JR.A.S Vol.XXXV No. 1-4. Jan-Dec. 2014 pp.29-42

A Study on Amashaya Sodhana with Sighru Patra Kashaya in theManagement of Parinamashula (Duodenal Ulcer)

GK Swamy* V Nagakakshmi** T Maheswar** GP Prasad>" V Subhose**& AJV Saiprasad***

Abstract

A clinical study was conducted on Amashaya shodhana with Shigru Patra kashaya anewtechnique of Gastric lavage at Clinical Research Unit. Hyderabad to evaluate it's efficacyon41 cases of Par inam as hula (Duodenal Ulcer). Among the studied 41 cases, 2 (4.88%) casesgotgood response, 27 (65.85%) got fair response, 11 (26.83%) got poor response and 1 (2.44%)case did not responded for the treatment. Based on the statistical analysis highly significant(P < 0.001) relief was found in Pain in Abdomen after meals, Vomiting, Burning Sensation inAbdomen, Tenderness in Epigastrium, Nausea, Acid Eructation, Flatulence, Indigestion andConstipation. Functional improvement was also found in Fraction Test Meal (FTM) study.

Introduction:

Amasaya sodhana a new technique of gastric lavage with herbal decoction wasintroduced by Dr. I. Sanjeevarao, former Project officer CRU (Ay) , Hyderabad. The basicideafor selection of this procedure has got from the earlier study of Dr. P.J. Deshpandey andDr.Satyadev rai of PGIIM, BHU, in which Varuna and Shigru were used for stomach· washas a pre operative procedure for peptic ulcer. Amasaya sodhana is a sort of Vamana karmaas in this procedure decoction of drugs introduced in the stomach through Ryle's tube andafter retaining for 5 minutes it is aspirated back. But in this procedure patient need not totake rest either before or after the procedure and will not get weakness or discomfort. ThediseaseParinamasula is characterized by a specific type of pain at the time of disintegration ofingested food (2-4 hours after meals). The disease though not mentioned in ancient Ayurvedicliterature, finds place in medieval Ayurvedic literature under the chapter Sula. It has beenconsidered as a Tridosaja Vyadhi though the Pitta Dosa plays predominant role. The clinicaldescription of Parinamasula is very close to the clinical picture of duodenal ulcer of modemmedicine. The treatment of this disease in modem medical science is based on the use of drugsto reduce acid secretion and to neutralize excessive acidity and help healing of the ulcer. Themedical management often does not provide relief and patient may ultimately has to undergosurgery.There is immense potential to explore the alternate means of treatment.

*Assistant Director in-charge ** Assistant Director (Ay.) ***Research Officer (Ay.)

Regional Research Institute (Ay.), IGMS Complex, Labbipet, Vijayawada.-520 010 (A.P.)

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GK Swamy et al.

The Ayurvedic treatment is found quite efficacious in the management of this disease. TheSamana and Sodhana therapies for this disease have been successfully tried under Council'sResearch projects. Certain single herbals e.g. Satavari, Varuna, Madhuyasti, Apamarga andherbal combinations e.g. Patoladi Kvatha and Yastimadhvadi Kvatha have; been found effectiveas Samana therapy along with certain dietary restrictions. First time a special. techniquenamed Amashaya Shodhana (gastric lavage with the herbal decoctions) was designed for themanagement of Parinama Sula (Duodenal Ulcer).

In this study decoction of Shigru Patra was used for Amasaya Sodhana to evaluate theefficacy of the treatment in parinama sula patients.Material and MethodsLevel of the StudyUnit,

I P D 1 OPD of Clinical ResearchHyderabad

Selection of drug Shigru patra kashayaProcedure of Amasaya sodhana

Amasaya Sodhana (Stomach wash) is done as per the prescribed schedule with twodays interval between each Sodhana. In this study the drug Shigru patra kashaya has beenselected for Amasaya sodhana as it is having Vedana sthapana (Analgesic), Sothahara (Antiinflammatory) and Vranahara (Wound healing) properties.

