Grahani Chikitsa

Grahani Chikitsa

Section/Chapter	Chikitsa Sthana Chapter 15
Preceding Chapter	Arsha Chikitsa
Succeeding Chapter	Pandu Chikitsa
Other Sections	Sutra Sthana, Nidana Sthana, Vimana Sthana, Sharira Sthana, Indriya Sthana, Kalpa Sthana, Siddhi Sthana

(Chikitsa Sthana Chapter 15, Chapter on Management of Digestive Disorders)

Abstract

Grahani Chikitsa consists of three parts. The first part explains the concept of normal digestion process. The second part describes the abnormal digestion and third part is about diseases caused by abnormality of digestive fire and its interaction with proximal intestine or grahani. These disorders are called grahanidosha.

Agni (digestive and metabolic agents), based on their specific functions of conversion of food into biological elements of the body are classified into thirteen types. First, the jatharagni is most important because it is the initiator of digestive process and it strengthens the digestive ability of other twelve agnis. Five bhutagnis transform the panchmahabhauika components of ahara rasa created by jatharagni into different structures of the body. Seven dhatvagnis create seven tissues elements(dhatu).

Jatharagni initiates the first phase of digestion process by conversion of food into nutrient fluid (ahara rasa). This nutrient fluid is further trifurcated into three biological substances kapha, pitta and vata in three stages to madhura, amla and katu awastha paka respectively. This biofluid is separated into excretable waste or impure products by samana vata in grahani (middle part of GI Tract) and useful, pure circulable products. Samana vata analyzes and separates the useful products (prasada) and waste (kitta). Useful products get absorbed by rasayani (villi) of the intestine, sent to the micro channels (srotas) by vyanvata, simutaneouly, to the entire body. Waste products are excreted out by apana vayu through urine, feces and sweat.

Now second and third phase of digestion process occur simultaneously in the srotas (microchannels). Five bhutagnis work on the formation of anatomical structure of the body from respective panchamahabhuta in the form of micro channels, by digesting needful components present in biofluid. Each gross and subtle particle of body is panchabhautika, but each one is having different proportion of mahabhuta.

Now the third phase of digestion is processed in seven micro channels (srotas) specified for seven body tissues (dhatu) for the formation of body tissues by their specific seven tissue transformers (dhatvagnis) Excreable waste products are carried out by three excreatory channels as feces, urine and sweat, along with sub tissues and sub excreta of sensory organs.

Second part of this chapter explains the etiopathology of abnormal digestion, and formation of intermediate products as seed cause of various diseases in the form of ama, shukta and amavisha.

Third part explicates the etiopathology, types, symptoms and treatments of grahanidosha as a syndrome of various digestive disorders. The chapter sums up in defining abnormal dietary habits.

Keywords: Digestion in Ayurveda, metabolism in Ayurveda, jatharagni, bhutagni, dhatvagni, grahani, grahanidosha, grahani roga, annavisha, atyagni, samashana, viṣamaśana, adhyashana.

Introduction

Grahani Chikitsa is one of the most important chapters of this compendium because most of the diseases originate from disorders of digestion. This chapter is described after arsha roga (hemorrhoids) because pathophysiology of arsha influences agni and before Panduroga Chikitsa because grahani roga influences panduroga. The initial portion of this chapter discusses the details of the physiological process of digestion and metabolism in human body. Agni, being the fundamental factor in maintaining health and in producing diseases, has been described in detail. The chapter begins with explanation of importance of normally functioning agni and then goes on to explain the various aspects of digestion, metabolism and tissue nourishment.

Different theories of tissue nourishment as explained by the commentators play a crucial role in the entire process. The concept of upadhatu and dhatumala has also been dealt with. These descriptions are followed by the pathophysiology of grahanidosha syndrome and its management. This chapter underscores that the knowledge of physiology is crucial in understanding the pathophysiology and therapeutics of a disease.

Protection of agni is very essential in treatment of all diseases.(Chakrapani Ca.Ci.14/244-246 )Arsha, atisara and grahanidosha are said to be paraspara hetu which means one disease becomes cause for another disease(Ca.Ci.14/244) e.g. in patients with chronic colitis, intestinal polyps are seen, in patients suffering from diarrhea colitis is observed. Therefore, one finds interrelation between these disorders and as explained earlier, special precaution should be taken with respect to agni bala.

Certain drugs like chitraka (Plumbago zeylanica), pippali (Piper longum), pippalimula (root of Piper longum), shunthi (Zingiber officinale), nagakesara, haridra, danti, duralabha, haritaki etc have been used in combinations with other drugs for the treatment of arsha considering the concept of agnibala vriddhi and vata anulomanam (facilitating passage of vata) and the same drugs have been used in grahani chikitsa with the same concept. Charaka explains that all the above three diseases are caused by agnimandya and if increase in agni is done then relief in the disease takes place. (Chakrapani Ca.Ci.14/244-246)

Further, vata is said to be agnisakha i.e. agnibala depends on vata. Vatakshaya or prakopa results in agnimandya. Therefore, anna, pana and ausadha which bring about vata anulomana are very useful in treatment of diseases like arsha and grahani dosha.

Vata anulomanam means to facilitate the gati (motion) of vata downwards to anus. Among five types of vata, samana and apana have major role in diseases like arsha, atisara and grahanidosha. Obstruction to movement of vata (avarudha gati) or diarrhea (atisaraṇa) leads to agni kshaya. Avarudha gati is the cause for vibandha (constipation), malavibandha (obstruction to feces) along with pravahana (urge to defecate) which increases the intra-lumen pressure leading to incompetency of valves in rectal veins leading to their varicosity which causes hemorrhoids where as atisarana (diarrhea) causes increased motility of intestine. Hence vata anulomanam should not be understood as virechana or laxation but regularization of vata gati so that there is no avarodha or atisarana. The same concept of vata anulomana is also mentioned in Grahani Chikitsa.(Ca.Ci.14/247)

Therefore, the line of treatment used in arsha with regard to agni bala and vata anulomanam is basically similar to that of grahanidosha hence Charaka has explained Grahani Chikitsa after Arsha Chikitsa.( Chakrapani Ca.Ci.15/1) Charaka could have restricted the name of chapter to Grahani Chikitsa i.e. treatment of the avayava grahani whereas he has increased the scope of chapter by using the word grahanidosha.(Chakrapani Ca.Ci.15/1).

There is always an inter-relationship between avayava (organ) and avayavi (part of organ) or ashraya(seat) and ashrayi (seated). Either of the one has an impact on the other, hence if grahaniavayava is in normal state then agni the avayavi functions normally and vice versa also holds true, whereas if dusti of grahani takes place agni vaishamyata (imbalance) is seen e.g. ileitis, wherein digestion is hampered. Grahani is the seat for jatharagni. (Ca.Ci.15 /56) Agni is responsible for ayu (longevity of life), varna (complexion), bala (strength), svasthya (health), utsaha (enthusiasm), upachaya (proper metabolism), prabha (glow) and oja (core energy). Prakrita agni (normal digestive power) is essential for long and healthy life while, vitiated agni is responsible for roga avastha(disease).(Ca. Ci. 15/3-4)

In this chapter, Charaka describes formation of body tissues in detail with the role of ahara which is supplied continuously to maintain homeostasis. Vyana vata is promoter of rasa raktadi circulation.( Ca. Ci. 15/36) It transports rasa raktadi drava dhatu throughout body continuously and as per metabolic demand. This explanation shows that closed circulation in human was known to Charaka.

