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Introduction

Today's unwholesome eating habits, numerous lifestyle changes, mental tension, anxiety, and grief generate gastrointestinal distress (Agnimandhya), which is the underlying factor in the occurrence of numerous ailments including Atisar, Pravahika, Amlapitta, and Grahani. Because it has a direct correlation to bad eating habits and a stressful lifestyle in the modern world, grahani is a disease with significant clinical importance in the modern era. Grahani refers to diseases where the small intestine becomes vitiated and Agni function is impaired.[1] The crucial component of the Mahasrotas is Grahani (Gastrointestinal system). Sushruta claims that the sixth Pittadhara Kala, which is located between Amasaya and Pakwasaya, is known as Grahani.[2] The portion Charaka described as being located above Nabhi, the site of Agni, the location of Anna's Grahana, and supported and fed by the power of Agni.[3]

The cardinal features of Grahani explained in the classical text books of Ayurveda, have at most similarities with the clinical features of Irritable Bowel Syndrome (IBS) explained in modern medicine. Approximately 50% of people with Irritable Bowel Syndrome report symptoms beginning before they were age 25 years.[4]

According to Acharya Charaka, Visamagni and Tikshanagni may cause Grahani Dosha but Grahani Roga is the consequence of only Mandagni. Chakrapanidutta has commented that Grahani Dosha. Grahani passes the food in the stage of Ama (Apakwaj) because of weak Agni and affection of Dosha. In the abnormal condition, when it gets vitiated because of weakness of Agni, it releases the food in undigested form only.[5]  The treatment principles of Ayurveda give prime importance to Agni as Ayurvedic concepts evolve around ‘Rogah Sarve Api Mande Agnau’.[6] In case of Grahani, foremost importance has to be given for Ama Pachana and Agni Deepana.[7] The general line of treatment for Grahani as per Charaka samhita includes Sadhyovamana (in saamaavasta kaphotklesha), Deepana, Shodana, Peyadikrama, Basti and Shamanoushadis.           Takra prayoga in Grahani is highlighted as the best Aushadhi in all the classics of Ayurveda, which posses deepana, grahi & laghu gunas.[8]

, in conventional system of medicine the commonly indicated drugs are NSAIDs and others. But the main problem in the treatment of IBS is its recurrence. The medicines of conventional system suppress the symptoms and exacerbate them if use is discontinued and cause inconvenience to those who are suffering. So, there is wide scope for proper management and treatment of IBS. Hence the present study entitled "A comparative clinical study to evaluate the efficacy of Marichyadi Churna and Pathadi Churna in the management of Grahani w.s.r. to Irritable bowel syndrome” was conducted to evaluate the management of Grahani (Irritable Bowel Syndrome) with Marichyadi Churna in comparison with Pathadi Churna. 

MARICHYADI CHURNA [9]

              The present drug formulation Marichyadi churna is taken from Chakradatta Grahani Chikitsa 28. It contains Kalimirch, Shunthi, Kutajtwak, Jaggery are all in powdered form. All ingredients of these are having Deepan, Panchan, Tridoshahara, Amapachak, Sangrahi, Krimighna & Vishaghna properties and it is beneficial for Atisar, Pravahika and Grahani. Marichyadi Churna  has been mentioned in the treatment of Grahani roga. Marichyadi

PATHADI CHURNA [10]

The present drug formulation Pathadi churna is taken from Chakardatta Grahani Chikitsa 29-30. It contains Patha, Bilwa, Chitrak, Sunthi, Marich, Pippali, Jambu, Dadim, Dhataki, Kutaki, Ativisha, Mustak, Daruharidra, Chirayata, Kutaja and Indrayava all in powdered form. All ingredients of these are having Deepan, Panchan, Tridoshahara, Amapachak, Sangrahi, Krimighna & Vishaghna properties and it is beneficial for Chardi, Atisar, Jwara, Shoola, Grahani dosha, Trishna, Daha, Arochaka and Mandagni.

