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Introduction

Panchakarma, also known as Samshodhana upakrama are the therapeutic procedures described in Ayurveda, which includes – Vamana (therapeutic emesis), Virechana (therapeutic purgation), Basti, Nasya and Raktamokshana.(1) Out of these pentamerous procedures Virechana, is the procedure of eliminating the doshas from body through lower gastrointestinal tract.(2) Virechana literally means to remove out something out of body by oral, nasal or by anal route, here the term is used to refer the elimination of doshas from lower gastrointestinal tract through the anal route. It is primarily indicated in management of diseases arising due to Pitta dosha(3) such as - Jwara, raktapitta, kamala, Visarpa, pandu etc. In Ayurveda, the vitiated doshas are managed either by Samshodhana or by Samshamana upakrama, but samshodhana being superior to samshamana has its uniqueness as the diseases are cured through their root cause by using this.(4) Virechana also establishes proper function of Jatharagni (digestive fire), as most of the diseases arises when the function of Jatharagni gets compromised;(5) mainly because of unhealthy, unwholesome food habits, lifestyle or by unsuitable weather conditions.(6) Grahani, is interpreted as one of the eight Maharogas, the diseases which are obstinate to treat as per Ayurvedic texts.(7) It is basically the place of Jatharagni situated above umbilicus having functions involved in the ingestion, digestion, absorption, assimilation and egestion of the food.(8) When these functions gets compromised the condition is termed as Grahani. The disease Grahani has four subtypes based on prominence of doshas involved – Vaataj, pittaj, Kaphaj and Sannipataj.(9) Amongs this, Pittaj Grahani presents with the classical symptoms like – Aruchi (tastelessness), Avipaak (Indigestion), Adhmaana (bloating), Amla udgar (acid irructation), Ura-Udardaah (burning in chest and abdomen), muhurbaddha muhurdrava mal pravritti (diarrhea and constipation accordingly) and general weakness.(10) This condition resembles with Gastroduodenitis. Gastroduodenitis is an intestinal condition caused by inflammation in duodenum lining. People suffering from this may have – feeling of fullness after eating, Bloating, Feeling sick, Cramping, Burning up and Nausea.(11) As Virechana is the best therapy for the Pitta dosha, in present case a 23 years old female patient having symptoms of Pittaj Grahani was treated with it along with Shamana Upachara. The case was assessed on subjective and objective parameters and some investigations. At the end of treatment and by following all the Pathya-apathya regulations patient got significant relief from the symptoms.

CASE REPORT:

A 23 years old female visited M A Podar Hospital, Mumbai having complains of – Urah- Udar daah prachiti (burning in chest and abdomen), Bhojanottar dravamal pravratti (loose motions after meal), Daurbalyanubhuti (general weakness), Udare vaat sanchiti (Belching), Avipaak (indigestion), and Hrillas (Nausea) since last 3 years especially after taking meal. Along with this patient was suffering from complains of Nasanaah (Nasal congestion) and frequent sneezing in morning hours and on exposure to cold environment. Patient initially took treatment from outside. Where she was diagnosed with Antral gastritis, Duodenitis and mild hiatus hernia and was suggested for operative procedure as part of management in July 2022. As patient was not ready for the operative, she visited Panchakarma OPD of our institute for Ayurveda treatment where patient was examined thoroughly and was diagnosed for Pittaj Grahani. Basic blood investigation, stool examination and Endoscopy was done.

DIAGNOSIS:

Before diagnosing the condition, the patient was examined using Ayurvedic methods of examination like – Trividh, Astavidha (12) and Dashavidha pariksha(13) thoroughly. The patient was having complains of – Ura and udar daah prachiti, udarshool, dravamal pravrutti (bhojanottar), Kshudhamandya, Trishnadhikya and Amlodgar on and off since 3 years; which were indicating Agnidushti and ultimately towards Grahani disease. The patient revealed no any history of serious past illness, the only family history was – DM (father), no any surgical history, no any history of any trauma before.