Grahani is prime place where digestion and absorption of ahara rasa takes place. Ahara rasa provides nutrition for the rasadi sapta dhatu, along-with three sharirika dosha and three manasika dosha. Nourishment of sattva, raja and tama is influenced by sattvika, rajasika and tamasika ahara. Tamasika and rajasika ahara suppresses sattva guna thereby causing alpa sattva in individual, a common predisposing factor of psychiatric disorders for e.g. alpa sattva as mentioned in unmada (Ca. Ci. 9/5)In vataja grahanivyadhishanka (feeling of suffering from disease) manifests in patients with alpa sattva.

Homeostasis at cellular level and gross level is maintained by vata, pitta and kapha in which digestive and metabolic contributions are due to agni. This chapter has been dedicated to agni to understand the manner in which it gets vitiated by dosha and accordingly the line of treatment for the agni dosha is explained. As the functions of agni take place in grahani hence disease related to grahani has been given the name.

Secondly, pandu roga is due to alpata of raktaposhaka sara bhaga (Chakrapani Ca. Ci. 16/3-7) and, one of the main causes of this alpata is mal-digestion and mal-absorption which takes place in grahani. It is well known fact, that various contributory factors for blood formation have their absorption in gastrointestinal tract such as folic acid, vitamin B12, iron, etc which if not absorbed causes anemia this is the reason why Charaka has placed this chapter in between arsha and pandu roga.

Sanskrit Text, Transliteration and English Translation

अथातो ग्रहणीदोषचिकित्सितं व्याख्यास्यामः||१||

इति ह स्माह भगवानात्रेयः||२||

athātō Grahaṇī dōṣacikitsitaṁ vyākhyāsyāmaḥ||1||

iti ha smāha bhagavānātrēyaḥ||2||

athAto grahaNIdoShacikitsitaM vyAkhyAsyAmaH||1||

iti ha smAha bhagavAnAtreyaH||2||

Now we shall describe the chapter on the management of Grahani Dosha, so said respectable Atreya [1-2]

Importance of dehagni

आयुर्वर्णो बलं स्वास्थ्यमुत्साहोपचयौ प्रभा| ओजस्तेजोऽग्नयः प्राणाश्चोक्ता देहाग्निहेतुकाः||३||

āyurvarṇō balaṁ svāsthyamutsāhōpacayau prabhā| ōjastējō'gnayaḥ prāṇāścōktā dēhāgnihētukāḥ||3||

AyurvarNo balaM svAsthyamutsAhopacayau prabhA| ojastejo~agnayaH prANAshcoktA dehAgnihetukAH||3||

Dehagni (all the entities in the body that are responsible for digestion and metabolism) is the fundamental causative agent for longevity, normal complexion, normal strength, good health, motivation, normal growth, normal luster, normal ojas, normal body temperature and various other forms of agni. Even the existence of an individual is said to be because of dehagni [3]

शान्ते

Tattva Vimarsha

• Dehāgni (all the entities in the body that are responsible for digestion and metabolism) is the fundamental causative agent for longevity, normal complexion, normal strength, good health, motivation, normal growth, normal luster, normal ojas, normal body temperature and various other forms of agni. Even the existence of an individual is said to be because of dehāgni (3).
• When the agni stops functioning, the individual dies; if the agni functions normally, the individual can lead a healthy and long life. . Similarly, if the agni becomes abnormal, the individual suffers from various diseases; and hence, the agni is said to be the root cause of health and longevity (4).
• Normal functioning of agni is essential to make the consumed food capable of nourishing the body tissues and of promoting the ojas (vital essence), strength, complexion etc. In the absence of normal digestion (and metabolism), the normal body tissues such as rasa cannot be formed nor nourished (5).
• Vata dosha, specifically prana vata and samana vata play significant role in process of digestion and metabolism.
• Three doshas are produced in three consequent stages of digestion after consumption of food. Kapha is produced in first stage of madhura avasthapaka; pitta in second stage of amla avasthapaka and vata is produced in third stage of katu avasthapaka. The site of production and time of production of dosha is in sequence as the process of digestion proceeds. Increase or decrease in quantity of dosha depends upon similarity or dis-similarity of basic composition of food consumed.
• The first phase of digestion is carried out by jatharagni, second phase by bhutagni and third phase by dhatvagni. These are different levels of action of agni where various digestive and metabolic processes take place.
• During the processing by dhatvagni, Stanya (breast milk) and the menstrual blood are derived after rasa. Kaṇḍarā (tendon) and sirā(vein) are derived after rakta. Vasā(fat) and the six layers of tvachā (skin) are derived after māṃsa (muscle) and snāyu(ligament) are derived after medas (adipose tissue) (17).
• The faeces and the urine are the kiṭṭa (non-nutrient portion/waste portion/byproduct) of ingested food. The kiṭṭa of rasa is mala-kapha (excretions). Mala-pitta (bile pigment) is the kiṭṭa of rakta. Kha-mala (the wastes accumulated in the hollow structures of the body such as external ears and nostrils) are the kiṭṭa of māṃsa. Sweda (sweat) is the mala of medas. Keśa (hairs on the head) and loma (body hair) are the mala of asthi. The mala of majjā is the oily excretion of the eye and the skin (sebum). Thus, the dhātus continuously undergo two kinds of transformation: prasāda (nutrient portion) and kiṭṭa (non-nutrient portion). This entire sequence of transformation and metabolism of dhātu is thus inter dependent (18-19½ ).
• Disorders of various factors mentioned above shall be treated after considering the original dhatu from which the factor is derived.
• Vyāna vāta forcefully propels the rasa dhātu out of the heart and spreads it all over the body simultaneously, continuously and for the entire life (36).
• Disease is produced only at the site of abnormality of body systems.
• Life and strength of an individual depends on agni hence one should take utmost care to maintain the agni by providing fuel in the form of food and drinks which should be taken as per the rules mentioned. (40)
• If the rules of diet and dietary habits are not followed due to greed, then disease of grahani occurs.
• The anna-visha (toxins) produced due to improper digestion and metabolism causes diseases at the sites of affliction.
• The vishāmagni (improper agni) causes irregularity in digestion and therefore defective formation of dhātu takes place. Whereas, tīkṣṇāgni (excessive agni) when associated with little quantity of fuel (in the form of food) causes depletion of dhātu (tissue elements) (50).
• The digestive disorder of grahani can lead to secondary disorders related with other body systems along with digestive system.
• Grahaṇī disease is classified into four types viz vātaja, pittaja, kaphaja and sannipātaja depending upon the dominance of dosha and on the basis of the classification, etiological factors, symptoms and signs are varied.
• When the dōṣhas are located in grahaṇī and are associated with incomplete digested food then vamana (emetic therapy) is advised.
• If the ama is in pakvāśaya and in anutkliṣṭa (stuck, not ready to come out) condition, then stravan (increasing secretion) with dīpana dravyas should be administered.
• If ama gets absorbed along with rasa dhātu and if it pervades throughout the body then laṅghana and pāchana should be advised.
• Various purification procedures are advised as per the state of dosha aggravation and site of affliction in disease. Ghee processed with digestive stimulant drugs, sour media like buttermilk is advised.
• Patient should be evaluated for amadōṣa whether sāmatā or nirāmtā is present or not and then appropriately treated with pāchana etc. treatment (95).
• Buttermilk due to its dīpana, grāhi (substances which increases appetite and digestive power and absorb fluid from the stool) and easy to digest actions is very useful in grahaṇīdōṣha.
• Vata dominant grahani shall be treated with basti, virechana and unctuous preparations.
• If pitta is dominant in its own place then virechana or vāmana should be administered for removal of pitta (122).
• In kaphaja grahaṇī, vamana and then drugs having katu, amla, lavana, kṣāra and tikta rasa shall be administered to increase agni (digestive power) (141).
• In tridōṣaja grahaṇī, panchakarma should be carried out as per predominancy of doṣha. Various ghee, kṣāra, asava and ariṣṭa preparation useful in stimulation of agni should be administered.
• Sneha is the best among the dipana dravya which helps in stimulating the inefficient agni (201)
• Fasting or over eating doesn’t stimulate agni. Proper intake of snēha, followed by eating proper food preparations as well as appropriate use of various chūrṇa, ariṣṭa, surā and asava along with proper medication as per condition, enhances the power of agni.
• Atygni is caused by diminished kapha, aggravated pitta and associated vāta. This leads to emaciation if proper food is not consumed. Excessively increased digestive power can be pacified by taking foods and drinks which are heavy to digest, unctuous, cold, sweet and liquid.
• Samaśana is taking wholesome and unwholesome foods together in diet. Viṣamaśana is taking food either in excess quantity or very little quantity and also if taken before or after appropriate time. Adhyaśana is having food even though previously eaten food is not yet digested. All the above three are causes for death or give rise to serious disorders (235-236).
• If morning eaten food is undigested and still if anyone takes evening food, it may not be more vitiative since in day time all the srotas (channels) are dilated and heart is active similar to the lotus which blossoms with sunrise. During daytime, exercise, other physical and mental activities (cause heart to pump blood properly to) prevent the genesis of kleda (excess moisture) in various dhātus. In the night, the channels are closed, so is the heart which functions at slow rate as demand is less, the apakva ahāra rasa increases in viscosity; thus ama adheres to the dhātus and if another food is taken in the morning the indigestion causes more apakva ahāra rasa causing disease.

