama Pachana and Bhedana Aushadhi. Once the doshas have been expelled and Aamashaya is devoid of vitiated Doshas, the physician should ask the patient to take care of the Agni. The doshas lodged in the Pakvashaya, should be removed with the help of Sramsana Aushadhi Aragvadha given at Swapna Kala along with cold water. Mainly Tikta Rasa, Laghu, Snigdha Guna, Katu or Madhura Vipaka, Sheeta Virya drugs are advocated by all Acharyas. Use of Shamana drugs that opposite to that of Pitta is beneficial in Amlapitta.

Discussion

Because of Hetu Sevena, Mainly Amla & Drava Guna of Pachakapitta increases. These increasede Amlata and Dravata produce Agnimandya, which further leads to Avipaka and Rasadushti. Avipaka gives rise to Vidagdhata of Pitta, while Rasa Dushti generates Ama, which once again produces Vidagdhata in Pitta. Both of these (Vidagdhata & Ama) further Vitiates Jatharagni leads to Agnimandya thus this Vicious Cycle continues.

The different components producing Amlapitta are as follows :

Dosha- In pathophysiology the involved doshas are Pachaka Pitta, Samana Vayu and Kledaka Kapha.

Samana vayu – Samana vayu is situated near Agni, it moves throughout the koshtha. It gives strength to jatharagni and helps in the process of pachana. Also it separates the end products of pachana kriya into sara and kitta. When it is vitiated, pachana kriya gets disturbed and causes ajeerna.

Pachaka Pitta- Pachaka pitta is situated in between the amashaya and pakwashaya, it is responsible for aahara pachana, and all bhutagni and dhatwagni depends on this. Pachaka pitta is teja mahabhuta pradhana and also having drava guna. The Amlaguna and Dravaguna of Pachakapitta get aggravate in amlapitta.

Kledaka Kapha- Kledaka kapha is also situated in amashaya and by breaking the sanghata of aahara, it helps pachaka pitta in digestion process. As it helps in pachana kriya, when it gets vitiated, it disturbs the pachana kriya.

Agni –Amashaya and grahani are the place of Jatharagni i.e. Pachakapitta. Agni performs it function with the help of samana vayu (for proper digestion) and Kledaka Kapha. Any disturbance in Agni will start the pathogenesis i.e. Vishamagni, Tikshnagni and Mandagni, which are said to be the work of tridosha. As the diseases of GIT are caused due to Agni Dushti, hence, all the three doshas may affect the Agni but the manifestation may be according to the dominance of three Doshas. In amlapitta mainly pachaka pitta is vitiated with increase in its amla and drava guna which causes the Agnimandya.

Ama19- Aam is the resultant of Agnimandya. In this condition Agni is not in position to digest the food completely resulting in production Ama. The first stage or phase of Dosha dushti is also known as ama. When this ama is combined or impregnated with tridosha or saptadhatus or with malas, then they are termed Sama and the diseases produced are also called as Sama rogas. Here the ama produced after vidagdhajeerna attains shuktata due to prolong stasis in amashaya and when mixes with pitta dosha leads to sama pitta.

Srotas – The disease involves Amashaya, Grahani and Pakvashaya. Hence Anna and Purishavaha Srotas seem to be mainly concerned. But the Rasavaha Srotasa which receives the first Ama Visha produced due to Agni Dushti is also involved. In Amlapitta, all the three types of srotodushti cab be observed, sanga, atipravritti and vimarga gamana. Aam causes sanga in annavaha srotas, because of this sanga, vimarga gamana of pitta will take place as seen in urdhwaga amlapitta, whereas atipravritti will be seen in purishavaha srotas in adhoga amlapitta.

Dushya – Rasa is considered as main dushya in amlapitta, if we review the symptomatology of Amlapitta and Grahani it can be concluded. This is the first dhatu receives the Ama Annarasa.

Conclusion

It is very difficult to correlate Amlapitta with a single disease of Modern science it can be correlated with hyperacidity, gastritis, dyspepsia, peptic ulcer disorders and anorexia. The main treatment of  Amlapitta is to improve digestion. As the saying goes “Prevention is better than cure” it is better to avoid all the Nidana of Amlapitta. Pittashamaka drugs and panchakarma also helpful in the management of Amlapitta.