In the preparatory procedure patient is advised to take dinner before 7 P.M. on theprevious day with easily digestible food and then if the patient feels hungry, can be allowedto take milk, gruel (kanji) before 10 P.M. only and after that patient should not take any thingincluding water. Amashaya sodhana was conducted on empty stomach in the next day morningbetween 6 A.M. and 12 noon. In the Sodhana phase decoction of Shigru patra is introducedin to the stomach through Ry1e's tube and allowed to retain for 5 minutes. During introducingthe decoction patient is laid down in straight position, then asked to turn right side for twominutes, left side for two minutes and lastly for one minute in straight position. After changingthe positions the decoction as well as stomach juices are aspirated. During aspiration positionof Ryle's tube and patient should be changed according to the position of stomach juices.Preparation of Shigru patra kashaya

50 gms of Shigru leaves is made in to coarse powder, added 800 ml of water and isboiled till water reduced to 1/4th i.e. 200 ml then filtered with cloth. The obtained decoction isused for Amasaya sodhana.

Dose, No. of Sodhana and duration:

Shigru patra kashaya 200 ml, 5 Amasaya Sodhanas with two days interval betweeneach sodhana and Fraction Test Meal (FTM) is done 2 days before and 2 days after AmasayaSodhana.

30

A Study on Amashaya Sodhana .

Fraction Test Meal (FTM)

FTM is an aid for the diagnosis of dyspepsia. The main purpose of FTM is to evaluatethe percentage of Hydrochloric acid in gastric juice. In the FTM continuous aspiration ofstomach contents by means of Ryle's tube is recommended with periodic aspirations at every10to 15 minutes with 20 ml syringe. (The Ryle's tube should be demonstrated radiographicallythat the tip lies in the p>,loric portion of the stomach).

Preparation of gruel: 15 gms of champion white oat meal powder is added with 600 ml waterand boiled till water reduces to 400 ml.

Procedure of FTM: First of all resting juices (fasting) of the stomach are aspirated throughRyle's tube, and then 400 ml of cooled gruel is given orally. 15 minutes after giving the gruelaspiration of gastric contents is started and aspiration is repeated at every 15 minutes intervalup to 2 hours. First specimen i.e. resting juice and aspirated fluid of every time is filtered andtested for Hydrochloric acid percentage.

Test for Hcl: 1ml of the filtered fluid is taken in to a conical flask, two drops of top hers reagentis added and titrated by 0.01 Normal sodium hydroxide by burrete till the red colour of thesolution turns to cannery (lemon) yellow. The volume of NaOH is noted and again titrationstarted till yellow turns to pink colour. This volume also noted, and then volume free acidityand total acidity levels were calculated.

Duration of the treatment: 19 days

Treatment schedule

SI.No. Days Treatment1 1SI day FTM and Routine investigations ( Before treatment)2 2nd & 3rd Day Rest3 41hday 1st Amashaya Sodhana with Sighru Patra Kashaya4 51h& 61hday Rest5 7thday 2nd Amashaya Sodhana with Sighru Patra Kashaya6 8th& 9thday Rest7 io- day 3rd Amashaya Sodhana with Sighru Patra Kashaya8 ll " & 12thday Rest9 13thday 4th Amashaya Sodhana with Sighru Patra Kashaya10 14th& l S'" day Rest11 16thday 5th Amashaya Sodhana with Sighru Patra Kashaya12 17th& lS'" day Rest13 19thday FTM and Routine investigations ( After treatment)

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GK Swamy et at.

Drug Review: Shigru- Moringa oleifera

Properties:

S.No. Rasa Guna Veerya Vipaka1 Katu, Tikta Laghu, Ruksha, Tikshna Ushna Katu

Karma: -Vedana sthapan (Analgesic), Sothahar (Anti inflammatory),Krimig~a (wormicidal) & Vranahar (Wound healing).