Vidhi Vimarsha

Importance of agni

The functions of gut are vital for maintenance and preservation of health. Grahani is the seat of jatharagni, which is the initiator of digestive process and strengthens the other 12 agnis. Jatharagni transforms food into biological substance (ahar rasa) which is further trifurcated into madhura, amla and katu avastha pak which gets transformed into three biological energies kapha, pitta and vata respectively. From the physiological point of view, the Jaṭharāgni or the active form of pāchaka pitta is responsible for the digestion of all kinds of foods in the gut. Therefore, this should include all amylolytic, proteolytic and lipolytic enzymes secreted by various kinds of exocrine glands in the gut, which actually cause digestion, i.e., breaking down of different macromolecules into their constituent units.

There are five bhūtāgnis and their function is to metabolize panchabhautic components of the food that are homologous to them in their composition. For instance, bhauma agni acts on the component that is bhauma or pārthiva in its composition. Bhūtāgnis act on the products of digestion (jaṭharāgni pāka), hence, must be acting after the absorption of the nutrients, but before the action of dhātvāgni. The major site where the absorbed nutrients undergo biochemical transformation is in the liver, which plays an important role in metabolism, wherein several processes such as trans-amination, de-amination, beta-oxidation of fatty acids, glycolysis etc. take place. Therefore, the overall intermediary metabolism (involving fats, carbohydrates and proteins) can be understood as the functioning of the bhūtāgni.

Dhātvāgni acts at tissue-level (in fact, at cellular level) upon the products of bhūtāgni pāka and are responsible for the building of the respective dhātus. In other words, the bio-energetic processes of a cell seem to be under the regulation of dhātvāgni. For instance, the common product of intermediary metabolism (involving fats, carbohydrates and proteins) is Acetyl-Co-A, which enters into Kreb’s cycle in the mitochondria of a cell. This is followed by electron transfer and oxidative phosphorylation. [ ] It is interesting to note that the Kreb’s cycle is also known as the ‘final common pathway’ in the process of catabolism of carbohydrates, proteins and fats. However, for the entry of amino acids, glucose and fatty acids into the cell, certain other factors such as hormones too are needed. For instance, insulin promotes the transportation of glucose, amino acids and fatty acids into the cell. Therefore, all these hormones (such as insulin, growth hormone, thyroid hormones, testosterone etc.) that promote the transportation of various nutrients into the cells, along with the enzymes participating in the Kreb’s cycle are to be included under the term dhātvagni.

Thus, the three major stages of the catabolism (involving fats, carbohydrates and proteins) i.e. digestion, intermediary metabolism and Kreb’s cycle - seem to represent the three sets of agnis, viz., jaṭharāgni, bhūtāgni and dhātvagni respectively.

Role of vata in digestion

Samana vayu separates nutritive (prasad) and waste (kitt) part from ahaar rasa. Nutritive part is circulated to entire body after absorption through rsayinii (villi) by vyan vayu. Waste part is excreted as feces, urine and sweat through their excretory channels by apaan vata. Absorbed nutritive substances circulate all over the body through seven specific micro channels of each of the seven dhatus.

Dhatvagni

Each dhatu has its own transforming agni and srotas. Srotus or micro channels have two functions of carrying and transforming the tissues with the help of their specific dhatu agni. Five bhutagnis, one for each mahbhuta, transform five bhautic elements into the body tissues and organs. Seven dhatuagni or tissue transformers, form the tissue elements of seven dhatus by their needed nutrients. After formation of dhatu, the microchannels permeates them into the organs for functioning. During this transformation process, updhatu or subtissues and dhatumal or waste products are formed. Updhatus of rasa dhatu is breast milk, menstrual blood is updhatu of rakta and tendons and six layers of skin is updhatu of maansa dhatu etc.

Apart from digestion, the gut performs various other significant functions as well. The gut has its own protective mechanism in the form of gut-associated lymphoid tissue, which prevents the entry of pathogens into the bloodstream. The micro-biota in the gut serves vital functions related to various aspects of health. The enteric nervous system of the gut has its own functional significance and has been proven to be very closely associated with the central nervous system functions. The gut secretes several hormone-like substances that are helpful in regulating long-term energy balance. All the factors mentioned are either directly or indirectly dependant on these functional domains of the gut. [ ] [ ] Other forms of agni in this context are indicative of bhūtāgni and dhātvāgni, which in turn, are functionally dependent on jaṭharāgni. ‘Prānāḥ’ in this context may stand for all types of vāta as well.

Three stages of digestion

There are three stages of digestion in the gut. The first stage (madhura) takes place in the upper gastro-intestinal tract, i.e., inside the eosophagus and stomach; the second stage (amla) takes place in the middle portion of the gut, i.e., in the small intestine; and the last stage (kaṭu) takes place in the colon.

The froth-like kapha seems to be the thick mucus that covers the entire stomach, providing a protective coating that prevents the gastric mucosa being digested and damaged due to the acid-pepsin mixture.