Objectives:                   

1. To study literature of Grahani Roga in details and its probable Ayurvedic correlations with Irritable Bowel Syndrome.
2. To compare the efficacy of oral Marichyadi Churna and Pathadi Churna in the management of Grahani.

Materials and Methods

Source of Data:

The patient attending the OPD & IPD of department of Kayachikitsa, Desh Bhagat Ayurvedic College & Hospital, Mandi Gobindgarh and from other referral hospital were selected for the study.

Method of Collection of Data:

a) The patients were chosen at random, irrespective of their socioeconomic status, caste, religion, or locality.

b) A case report form was created using relevant details from the history-taking process and symptoms taken directly from Ayurvedic texts.

c) Data from the patient's history, physical examination, and laboratory tests were gathered to provide a clinical evaluation of the patient.

d) Ayurvedic classical texts, commentaries, research journals, contemporary literature, websites, and digital publications, among other sources, were reviewed.

e) Using statistical techniques, the data from the clinical trial were compiled and examined.

Inclusion Criteria:

1. Patients of all sexes and from various ethnic backgrounds were taken into consideration, as well as patients between the ages of 20 and 60.
2. Patients with Grahani syndrome and irritable bowel syndrome, as described in classical texts.
3. Willing to consent

Exclusion Criteria:

1. Patients under 20 and older than 60.
2. People suffering from various diseases include tuberculosis, malignancy, ulcerative colitis, and acute illnesses like cholera and gastroenteritis. intestinal obstructions, etc.
3. Women who are pregnant or lactating.

Criteria of Selection of Drugs:

              In Chakradutta 28-30, the drugs Marichyadi churna and Pathadi churna have been mentioned in the treatment of Grahani.  Also, the raw drugs are easily available and low cost compared to other therapy.

Diagnostic Criteria- Subjective criteria:

The patients having complaints of Grahani Roga, i.e. Muhurbaddha/Muhurdrava Mal Pravriti, Udara Shoola, Udara Gaurava, Apachana, Aruchi, Atopa, Vidaha, Aalasya, Vistambha, Praseka, Tamak Swasa, Pain in joint, Swelling, Trishna were selected for the study. For the purpose of perfect diagnosis and assessment an exceptional research Proforma was structured.

Objective criteria:

Routine Haematological, Biochemical and Routine-Microscopic, Urine & Stool examination were carried out to assess the general condition and exclusion of other pathogenesis of the patients.

Research Design:  It is parallel Group randomized clinical study.  Patients were assigned in two groups i.e., Group A and Group B consisting of 20 Patients in each group considering 10% drop out during study.

Intervention:

Group A – 20 patients (Marichyadi churna – 5 gm TDS with warm water after meal)

Group B - 20 patients (Pathadi churna – 3-5 gm TDS with warm water after meal)

Dose of drug: 5 gm TDS with warm water after meal

Duration of study: 30 days

Scheduled follow-up

1. 0 day – Enrolment Day
2. 15th   Day - 1st follow up
3. 30th Day - 2nd follow up
4. 45th Day – 3rd Follow up

Serious adverse events

Any serious adverse events happened was recorded and immediately reported to the Ethics Committee.

Criteria for Assessment

1. The assessment was made before, during and after the treatment on scoring of cardinal signs and associated symptoms.
2. Scoring design was created according to severity of symptoms.
3. Result was analyzed statistically on the basis of improvement in subjective as well as objective criteria.
4. Relief in Ama Lakshanas of Grahani Roga.

Assessment of Total Effect:

                             The changes in clinical features of Grahani (Irritable Bowel Syndrome) were recorded before and after the treatment based on improvement in scoring Index.  The result was recorded as-

              Marked relief                 -             Above 75% improvement

              Moderate relief             -             50% - 75% improvement

              Mild relief                        -             25% - 50% improvement

              No relief                          -             Below 25% improvement

OBSERVATIONS AND RESULTS

This observation reveals that 62.5% patients in indulged in Vishamasana, 40% patients in Atibhojana, 10% patients in Ajirnabhojana, 30% patients in Asatmyabhojana & Gurubhojana, 20% patients in Atirukshabhojana, 25% patients in Sandustabhojana, 5% patients in Viruddhan Aahara, 42.5% patients had divaswapna nidan, 17.5% patients indulged in virekavamana sneha, 45% had vibhrama, 15% had kala ritu desha vaismya nidan, 42.5% patient had Vegadharana, 35% patients had Manasika nidan and 12.5% patients had Vyadhi karshana nidan.