Pharmacological properties:- Antibacterial, Antiviral, Anti inflammatory, depressant, hepatcprotective & anticancer.

Criteria for inclusion of study:

1. Age between 20-50 years2. Pain in abdomen 2-4 hours after meal3. Burning sensation in epigastric region4. Acid eructation.5. Pain relieved after vomiting6. Nausea7. Tenderness in epigastric region8. Barium-meal X-Ray showing ulcer.9. Endoscopic evidence of ulcer.

10. Duration of disease between 6 months and 10 years.

Criteria of Exclusion:

1. Age below 20 years and above 50 years:2. Pain due to gall bladder diseases3. Continuous pain due to other reasons specifically due to pancreatitis4. Acute abdominal colics5. Malignancy in any part of the body.6. Pyloric stenosis7. Patient with Haematemesis or severe malena8. Duration of disease below 6 months and above 10 years

Criteria for assessment of Results

Specific scores were given for each and every parameter and recorded initially anduring subsequent assessments.

A Study on A mashaya Sodhana .

Basedon the individual score of each finding before and after treatments, the response of thetreatmentwas assessed. Over all effect of the treatment in each individual patient was assessedby the below formula.

i.e.over all percentage of relief = (Total-store of all findings before treatment -Total score ofallfindings after the treatment) X 100 / Total score of all findings before treatment.

Assessmentsof both subjective and objective parameters:

IPain in abdomen 2-4 hours after meals

GO No Pain

Gl Mild pain

G2 Moderate pain

G3 Severe pain

II. ausea

Present

Absent

III.Vomiting

Present

Absent

IV. Burning sensation in abdomen

GO No burning sensation in abdomen

G1 Mild burning sensation

G2 Moderate burning sensation

G3 Severe burning sensation)-'

V. Acid Eructation

No acid Eructation

Mild acid eructation

Severe acid eructation

VI. Flatulence

Present

Absent

33

o5

10

15

5

a

5

a

o5

10

15

o5

10

5

o

Absent

VIII. Constipation

Present

5

o

GK Swamy et al.

VII. Indigestion

Present

10

Absent

5

oIX. Tenderness in epigastria

GONo pain on palpation

G 1 Mild pain on palpation

G2 Moderate pain on palpation

G3 Severe pain on palpation

Classification of the Results:

1. Good Response: 75% or more relief in clinical symptomatology2. Fair Response: 50% to 75% relief in symptomatology.3. Poor Response: 25% to 50% relief in symptomatology.4. No Response: Relief below 25% in symptomatology

Observation and Results:

o5

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Demographic pattern of 41 Parinamasula Patients studied:

Patients were selected in between the age of 20-50 years. Highest incidence ofpatients was observed in between the age of 41-50 years 26 (63.42%) patients (Table no-I)and Male patients 36(87.81 %) were the maximum sufferers with the disease (Table no-2).Majority of the patients 23(56.1%) were having 1461-1825 days duration of illness (Tableno-3). In Shareera Prakriti (Physical body constitution) majority of patients were Vatapitta22 (53.66) and Pittakapha 18 (43.90) in nature and in regards to Manasika Prakriti (mental orpsychological constitution) Rajostamas 18 (43.90) and Salva Tamas 15 (36.59) observed inthe patients (Table no-4). All the patients are having Am/a (acidic) Katu (pungent) bhojana,Vishamashana (Irregular food timings) and Anashana (not taking food in time) food habits.

Results

Based on total score of each clinical finding before and after treatments 68.67% reliefwas found on Pain abdomen, 38.46 % in Nausea, 78.95 % in Vomiting, 67.74 % in Burningsensation in abdomen, 82.14% inAcid eructation, 42.10 % in Flatulence, 31.71 % in Indigestion

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A Study on Amashaya Sodhana .