Accha pitta is ‘liquid’ in nature, released in the duodenum and can be correlated with bile.

Pācaka pitta has the functional site between amāśhaya (stomach) and pakvāśaya (colon), which is indicative of small intestine. It is composed of five mahābhūtas but the agni mahābhūta is predominant; and hence, it becomes devoid of fluidity and therefore is also known as agni. It splits the food into sāra (nutritive) and kiṭṭa (non-nutritive) portions. (Ashtanga Hridaya, Sutra Sthana, 12/10-12). Sāra portion of the food is the minutest fraction (parama sūkṣma). This portion reaches the heart in the form of ‘ahara rasa’. From the heart, it then gets re-distributed into 24 pulsatile vessels to be carried into the whole body. (Sushruta Samhita, Sutra Sthana, 14/3) The portion that reaches the colon is the one that is designated as ‘kiṭṭa’. During the third stage of digestion, there occurs the solidification of fecal matter and formation of certain pungent gases such as ammonia, methane, hydrogen sulfide etc. The term ‘pakva’ in this context indicates pakva mala; not pakva ahāra (Verse 9-11).

Formation of the seven dhātus

Rasa, rakta, māṃsa, meda, asthi, majjā and shukra are the seven fundamental entities that sustain the human body. These can be called ‘tissues’ for the sake of convenience, though some of them are not tissues in a strict sense. It will be pertinent to look into these individual entities at this stage to understand what they really are in terms of anatomy. [ ]

Rasa: A colorless fluid that gets ejected out of the heart and nourishes the entire body.

Rakta: The red colored fraction that is formed in liver and spleen after the action of rañjaka pitta on rasa. It is essential for life and its function is to supply the life principle (jīva).

Rasa and rakta together form what is generally known as blood: rakta being the red fraction (red blood corpuscles) and rasa being the colorless fluid (plasma).

Māṃsa: The correct translation of this term would be ‘flesh’. Flesh generally means all kinds of muscles and also the parenchyma of the different viscera such as thyroid, liver, spleen, kidneys etc.

Medas: This generally stands for fatty tissue, however, it is to be noted that it is of two types: Baddha (bound, stable, fixed, stored) and abaddha (free, unbound). The baddha form, therefore, must include the stored fat in the form of adipose tissue; and the abaddha form must include the circulating lipids such as cholesterol, LDL, HDL etc.

Asthi: Though the term asthi generally stands for bony tissue, it may in some contexts, include all such relatively hard structures that resist easy decaying, viz., teeth, nails and hair.

Majjā: Generally, the substance that fills all the bony cavities is called majjā. However, the brain substance that fills the cranial cavity too, must be included in majjā. Therefore, majjā is of two types: asthigata (bony) and mastakagata (cranial).

Shukra: The term ‘shukra’ has been described to be of two forms in Ayurveda textbooks: 1. The one that is ejaculated during the process of mating, which is responsible for fertilization of ovum and thus embryogenesis, 2. The one that is formed from majjā (the tissue that fills the bony cavities) which in turn circulates all over the body both in males and females. Reproduction is the function of this second form of shukra too. Therefore, on careful examination, it seems that the first form of shukra stands for the semen in general and for sperms in particular; and, the second form of shukra stands for hypothalamo-pituitary-gonadal axis of hormones that circulate all over the body.

The process of nourishment of dhatu

The process of nourishment of dhātus is explained by three analogies: Kṣīra-dadhi (milk curdling analogy), khalekapota (analogy of pigeons picking up the choicest grains) and kedārī-kulyā (irrigation analogy).

Ksheera-dadhi nyaya (milk curdling analogy)

According to this analogy, the nourishment of a dhātu takes place according to the rule of conversion (of one substance into another). Just as the milk is converted into different forms (from milk to curd, curd to butter, butter to ghee) successively, the preceding dhātu too is converted into the next one. The sequence of this conversion is as follows: rasa - rakta - māṃsa – meda – asthi – majjā – and - shukra in the same order.

The transformation of various substances that takes place due to various biochemical reactions could be one way of understanding this analogy. For instance, the process of glycolysis involves different enzymes acting on different substrates at different steps and converting them from one to another. The ability of one kind of stem cell derived from one tissue in giving rise to different forms of cell types of different tissues is known. The response of mesenchymal stem cells to certain stimuli such as hypoxia in the form of migration and tissue regeneration is also known, which can further support this analogy.

Khalekapota nyāya (analogy of pigeons picking up the choicest grains)

According to this analogy, the nourishment of different dhātus takes place according to the rule of selectivity. Just as the pigeons coming from far off places, picking up the grains of their choice from the granary (a storehouse for thrashed grain, khala) and flying back to their destination, the different dhātus too, pick up the required nourishment from the common nutrient pool known as rasa. The dhātu that is situated nearer to rasa is nourished first and the remaining later, just as the pigeon from a nearer place gets a chance to pick up grains quickly in the given analogy.

In this analogy, the choice that the pigeons have in picking up the grain (selectivity) and the energy they spend in the process of obtaining grains (actively) are the vital features. The tissue metabolism can influence the extent of vasodilatation and thus its own perfusion. This is known as auto-regulation of blood supply. Similarly, the specific kind of tissue has affinity for specific nutrient and other substances. For example, the calcium gets deposited normally in bones, but not in the mucous membranes. Similarly, vitamin B-12 is stored in liver and not in other tissues.

Kedārī-kulyā nyāya (analogy of irrigation)

According to this analogy, the nourishment of dhātu takes place according to the rule of irrigation. Just as the kulyās (small canals / trenches / channels) receive water from the kedārikā (the bigger water reservoir) and then irrigate the nearest field first, the rasa too, nourishes the dhātus in a sequential fashion depending on the location of the dhātu.

The anatomical location of a cell in the body can influence the amount of perfusion it receives. For instance, the apical regions of the lungs are less perfused than the other areas of the lung, and hence, are susceptible to be affected in some infectious conditions such as tuberculosis. Similarly, the hepatocytes that surround the central vein in a hepatic lobule are more susceptible to hypoxic injury than those situated in the periphery. Sub-endocardial region of the heart is, in the same manner, is more susceptible to ischemia than the epicardial region.

Another important feature to be noted in this analogy is the passive flow of water from higher altitude to lower altitude, where no external energy is spent. This is in contrast to the pigeons expending their energy to pick up the grains of their choice actively. It is interesting to note the process of transportation of substances across the cell membrane, which has been divided into two major types: active transport and passive transport (Verse-16).

Bilirubin is a metabolic byproduct of heme portion of the hemoglobin. This is secreted into bile juice in the liver which is in turn released during the process of digestion. Features of pitta vr̥ddhi therefore, are yellowish discoloration of sclera, skin, urine and feces. Mucous is rich in water that is derived from extracellular fluid while it is being formed. The cerumen, sebum, and other similar external secretions perform some functions such as providing a waxy protective layer. Sweat and urine share similarities in function as well as composition. Therefore, vr̥kka mentioned as the site of origin of medavaha srotas makes sense when one considers sweda as the mala of meda. Hair and bones share similarity when it comes to the power to resist easy biodegradation. They also grow weaker in old age. Therefore, hair are the mala of asthi (Verse 19).