Effect of therapy - The total symptom score and percentage of each symptom of all patients of both groups were evaluated. The relief percentage in individual symptoms of Grahani revealed a better therapeutic efficacy of treatment in both the groups.

Overall Effect of therapy –

              The efficacy of Marichyadi churna in Grahani Roga (Irritable Bowel Syndrome) i.e. Group A provided moderate response in 14 (70%) patients and 06 (30%) patients showed mild improvement after completion of treatment. The efficacy of Pathadi churna in Grahani (Irritable Bowel Syndrome) i.e. Group B provided marked relief in 03 (15%) patients, moderate response in 16 (80%) patients and 01 (05%) patients showed mild improvement after completion of treatment.

Discussion

Agni is present in every paramanu and every kosha, as every process takes place with the help of agni. According to fundamental principal of Ayurveda, Agni has an important role to play in the physiological, functioning of body. Jathargni has been considered to be prime among all agnis. The functioning of other agnis, Dhatvagni and Bhuthagni are dependent upon the strength of Jatharagni. The main function of the agni in the body is to breakdown or to disintegrate the food into their simplest possible components making it fit for absorption and utilization by the body.

Grahani is amashaya udbhava vyadhi and its vyakta sthana is Guda so the morbid doshas srttle in the guda is removed by Basti only. Grahani Roga is of chronic in nature, which occurs due to the negligence of long standing Atisara. The Vataja Grahani Lakshanas like Punah Punah Srujet Varchah, Ama Mala, Chirat Pachana, Visuchika, Jeeye Jeeryati Adhmanam Bhukte Swasthyamupaiti has some similarities towards symptoms of IBS. Whereas almost all the Sangraha Grahani Lakshanas like Antrakujana, Drava Snigdha Mala, Ama Yukta Bahu Picchila Mala, Sasabda Manda Vedana, Pakshad Masad Dasad va Nityam Va, Diva Prakopo Ratrou Shanti have very good similarity with IBS. And it is also told that this disease is Durvigyeya, Dushchikitsaya, Chirakalanubandhini which is also the nature of Irritable Bowel Syundrome. But we cannot confirm that IBS is same as Grahani Roga.

PROBABLE MODE OF ACTION OF DRUGS

Mode of Action of Marichyadi Churna – The present drug formulation Marichyadi churna is taken from Chakradatta Grahani Chikitsa 28. It contains mainly Kalimirch, Sunthi, Kutaj Twak, Jaggery all are in powdered form.[11] All ingredients of these are having Deepan, Panchan, Tridoshahara, Amapachak, Sangrahi, Krimighna & Vishaghna properties and it is beneficial for Atisar, Pravahika and Grahani. It acts as anti-diarrheal, anti-dysenteric, appetizer, astringents, carminative, digestive and stomachic. It reduces the frequency of bowel movements. It gives relief in intestinal spasms and pain. It controls diarrhea by preventing micro-organism and their toxic effects in the intestines. It supports intestinal flora and aids healthy digestion. Kutaj lowers the viral load on the liver. The anti-inflammatory and hepato-protective activity help in liver disorders.[12] Sunthi is unctuous, hot in potency and increases Pitta and decreases Kapha. It improves taste, light to digest, improves digestive strength, and helps to absorb excess moisture especially in intestine. [13] Marich is an excellent antiviral and antibacterial helps in treating liver infection. Jaggery is rich in minerals, iron & instant glucose. It is not only easily digestible but has various minerals & vitamins in right proportion, which is extremely useful for our body.[14] Carbohydrate which is prominently present in Sugar, needs Vitamin-B for their proper utilization by the body.