25.81%in Constipation, 65.57 % relief in Tenderness in Epigastrium was observed. On overallsymptoms59.46 % relief was observed (Table 5). Among the 41 cases studied 2 (4.88%)casesgot good response, 27 (65.85%) got fair response, 11 (26.83%) got poor response and 1(2.44%)case did not responded for the treatment (Table 6).

Based on the statistical analysis highly significant (P < 0.0001) relief were found inPaininAbdomen 2-4 hours after meals, Vomiting, Burning Sensation in Abdomen, Tendernessin Epigastrium, Nausea, Acid Eructation, Flatulence, Indigestion and Constipation (equals0.0030)(Table no-7 to Table no-16)

Functional improvement was also found in FTM study (Table no-17).

Table-I:Distribution of cases according to Age

S. No Age Group No. of Patients1 20-30 8(19.51%)2 31-40 7(17.07%)3 41-50 26(63.42%)Total 41(100%)

Table-II:Distribution of cases according to Sex

S. No Sex No. of Patients1 Male 36(87.81 %)2 Female 5(12.19%)Total 41(100%)

Table-III:Distribution of cases according to duration of illness

S.No Duration of illness (in days) No of Patients1 90-365 1(2.44%)2 366-730 6(14.63%)3 731-1095 2(4.88%)4 1096-1460 9(21.95%)5 1461-1825 23(56.1 %)Total 41(100%)

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GK Swamy et at.

Table-IV: Distribution of cases according to Sharira and Manasika Prakriti

Sl. Sharira No of 0/0 Manasika o of 0/0No Prakriti Patients prakriti Patients1 Vata 0 0.00 Satva 0 0.002 Pitta 0 0.00 Rajo 0 0.003 Kapha 0 0.00 Tamo 0 0.004 Vata pitta 22 53.66 Satya rajo 8 19.515 Vatakapha 0 0.00 Rajo tamo 18 43.906 Pitta kapha 18 43.90 Satya tamo 15 36.597 Sannipata 1 2.44 Sarna 0 0.00Total 41 100.00 41 100.00

Table-V: Relief of treatment in various subjective parameters

Sl. Parameters Total score Total score PercentageNo Before Treatment After Treatment of relief1. Pain abdomen 415 130 68.672 Nausea 195 120 38.463 - Vomiting 190 40 78.954 Burning sensation in abdomen 310 100 .67.745 Acid eructation 280 50 82.146 Flatulence 190 110 42.107 Indigestion 205 140 31.718 Constipation ]55 115 25.819 Tenderness in Epigastrium 305 105 65.5710 Overall 2245 910 59.46

Table-VI: showing the results of Patients

Drugs Results of the treatmentGood Fair Poor No TotalResp. Resp. Resp. Resp.

Shigrupatra Kashaya 2 27 11 1 41Amashaya Sodhana (4.88%) (65.85%) (26.83%) (2.44%) (100%)

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A Study on Amashaya Sodhana .

Table-VII: showing the effect of treatment on Pain abdomen [ =41]

Mean Grade Score S.D Standard Error t PB.T A.T BT-AT B.T A.T of Difference

(SE)10.12 3.17 6.95 ± 5.06 ±3.11 0.759 9.1626 <0.0001

Interpretation of the result.-

Thetwo-tailed P value is less than 0.0001. By conventional criteria, this difference is consideredto be extremely statistically significant.