Circulating provoked dosha settles in a tissue whose channels are defective (kha-vaigunya) and perfuce the lesion. This pathogenesis has been compared with rain production. The obstruction to the moving rasa by the abnormality of srotas, results in causation of disease, just as the obstruction to the cloud laden monsoon winds by the tall mountains results in the causation of rainfall (Verse 37).

Causes of grahani disorder

Abhōjana (starvation) leads to increase in vāta and in turn agnimāndya.(Ca.Vi/ 2/7) Starvation and protein malnutrition disrupts the normal indigenous gastro intestinal tract micro-flora and impairs host antibacterial defenses. Both starvation and protein malnutrition increases the cecal levels of gram negative enteric bacilli and decrease the level of lactobacillus and promote growth of anaerobes that inturn disturb the gut flora. Gut flora also known as gut microbiome has a unique role in digestion and absorption. Once the gut microbiome gets vitiated it leads to indigestion and malabsorption.

Atibhōjana (excessive intake) causes provocation of all the doṣha and thereby causing agnimāndya. Protein rich diet or fat laden diet or excessive diet takes longer time for emptying of stomach. Longer stay of food explains increase of acidic pH. Therefore, whenever such chyme enters the duodenum the liver and pancreas need to increase secretion of alkali pH. Repeated, such dietary habits lead to indigestion. Further increase of alkali pH causes reduced transit time in small intestine leading to the symptoms like diarrhea. Diet which is atiguru (heavy) and indulging viṣamāśana( irregular food habit) will have similar effect. Atirukṣa ahāra or diet has low protein value. Protein malnutrition leads to decrease of enzyme secretion as proteins are the building blocks of enzymes. Asātmya deśa, kāla, ritu only explain the dietary changes which dramatically alter the balance of bacteria in the gut on daily basis. Research shows that these fluctuations could lead to various digestive and absorptive problems. Duṣiṭa bhojana or contaminated food reacts directly with intestinal flora disturbing their quantitative and qualitative growth causing indigestion. Intake of unctuous substances in sāma pitta condition leads to grahaṇīdoṣha and various other disorders.( Ca. Su 13/76 ) Emaciation due to disease also has its own impact on digestion. Mandāgni is a causative factor for all diseases but if patient continuously indulges in apathya then complications may increase or the prognosis turns bad.

Suppression of manifested natural urges may have impact on nervous system resulting in effect either on enzymatic secretion or on the hormonal secretion.These factors have role in digestion and absorption as may be understood in case of adhovāta (accumulation of vata in rectum and pelvic region) and puriṣa vegadhāran (suppression of urge of defecation), wherein regular urge suppression disturbs the intestinal pro-kinetic movement.( Ca. Su. 7/ 6,8,12) Disturbed pro-kinesia increases the transit time leading to the change in pH which further has its impact on electrolytes and enzymatic secretion leading to reduced digestive power (agnimāndya).

Further kṣudhā vegadhārana (avoiding sense of hunger) effect will be similar to abhojana (not eating). It may also be noted that repeated kṣudhā vegadhārana leads to atrophy of the stomach which further weakens the perception of hunger which is controlled by the percentage of the stomach that remains empty similar to the explanation given by Charaka that excessive fasting leads to diminution in agni.(Ca.Su.22/37) Tr̥ṣṇā vegadhārana (avoiding thirst) leads to reduced fluid balance in the body. Nearly seven liters of water is secreted during various gastrointestinal secretions. Reduced water intake in long term will reduce gastrointestinal secretion leading to impaired digestion.

Abnormal digestion is from faulty food habits and unwholesome diet, that causes jatharagni dushti or vitiation of digestive power. The improperly digested food turns into toxic substance called aamavisha, basic cause of most diseases. If aamavisha associates with any balanced dosha or healthy dhatu, they turn pathogenic. Grahanidosha is an important example of aamavisha and agnidushti.

Grahinidosha is of four types. It starts with inflammation of elementary canal at different places and is called by different names e.g gastritis, duodenitis and colitis. In the second stage erosions and ulcers develop. In third stage mental symptoms like anxiety, illusions, fear, and IBS like symptoms. Fourth stage is sannipatic with clinical features resembling ulcerative colitis.

Treatment of grahanidosha is to enhance jatharagni, bhutagni and dhatuagni which encompasses the whole digestive process. Food and drinks are also medicated depending upon the patient and the stage of disease, for extended period of time.

Effect on immunity

Prayatna (effort), urjā (energy) and bala (strength) are the role played by vāta, pitta and kapha in building up of immunity. When the doṣha gets vitiated prayatna, urjā and bala are hampered leading to suppression of immunity. Exogenous and endogenous factors vitiate the doṣha which when associated with ama produce either local or systemic disorders. Tridoṣha play role in impairing immunity and depending on the dominance of a particular doṣha they are classified as vātaja, pittaka and kaphaja disorders.(Ca. Su. 28/7)

Equilibrium of agni

Agni should be associated with balance of vāta, pitta and kapha or Samāgni. Digestive enzyme secretion is controlled by sympathetic and parasympathetic nerve supply. Samāgni may be compared with balanced state of sympathetic/ parasympathetic activity which explains the role of balanced or Samān vāta. It may also be noted that prāṇa vāta and apāna vāta also have impact on balancing the normal status of agni. Acidic and alkaline pH of digestive secretions explains the balanced pitta. Modern science explains specific range of pH of digestive secretions e.g. pancreatic juice has pH in range of 7.1 – 8.2 that buffers acidic gastric juice in chyme, stops the action of pepsin from the stomach and creates proper pH for action of digestive enzymes in small intestine. Specific pH of gastric juice is essential to convert pepsinogen into pepsin, an active form of proteolytic enzyme thus improper pH will cause variation in digestion.

Mucosal resistance explains role of kapha in maintaining samāgni. Intact mucosal lining is present in stomach and small intestine. Breach in mucosal lining causes gastritis, burning sensation etc whereas increased size of mucosal cells alters the pH thereby a balanced kapha plays essential role in samāgni. Role of prostaglandins to maintain gastric mucosal resistance to prevent the action of HCl in gastric mucosa is to be considered as part of kledaka kapha as sodium bicarbonate and mucus is secreted by prostaglandins. Drugs which inhibit prostaglandins e.g. aspirin, impairs gastric mucosal barriers leading to gastritis, duodenitis and peptic ulcers.

Clinical features

Ārōcaka (aversion to food), vairasya (distaste), prasēka (excessive salivation) are general gastro intestinal manifestations of indigestion. Tamaka or blackout occurs due to nutritional deficiency. Mal-absorption causes diarrhea which leads to decrease in circulating liquid, a cause of hypotension a reason for blackout. Impaired absorption of iron, folate, vit. B12 leads to anemia which may be the cause for blackout (tamakānvitaḥ). Resulting anemia and electrolyte depletion (particularly K+) leads to weakness. 1) Peripheral neuropathy due to Vit B12 and thiamine deficiency 2) Dermatitis due to deficiency of Vit. A, Zinc and essential fatty acid 3) Night Blindness/Xeropthalmia due to Vit A mal-absorption. 4) Bleeding due to Vit K malabsorption and hypo prothrombinemia 5) Anemia impaired absorption of iron, folate, and vitamin B12 6) Amenorrhea, decreased libido due to protein depletion decreased calories and secondary hypopituitarism. 7) Tetany, paresthesia due to calcium and magnesium mal-absorption 8) Glossitis, cheilosis, stomatitis due to deficiency of iron, Vit B12, folate and Vit A (Verse 52-54).