Mode of Action of Pathadi Churna - The present drug formulation Pathadi churna is taken from Chakardatta Grahani Chikitsa 29-30. It contains Patha, Bilwa, Chitrak, Sunthi, Marich, Pippali, Jambu, Dadim, Dhataki, Kutaki, Ativisha, Mustak, Daruharidra, Chirayata, Kutaja and Indrayava all in powdered form. All ingredients of these are having Deepan, Panchan, Tridoshahara, Amapachak, Sangrahi, Krimighna & Vishaghna properties and it is beneficial for Chardi, Atisar, Jwara, Shoola, Grahani dosha, Trishna, Daha, Arochaka and Mandagni. Patha has Tikta Rasa, Laghu Guna, Katu Vipaka, Ushna Veerya and Kaphavatahara in nature. It improves taste, helps in digestion, abdominal colic pain.[15] Belgiri inhibits the growth of pathogenic bacteria and reduces inflammation. It improves digestive fire and small intestinal function. The potent Rechana property of Chitrak softens the stools and facilitates effortless passage of the stool from the intestine and the anus. It decreases the pressure on the lower poption of the intestines, also enhances the strength of the intestines and helps in cleansing the colon. Sunthi is unctuous, hot in potency and increases Pitta and decreases Kapha. It improves taste, light to digest, improves digestive strength, and helps to absorb excess moisture especially in intestine. Pippali is useful in hepatomegaly. Marich is an excellent antiviral and antibacterial helps in treating liver infection. Jamun guthali is pungent, astringent, sour taste, dry in nature, improves taste and vitiates Vata dosha and increases pitta dosha. Dadim Twak has astringent tast, helps to relieve diarrhea, useful in IBS having anti-inflammatory and antibacterial properties. Dhaya Phool is stimulant and astringent. Kutki has Yakrit Uttejaka and purgation property It protects the liver against cell damange caused by free radicals due to its antioxidant and hepatoprotective properties. Atis roots are astringent and used in irritability of the stomach and colic. It exhibited antiviral activity against spinach mosaic virus. Mustak is cold in potency, promotes digestive fire and manages Kapha Pitta diseases. [16] Daruharidra is having stomachic, laxative, diaphoretic, antiseptic and antipyretic properties. Chirayata possesses potent hepatoprotective and hepato-stimulative properties by secreting bile which in turn helps the liver enzymes to come down to normal levels. It also cleanses and detoxifies the liver and improves liver functioning. Indrayava and Kutaj Chaal is bitter and pungent in taste, Katu Vipaka, Sheeta Virya, Laghu and Ruksha in Guna. It pacifies Tridosha, Deepan, Sangrahi in action.

Conclusion

Grahani roga represents a class of digestive disorders. It has close relationship with Agnimandhya, Koshtagatavata and Atisara. The main contributors to the pathophysiology of Grahani include impaired Agni, Kledaka Kapha, Pachaka Pitta, and samana Vata. Prana vata and Apana vata also have a significant role in Grahani. The clinical characteristics of vataja Grahani are the ones that most resemble those of irritable bowel syndrome among the several forms of Grahani. The condition is more prevalent among people in their middle years. The middle class is mainly impacted. Unhealthy eating patterns, anxiety, and mental stress are risk factors that lead to Grahani Roga.The observation on onset, chronicity and previous treatment shows the chronic nature of the disease, and the need of long course of treatment. Marichyadi and Pathadi churna exhibit antimicrobial activity and may act as an anti-inflammatory agent. Both groups provided better relief in the amelioration of signs and symptoms of Grahani (Irritable Bowel syndrome).  Group B might be contributing better as compared to Group A in the overall recovery of the patient. Adverse events as such there were not much noticed during the course of treatment, and were managed easily during the course of the treatment. There is sufficient evidence provided by this study that Marichyadi Churna and Pathadi Churna have definite role in the management of Grahani.