Confidence interval:

Themean of Pain abdomen before treatment minus Pain abdomen after treatment equals 6.95.95% confidence interval of this difference: From 5.42 to 8.48

Table-VIII: Effect of treatment on Nausea [N=39]

Mean Grade Score S.D Standard Error t PB.T A.T BT-AT B.T A.T of Difference

(SE)

5.00 3.08 1.92 ± 0.00 ± 2.46 0.395 4.8734 <0.0001

Confidence interval:

Themean of Nausea before treatment minus Nausea after treatment equals 1.9295% confidence interval of this difference: From 1.12 to 2.72

1 lie-IX: Effect of treatment on Vomiting [N=38]

Mean Grade Score S.D Standard Error t PB.T A.T BT-AT B.T A.T of Difference

(SE)

5.00 1.05 3.95 ± 0.00 ± 2.07 0.335 1l.779 <0.0001

Confidence interval:

Themean of Vomiting before treatment minus Vomiting after treatment equals 3.9595% confidence interval of this difference: From 3.27 to·4.63.

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GK Swamy et at.

Table-X: Effect of treatment on Burning sensation in abdomen [N=41]

Mean Grade Score S.D Standard Error t PB.T A.T BT-AT B.T A.T of Difference

(SE)

7.56 2.44 5.12 ± 3.56 ± 2.53 0.565 9.058 <0.0001

Confidence interval:

The mean of Burning sensation in Abdomen BT minus Burning sensation in abdomenequals 5.12. 95% confidence interval of this difference: From 3.98 to 6.26.

Table-XI: Effect of treatment on Acid eructation [N=41]

Mean Grade Score S.D Standard Error t PB.T A.T BT-AT B.T A.T of Difference

(SE)

6.83 1.22 5.61 ± 2.44 ± 2.17 0.468 11.977 <0.0001

Confidence interval:

The mean of Acid eructation BT minus Acid Eructation AT equals 5.61.95% confidence interval of this difference: From 4.66 to 6.56

Table-XII: Effect of treatment on Flatulence [N=38J

Mean Grade Score S.D Standard Error t PB.T A.T BT-AT B.T A.T of Difference

(SE)

5.00 2.89 2.11 ± 0.00 ± 2.50 0.406 5.1874 <0.0001

Confidence interval:

The mean of Flatulence BT minus Flatulence AT equals 2.1195% confidence interval of this difference: From 1.28 to 2.93

Table-XIII: Effect of treatment on Indigestion [N=41]

Mean Grade Score S.D Standard Error t PB.T A.T BT-AT B.T A.T of Difference

(SE)

5.00 3.41 1.59 ± 0.00 ± 2.36 0.368 4.3095 <0.0001

A Study on Amashaya Sodhana .

Confidence interval:

Themean of Indigestion BT minus Indigestion AT equals 1.5995%confidence interval of this difference: From 0.84 to 2.33

Table-XIV:Effect of treatment on Constipation [N=31]

Mean Grade Score S.D Standard Error t PB.T A.T BT-AT B.T A.T of Difference

(SE)

5.00 3.71 1.29 ± 0.00 ±2.22 0.399 3.2303 Equals to 0.0030

Interpretation of the result:-

Thetwo-tailed P value equals 0.0030By conventional criteria, this difference is considered to be very statistically significant.

Confidence interval:

Themean of Constipation BT minus Constipation AT equals 1.2995%confidence interval of this difference: From 0.4 7 to 2.11

Table-XV:Effect of treatment on Tenderness in epigastrium [N=41]

Mean Grade Score S.D Standard Error t 1 PB.T A.T BT-AT B.T A.T of Difference

(SE) -e

7.44 2.56 4.88 ± 3.56 ± 2.98 0.641 7.6070 <0.0001

Interpretation of the result:-

Thetwo-tailed P value is less than 0.0001By conventional criteria, this difference is considered to be extremely statistically significant.

Confidence interval:

Themean of Tenderness in epigastrium BT minus Tenderness in Epigastrium AT equals 4.88.95%confidence interval of this difference: From 3.58 to 6.17

Table-XVI:Overall response of the treatment. [N=41]

Mean Grade Score S.D Standard Error t PB.T A.T BT-AT B.T A.T of Difference

(SE)

54.76 22.20 32.56 ± 14.70 ± 10.49 2.237 14.556 <0.0001

39

AGK Swamy et af.