Spices are basically a combination of acids. When too much of these acids are introduced in gastrointestinal tract which has its own acidic contents it starts damaging the mucosal lining of walls of gastrointestinal tract. It also reduces the pH thus activation of enzyme is hampered leading to indigestion.

Etiological factors as mentioned in the text have impact mainly on the neural stimulation of digestive secretions affecting the flow of gastrointestinal secretions into the gastrointestinal tract thereby hampering the digestion. Hence it is explained that aggravated vāta encompasses the agni. Altered canalicular functions hampers digestion, easily understood in primary biliary cirrhosis wherein biliary secretion is restricted. Atrophy of gastric mucosa reduces HCl secretion causing indigestion. The gastric gland contains three types of exocrine gland cells that secrete their products into stomach lumen. ‘srotasām kharatvam’ (hardness in channels) quality of tikta rasa destroys the exocrine gland cell reducing their secretions. Gastric glands include a type of enteroendocrine cell, the G cell which is located mainly in the pyloric antrum and secretes the hormone gastrin into the blood stream which stimulates parietal cells to secrete HCl and chief cells to secrete pepsinogen, it also contracts the lower esophageal sphincter, increases motility of the stomach and relaxes pyloric sphincter. G cells when get destroyed the above action of kapha inturn agni is hampered so also contraction and relaxation karma of vāta is vitiated.

Further kaṣāya rasa reduces peristaltic movements called as mixing waves which reduces the maceration and mixing of food with secretions of gastric glands, thus improper chyme is formed. Deficiency of gastrointestinal secretions due to damage to the glands or canaliculi or intestine may be mostly considered as having vātaja origin. Loss of pravartan karma is to be understood where the transport of secretions is hampered (except in obstructive pathology where kapha to be considered). Hartnup’s syndrome a defect in neutral amino acid transport and cystinuria a defect in dibasic amino acid transport explain the rare genetic disorders (Bija Dusti) involved in protein digestion absorption.

Further due to vāta prakopa, intestinal activity is increased which is manifested as mal-absorption. For e.g. lactose intolerance is related to rate of gastric emptying. Symptoms are more likely when gastric emptying is rapid than when gastric emptying is slower. Therefore it is more likely that skim milk will be associated with symptoms of lactose intolerance than with whole milk as rate of gastric emptying is more rapid in skim milk. Milk proteins, particularly caseins have appropriate amino acids composition for growth and development of young. Caseins are highly digestible in intestine and high quality source of amino acids. Most of whey proteins are relatively less digestible in intestine, although all of them are digested to some degree. When substantial whey proteins are not digested fully, some of intact protein may stimulate a localized intestinal or systemic immune response this is due to beta lactoglobullin referred to milk protein allergy. Similarly, diarrhea observed following subtotal gastrectomy is often a result of lactose intolerance as gastric emptying is accelerated in patients with gastrojejunostomy, rapid small intestinal transit time develops symptoms of lactose intolerancy. Kaṇṭhāsya-Śōṣaḥ (dryness of mouth also known as xerostomia) occurs due to diminish salivary gland secretion. Primary cause being fluid loss through diarrhea secondarily it may be association of Sjogrens syndrome with autoimmune disease like primary biliary cirrhosis ~ a secondary Sjogrens syndrome. In this syndrome involvement of other exocrine glands occur leading to diminished secretion of exocrine glands of the gastrointestinal tract, leading to esophageal mucosal atrophy, atrophic gastritis and subclinical pancreatitis.

Increased appetite (Kṣudhā) is seen because of a negative feedback due to mal-absorption or it may be understood under rasasheshājīrṇa.

Tṛṣṇā is manifested due to increased Rukṣa Guna of vāta and decreased Jalādi Ansha due to diarrheas and low fluid intake.

Timira (blurred vision) results from vitamin A mal-absorption and anemia.

Tinnitus is a symptom also found in Pāndu (anemia)(Ca. Ci. 15/61), which is observed due to mal-absorption of essential elements like vitamin B12.

Pain in flanks, thigh, pelvis, cervical area occurs due to calcium and Vitamin D mal-absorption. Pain is also contributed by protein deficiency due to low nutritional diet, osteoporosis, anemia and decrease lactic acid neutralization due to reduce peripheral circulation.

Whipple’s disease is chronic multisystem disease associated with diarrhea, steatorrhea, weight loss, arthralgia and CNS and cardiac problems caused due to tropheryma whipple.

Hr̥tpīḍā is chest discomfort or chest pain which may be resultant of anemia but most probably due to gastro esophageal reflux disease.

Mal-absorption may be for single entity or for various minerals and vitamins and may lead to emaciation and weakness.

Vairasyaṁ (distaste) is probably because of taste projections to the hypothalamus and limbic system, there is a strong link between the taste and pleasant and unpleasant emotions. Parikartikā (cutting pain) is due to Śuṣkā-mala Pravṛtti (pellet stools) which causes pressure and rupture of anal mucosal lining that may lead to cutting pain.

Craving for all types of food (Gr̥ddhiḥ Sarvarasānāṁ) is seen due to mal-absorption of various elements, mineral and vitamins causing deficiency of the essential requirements of elements. The negative feedback system creates the craving for essential elements which is presented in the form of craving for all six rasa. rasa should be understood for food which will fulfill the requirements.

Mood disorders are observed due to depletion of essential vitamins, mineral and other elements. Electrolyte difference creates confusion which may be the cause for Mano Avasāda.

Bloating of abdomen is manifested while digestion is in process or after digestion is completed because of indigestion that causes abnormal growth of gut microbiome. Bacterial fermentation of unabsorbed carbohydrates leads to flatus. Carbohydrates metabolism occurs in small and large intestine therefore the symptom occurs during Jīrṇē Jīryati Cādhmānaṁ i.e. during and after the process of digestion. Once the patient takes food, circulation towards stomach is increased and digestive activity in the colon is reduced thus carbohydrate metabolism is depressed reducing the formation of flatus in rectum thereby reducing the bloating of abdomen.

Patient doubts as if he may be suffering from following of the disorders like vātavikār, gulma, hridroga and pleeha. Due to formation of flatus and later on bloating of abdomen makes the patient feel he is suffering from vātika disorders related to gastrointestinal tract. Especially gulma since the patient feels the movement of flatus, so doubts about gulma.

Ūṣnā and Tīkṣṇa Guna of pitta trigger inflammatory response by irritating the intestinal mucosa. Indigestion causes depletion of beneficial gut bacteria thus breakdown in the balance between the putative protective and harmful intestinal bacteria leads to chronic inflammation.

Antigenic nature of endogenous factors can be understood when helpful bacteria and ūṣnā, tīkṣṇa Guna of kapha trigger inflammatory response leading to autoimmune pathogenesis.