Personal History :

1. Ahara (Diet) – vegetarian diet with cereals, pulses, rice, vegetables, Street food items (guru, ushna vidahi ahara), Atitkaal bhojan

2. Vihara (Regime) – Pratah utthan – 8 am, Ratri shayan - 12 am, working hours 8, Exercise, Yoga for about 20 mins (Irregular)

3. Vyasana (Addiction) – NAD

4. Anurjata (Allergy) – allergic to dust, cold environment

General Examination (Astavidha Parikshana) :

1. Naadi (Pulse) - Vaatpitta Pradhan, vaat sthani, jalouka gati, alpa bal, 86/min

2. Mutra (urine) – Samyak pravrutti, 4-5 vegas a day

3. Mal (stool) – Dravamal pravrutti (bhojanottar), 3-4 episodes a day

4. Jivha (tongue) – Alpa saam

5. Shabda – Prakrut, Spasta

6. Sparsha – Prakrut, Anushna

7. Drik (Vision) - Prakrut

8. Akruti (Weight) – Madhyam krish

• Koshtha - Mrudu

• Agni - Manda

• BP – 100/70 mmHg

• Temp – 970 F

Dashavidha Pariksha :

1. Prakruti - Vaatpittaj

2. Vikruti – Annavaha srotas, Purishvaha srotas vikruti

3. Saar – Avara (poor)

4. Samhanana : Madhyama

5. Satmya : Madhur ras,tikta ras ahara dravya, Katu lavan ras Asatmya

6. Aharshakti : Avara

7. Satva – Pravar

8. Vyayamshakti : Avara

9. Praman – Saardha trihasta, 84 angul

10. Vaya – Balavastha – 23 year

Nidaan Panchak:

1. Hetu: Katu-Amla-lavana ras, Ushna, vidaahi guru bhojan (street food items), Atitkaal bhojan, Kshudha veg dharana

2. Purvaroop : Anna vidaah (heart burn aft eating), Excessive thirst, general weakness

3. Roop: Urah- Udar daah prachiti (burning in chest and abdomen), Bhojanottar dravamal pravratti (loose motions after meal), Daurbalyanubhuti (general weakness), Udare vaat sanchiti (Belching), Avipaak  (indigestion), and Hrillas (Nausea)

4. Upashaya: Madhur, tikta ras sevan Anupashaya– Katu , amla, guru ahar sevan

5. Samprapti (Pathogenesis):

Investigations: The patient underwent blood investigations, stool examinations which were nil and doesn’t reveal anything and the Endoscopy which showed – antral gastritis, duodenitis and mild hiatus hernia at GE junction. The blood investigation values were – Hb – 10.2 gm/dl, WBC – 5200 per microliter, Neutrophils % - 60%, eosinophils – Monocyte % - 06%, Platelet – 358000 per microliter, Basophils% - 00%, Lymphocyte % - 29%

 

TREATMENT PLAN:

Acharya Charak, in Grahanidosh chikitsa adhyay has given plan for the management of Pittaj Grahani,(14) where its indicated to undergo samshodhana upakrama and expel out vitiated pitta dosha using either by virechana or by vamana karma. The patient was vitally stable but was not fit for vamana karma because of her Sukumar prakruti (delicate body nature). Initially patient was treated with Samshamana upachara for more than a month by using some Ayurvedic formulations as given in table 1. The symptoms of Saam avastha and associated complains like nasal congestion, frequent sneezes were managed.

After managing the condition using formulations, the patient was advised to undergo Virechana. As the act of removing saam dosha is contra indicated. (21) The patient was Planned for Virechana initially by Rukshana, Pachana and deepana upakrama using the combination of Ayurvedic drugs – Triphala, Musta and Shunthi churna for 1 week. The patient was re- examined before Snehapaana, consent was taken in written form. The Snehapaana was given with the combination of Mahatikta ghrita(22) and Yashtimadhu ghrit(23) in half amount each

Snehapaana:

The patient was advised to take Sneha (combination of Mahatikta and Yashtimadhu ghrit) in early morning with lukewarm water as Anupana, to drink lukewarm water whenever felt thirsty. The diet advised was of Laghu, drava, alpa snigdha and ushna guna (light, semisolid and bland diet) during Snehapaana and also for three days rest after Snehapaana. Following of Pathya-apathya regime was also advised strictly. After 5 days of consuming this Sneha, patient showed signs of samayak snehapaan like – Purish snigdhata, vit shaithilya, Adhastat Sneha darshan, Sneha dwesha and gaatra snigdhata. The Snehapaana vidhi is described in table no. 2

Virechana Karma:

Before posting to the Virechana karma patient underwent whole body oleation and sudation therapy (Sarvanga Snehana and Swedana), both before one day and on the Virechana day. The Patient was examined prior to the karma using astavidha pareekshana vidhi, Abdomen palpation and percussion and general examinations as follows:

1. Naadi – Vaatpitta Pradhan, Laghu, having Jalouka gati with rate of 70/min

2. Mutra – Samyak pravritti, 4-5 vegas a day

3. Mal – samyak pravritti, 1-2 vegas a day

4. Jivha – Niraam

5. Shabda – Spasta, prakrut

6. Sparsha – Parkrut, anushna

7. Drik – Prakrut

8. Akruti – Madhyam krish

• Koshtha – Mrudu

• Agni – Prakrut

• BP – 110/70 mmHg

• RR – 18/min

• Temp – 97.20 F

• P/A – Soft, non-tender

After examining thoroughly, Virechana aushadhi – Trivrittavaleha(24) was given in 60 gm amount with Draksha faant as anupana at late morning 10:30 am. Draksha faant was also used as Virechanopag(25) to enhance the procedure of purgation. Total virechana vegas were 16 with Samyak shuddhi lakshanas at the end. Patient was advised to follow Peyadi Samsarjana krama for the next 5 days with regime of Pathya-apathya. Follow up after 14 days of completion of samsarjana krama.

TREATMENT OUTCOMES: General examinations were done on follow up day, patient was vitally stable. The main complains were assessed using gradation and compared before and after treatment.The treatment yield near about 80% relief from the symptoms when compared with the symptoms on first follow up. There was significant improvement in the health of patient after virechana karma. The patient was advised to take Mahatikta ghrit – 10 ml twice a day at rasayana kaal for the next 21 days as shamana upachara with Jeerak, Shatapushpa churna 3 gm and Praval panchamrit ras 250 mg BD after meal.

Discussion

Virechana, is the best treatment of Pitta dosha. Which also establishes proper function of Jatharagni (digestive fire). Here in presenting case the symptoms were indicating pitta dushti, Agnidushti and ultimately its place “grahani” as well. The management was done according to the treatment principles explained in Grahanidushti chikitsa adhyay(26) by Charaka acharya. The snehapaana, prior to virechana was given with combination of Mahatikta and Yashtimadhu ghrit to oleate body inside out, to liquify doshas and make dosha vriddhi. After sarvang snehana an swedana for movement of dosha from shakha to koshtha. With the help of virechana these doshas can be eliminated through lower gastrointestinal track. Virechana karma was done using “Trivruttavaleha” as “Trivrutta” ( Operculina turpethum) is “ sukhvirechak” aushadhi and can be used in Sukumar vyakti.(27) It is Madhur ras aushadi virechak kalpa and easily palatable for the patients. Patient got 16 vegas of virechana and peyadi samsarjan krama was advised for the next 5 days to establish Jatharagni again. After 14 days of completing it, patient was having significant relief from the symptoms. Mahatikta ghrita is Swadutikta aushadi kalpa and is mentioned to use in treating Pittaj grahani.(28) It is used in shamana matra (10 ml) also to work on Pittadhara kala i.e. on Grahani (29) itself along with this Panchamrit parpati (30) is used as vyadhi pratyanik medicine. The patient is still on follow up and has no symptoms related to Pittaj Grahani (Gastroduodenitis) these days.

Conclusion

The motive behind this case report is to document the condition Pittaj Grahani which was treated successfully using Ayurvedic way of management i.e. with using Samshodhana (Virechana) and Shamana Upakrama. This case also highlights the importance of avoiding inappropriate diet and mismanaged lifestyle which may result in GIT Pathologies.