In case of hypersecretion of gastrin in gastrinoma [Zollingers – Ellison Syndrome] stimulate the parietal cells of the stomach to secrete acid to their maximal capacity and increase the parietal cell mass three to six fold. The acid output may be so great that it reaches the upper small intestine reducing the luminal pH to 2 or less. Pancreatic lipase is inactivated and bile acids are precipitated. It results in diarrhea and steatorrhea. Subtotal villous atrophy occurs due to hyper-secretion which may cause mal-absorption. Excessive gastrointestinal secretions cause derangements in fluid and electrolyte transport across the entero-colonic mucosa leading to diarrhea. They are characterized clinically by watery, large volume fecal outputs that are typically painless and persist with fasting because there is no mal-absorbed solute; stool osmolalirity is accounted for normal endogenous electrolytes with no fecal osmotic gap.

Other than excessive secretion, condition like ileal dysfunction caused by either Crohn’s disease or surgical resection results in a decrease in bile acid re absorption in the ileum and an increase in the delivery of bile acids to the large intestine. The resultant is a diarrhea with or without steatorrhea. It becomes a cause for mal-absorption syndrome.

Inflammatory Bowel Disease needs consideration in pittaja grahaṇī. Exogenous factors trigger inflammatory response that the mucosal immune system may fail to control. With mild inflammation the mucosa is erythematous and in severe condition the mucosa becomes hemorrhagic, edematous and ulcerated (Verse 65).

Loose motions (Drava Mala Pravṛtti) are mainly due to excessive secretion of bile juice (Drava guna of pitta). Excessive secretion may be due excessive formation in liver or decrease absorption in the intestine.

Bile acids are not present in the diet but are synthesized in the liver by a series of enzymatic steps that also include cholesterol catabolism. Bile acids are either primary or secondary. Primary bile acids are synthesized in the liver from cholesterol and secondary bile acids are synthesized from primary bile acids in the intestine by colonic bacterial enzymes. Bile acids are primarily absorbed by active, sodium dependent process that is located exclusively in the ileum; secondly bile acids can also be absorbed to a lesser extent by non carrier mediated transport processes in the jejunum, ileum and colon. Conjugated bile acids that enter the colon are deconjugated by colonic bacterial enzyme to unconjugated bile acids and are rapidly absorbed. Colonic bacterial enzymes also dehydroxylate bile acids to secondary bile acids, thus if exogenous factors like diet as discussed above disturb the colonic bacterial growth than bile acids are not absorbed. A decrease in the amount of bile acids returning to the liver from the intestine is associated with an increase in bile acids synthesis/cholesterol catabolism, which helps keep bile acid pool size relatively constant. Defects in any of the steps of the enterohepatic circulation of bile acids can result in decrease in duodenal concentration of conjugated bile acids as a result steatorrhea. Thus steatorrhea can be caused by abnormalities in bile acid synthesis and excretion, their physical state in the intestinal lumen and reabsorption. The bile gives the yellowish nature to the stools (Verse 66).

Guru, snigdha and sītā ahara is dominated by prithvi and jala mahābhuta, these qualities help in reducing the impact of agni mahābhuta thus causing jatharāgni māndyatā resulting in indigestion leading to formation ama. Such ama is responsible for doṣha prakopa.(Madhukoshatika Ma. Ni. Jwara adhyaya/2)

Klinna(moist), guru, piṣṭānna(malt), abhiṣyandi(which increases secretions) ahāra and adhyāśana(over eating) are source for extra calories. Fast foods are defined as any food that contributes little or no nutrient values to the diet, but instead provides excess calories and fat. Common foods include salted snack foods, gum, sweet desserts, fried fast foods, carbonated beverages and candy.

Diets rich in trans-fatty acids like deep fried fast food, cake mixes, chips and packed cookies, all have inclusion in guru, piṣṭānna, vishtambi(causing obstruction) ahara. People consuming snigdha ahāra (fatty food) and have sedentary lifestule with very little energy expenditure, and most fat is stored. The above 2 concepts explain why agnimāndya and ajīrṇa have been mentioned after taking heavy food. Excessive heavy food (guru ahara) slows down emptying of stomach (samāna vāta karma is hampered) and enzymes are not secreted into lumen (pitta action hampered) causing agnimāndya. Substances of sīta vīrya causes constriction reducing the secretion (stambhana) of gastrointestinal juices thus hampering lipase activity therefore leading to steatorrhea.

Further heavy meals increase the transit time causing functional stasis which may cause bacterial overgrowth syndrome. Sleeping just after meals may also lead to functional stasis (further study required). Peristalses are also reduced with heavy meals and sleeping after meals causes bacterial overgrowth. Bacteria deconjugate conjugated bile acids and as a result intraduodenal concentration of bile acids will be reduced resulting in steatorrhoea and macrocytic anemia. Bacterial overgrowth also occurs with stasis from a blind loop, small bowel diverticulum or dysmotility.

Postmucosal lymphatic obstruction- The pathophysiology of this condition which is due to the rare congenital intestinal lymphangectasia or due to acquired lymphatic obstruction secondary to trauma, tumour or infections, leads to the unique constellation of fat malabsorption with enteric loss of protein (often causing edema) and lymphocytopenia. Carbohydrates and amino acid absorption are preserved (Verse 67). Nausea and vomiting are both caused by stimulation at one of the four sites: the gastrointestinal tract, the vestibular system, the chemoreceptor trigger zone and the cerebral cortex. Nausea and vomiting occurs due to disturbed gastric motility caused by heavy meal and delayed gastric emptying. The same is the cause for heavy abdomen and eructation with foul smell and sweet taste. As the food stays for long time in gastrointestinal tract blood flow increases centrally and reduces the enthusiasm and decrease in libido. The sluggish activity of gastrointestinal tract causes symptoms such as absence of movement in the abdomen (udaraṁ stimitaṁ guru). The heavy abdomen puts pressure on the diaphragm causing symptoms of heaviness in chest (hr̥dayaṁ manyatē styānam).

Bacterial overgrowth due to undigested guru, klinna, snigdha and abhiṣyandi ahāra causes increased mucoid secretion, thus formed stool is not observed instead bhinnāmaślēṣma-saṁsr̥ṣṭa varcā(loose stools with ama and kapha) is seen; which is also cause for heaviness of stools (guru-varcaḥ-pravartanam) Due to diet pattern and sedentary lifestyle there is accumulation of fat (obesity) but due to decrease protein absorption and malabsorption of essential elements patient feels weakness and laziness without weight loss (Verse 68-70).

Normalcy of vāta pitta and kapha keeps the agni in balanced condition, it means that a specific pH is maintained (pitta); secretion, transportation and villi movement are normal (vāta) and mucosal bed secretes normal mucus and is healthy (kapha), thus maintains samāgni or a normal digestive process (Verse 71).

Protein losing enteropathy is increased protein loss into the gastrointestinal tract which is classified into three groups.

a) Mucosal ulceration; there is protein loss by exudation across damaged mucosa e.g. Ulcerative colitis, peptic ulcer, gastro intestinal carcinoma. In such cases dominance of pitta doṣha needs to be considered.

b) Non ulcerated mucosa but evidence of mucosal damage; Protein loss primarily represents loss across epithelia with altered permeability e.g. celiac sprue and menetrier’s disease in small intestine and stomach respectively, vāta doṣha and/or kapha doṣha dominancy should be considered.

c) Lymphatic dysfunction, represents either primary lymphatic disease or secondary to partial lymphatic obstruction that may occur as a result of enlarged lymph nodes or cardiac disease. Patient with increased protein loss into gastrointestinal tract due to lymphatic obstruction often have steatorrhea and diarrhea. The steatorrhea is a result of altered lymphatic flow as lipid containing chylomicrons exit from intestinal epithelial cells via intestinal lymphatic’s which may be compared with flow of ahar rasa and/ or presence of vata and kapha.

Genetic factors (bija dushti) almost all patients with celiac sprue express the HLA-DQ2 allele. Environmental factor, gliadin a component of gluten that is present in wheat, barley and rye contributes to the disease. Immunologic component (prayatna, bala and urja of vāta, kapha and pitta respectively), serum antibodies – IgA antigliadin, IgA antiendomyasial and IgA antibodies and IgG antibodies are present. In addition, gliadin peptides may interact with gliadin specific T cells that may either mediate tissue injury or induce the release of one or more cytokines that cause tissue injury (Verse 72).

Further research shows that incase of uncontrolled growth of gut microbiome, flushing of gut reduces both psycho-somatic symptoms. Shodhana therapy not only flushes the vitiated gut microbiome but also flushes out the substrata due to which growth of microbiome is controlled (Verse 73-74).

Kṣāra has been advised along with tilvaka sneha; kṣāra has alkaline pH. In duodenum and small intestine, enzymes with alkaline pH are secreted. uṣṇa, Tīkṣṇa and Laghu guna helps in digestion. ‘Kledayati ādo Paschata Visoshayati’(Ca. Vi. 1/17 ) i.e. secretion are first increased and later on absorbed is very essential in grahaṇī Doṣa. Both these actions help in secretion of digestive enzymes thereby increasing agni and by absorption correct the malabsorption. Therefore use of kṣāra is more in grahaṇī doṣha and gulma (Verse 79).

Āranāla(a fermented preparation), dadhimanda(thin part of curd) or sauvīraka are all fermented liquids. Fermented liquids contain probiotic organisms. Probiotic foods are produced by chemical action of lactic acid, bacteria, yeast or combination of both. These useful microorganisms help in breaking down carbohydrates, sugars making them easily digestible. Probiotics improves absorption of nutrients; improve synthesis of vitamins, essential fatty acids and enhance nutritional qualities of food grains. Fermented foods increase the absorption of vital minerals from gastrointestinal tract thus preventing mineral deficiencies and also treat the diarrhea. It explains the role of helpful gut microbiome (Verse 82-86). Use of fermented products explains the concept of gut microbiome and use of kṣāra and amla drug for maintaining pH (Verse 88-93).

Vamana (medicated emesis) reduces gastro-paresis by emptying the gastrointestinal contents (Verse 101-102).

Fermented liquids are rich source of gut microbiome which will help to replace the unhealthy microbiome. These fermented liquids also help to balance the pH of the gastrointestinal tract. Further study is required to decide impact of above mentioned liquid diet on pH and specific enzymes (Verse 115-116).

One cup of buttermilk contains 152 calories and 8.11 grams of fat, of which 4.65 grams are saturated, 282 milligrams of calcium and 127 international units of vitamin D. The vitamin also helps to maintain normal phosphorus levels. Phosphorus is another nutrient that contributes to bone health (Verse 117-119).

Samāna vāta regularizes the secretion of pancreatic and intestinal enzymes. Initially the enzymes are in zymogens (inactive form). Samān vāta helps in conversion of zymogens into active enzymes so all the factors which help in stimulating exocytosis can be considered as functional components of Samān vāta. Once Sāmana vāta is stimulated efficiently the digestive process becomes intact to digest all types of nutrients (Verse 202-203 -1/2).

Hyperthyroidism is one of the causes for hypermetabolic disorders but extra thyroidal causes are also important. Hypermetabolism typically occurs after significant injury to the body. Infections, sepsis, burns, multiple traumas, fever, long bone fractures, prolonged steroid therapy, pheocromocytoma, surgery and bone marrow transplants. Hypermetabolism may occur particularly in the brain after traumatic brain injury (Verse 217-219).

Hypermetabolism is accompanied by a variety of internal and external symptoms most notably extreme weight loss. External symptoms of hypermetabolism may include anemia, fatigue, elevated heart rate, irregular heartbeat, insomnia, shortness of breath, dysautonomia, muscle weakness, excessive sweating while internal symptoms include peripheral insulin resistance, elevated catabolism of proteins, carbohydrates triglycerides and negative nitrogen in the body.

In this context there is increased function due to excess secretion of thyroid hormones. Thyroid hormones act as catabolic hormones and promote calorigenesis and develops hypermetabolic state which may result in gluconeogenesis, lipolysis and glycogenolysis causing decreased muscle mass and weight loss. Metabolic rate is enhanced, because of vitiated pitta and associated Vāta. This is the condition where increased appetite with weight loss is seen due to insufficient supply of nutrients in relation to agnibala. Thyroid storm/ thyroid-toxic crisis is rare and life threatening exacerbation of hyperthyroidism, accompanied by fever, delirium, seizures, vomiting, diarrhea and jaundice. Death may occur due to cardiac failure, arrhythmia and hyperthermia. Management requires intensive monitoring, supportive care, identification of the precipitating causes (stroke, infection, trauma, diabetic ketoacidosis, surgery and radio iodine treatment), and measures that reduce thyroid hormone synthesis (Verse 220-222½).

Kleda can also be considered as inter-mediory product of metabolism like ketones, pyruvate, lactate which are well utilized in active/healthy persons as fuel and therefore does not cause inflammation/disease process (Verse 237-239).

Current clinical practices

Sr.No. Name Dose Time of administration Anupana 1. Chitrakadi vati 250-500 mg Between meals Buttermilk or lukewarm water 2. Shankha vati 250-500 mg Between meals Buttermilk or lukewarm water 3. Lashunadi vati 250-500 mg Between meals Buttermilk or lukewarm water 4. Hingvadi vati 250-500 mg Between meals Buttermilk or lukewarm water 5. Shiva kshara pachana churna 1-5 grams Between meals Buttermilk or lukewarm water 6. Hingvashtaka churna 1-5 grams Between meals Buttermilk or lukewarm water 7. Bhunimbadi churna 1-5 grams Between meals Lukewarm water 8 Avipattikara churna 1-5 grams Between meals Lukewarm water 9 Lavana bhaskar churna 1-5 grams Between meals Buttermilk or lukewarm water 10 Swadishta virechana churna 1-5 grams Between meals Lukewarm water 11 Nagaradi churna 1-5 grams Between meals Buttermilk or lukewarm water 12 Dadimashtaka churna 1-5 grams Between meals Nimbu panaka or lukewarm water 13 Pippalyasava 10-40 ml Between meals Lukewarm water 14 Jeerakadyarishta 10-40 ml Between meals Lukewarm water 15 Abhayarishta 10-40 ml Before meals Lukewarm water 16 Takrarishta 10-40 ml Between meals Lukewarm water 17 Chitrakadi ghrita 5-40 ml Between meals Lukewarm water 18 Dadimadi ghrita 5-40 ml Between meals Lukewarm water 19 Kiratadi churna 1-5 grams Between meals Honey or Lukewarm water 20 Marichyadi churna 1-5 grams Between meals Buttermilk or lukewarm water

Areas of Further Research

• To study asava and arishta in relation with microbioma. • To understand concept of ama with relation to autoimmune diseases. References