Interpretation of the result:

The two-tailed P value is less than 0.0001 ttBy conventional criteria, this difference is considered to be extremely statistically significant. PConfidence interval: (

1<

tls(

The mean of Overall BT minus Overall AT equals 32.5695% confidence interval of this difference: From 28.04 to 37.08

B.T- Before Treatmentt - Students paired't' test

A.T. - After TreatmentP - Probability

s(

S.D- Standard Deviation ,i

Table-XVII: Showing F.T.M changes before and after treatment

Drug *Hyper Hyper Hypo Hypo Hyper Hypo Normal Normal Normal TOTAL

to to To to To to to To to

Normal Hypo hyper normal Hyper Hypo Hypo Hyper Normal

Shigrupatra 16 2 I 4 8 3 I 4 2 41

Kashaya 39.02 4.88 2.44 9.76 19.51 7.32 2.44 9.76 4.88 100

Amashaya % % % % % % % % 0/0 %

Sodhana

*Hyper to Normal means before treatment Hydrochloric acid percentage was high and aftertreatment it was Normal reading. Remaining headings can be under stood in the same way.

Discussion

Based on Parinamasula symptoms of Ayurvedic literature, the disease can be consideredas Duodenal ulcer of Modern Medicine. Shigru Patra Kashaya Amasaya Sodhana (Gastriclavage with decoction of bark of Moringa oleifera), a special procedure was studied on41 Duodenal ulcer patients to evaluate the effect. By the treatment overall 59.46 % reliefwas observed in all clinical findings. Statistically the effect on all clinical findings exceptconstipation (equals 0.0030) was found highly significant (P< 0.0001). In FTM study asignificant improvement was also observed.

This effect can be supported by the pharmacological activities of Shigru like Vedanasthapan (Analgesic), Sothahar (Anti inflammatory), Vranahar (Wound healing). ThoughAmashaya sodhana is considered as a sort of Vamana karma or a type of Sodhana procedure,the patient need not take any type of rest or there is no need of Hospitalization before or afterthe procedure. Many patients expressed a sense of well being and comfort immediately after

40

A Study on Amashaya Sodhana .

the first Amashaya Sodhana. This sort of confidence turned them to complete 5 Amashayasodhanas and 2 FTM studies. Many new inventions with little changes made to old ancienttraditional wisdom and time tested procedures are found successful and suitable to present era.Amashaya sodhana with medicated decoctions is one among them.ConclusionKeeping in view the overall results of the present study it can be concluded that Amashayasodhana with Shigru Patra Kashaya is effective for the management of Parinama sula(Duodenal ulcer). During the study period no untoward effect was observed and treatment waswelltolerated by all the patients. Further research in this aspect can provide more benefits inAcidpeptic diseases as a whole and Parinamasula (Duodenal ulcer) patients in particular.

AcknowledgementsAuthors are thankful to Director General, C.C.R.A.S., New Delhi, for providing necessaryfacilities and also for the investigating team who involved in completion of this study.

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Chowkhamba Sanskrit Sansthan; 1981.6. Anonymous.Sahasra yoga, Telugu Subhodini Vyakhya by Shastri Koteswarara

Vempati, I" ed. Vijayawada:Andhrayurveda Parishad; 1961.7. Singh RH. Ayurvediya NidanaxChikitsa Ke Siddhanta, Vol-II. 2nd ed. Varanasi:

Chowkhamba Sanskrit Series; 1991.8. Sharma PC, Yelna MB, Dennis TJ. Database on Medicinal plants used in Ayurveda,

Vol. I, II &III. Central Council for Research in Ayurveda and Siddha: 2001.9. Sharma PY. Dravyaguna vignanam, Part II & III. 2nd ed. Chowkhamba Sanskrit

series; 1969.10. Dixom MF, Genta RM, Yerdley JH. Classification and grading of gastritis. International

Workshop on Histopathology of Gastritis. Houston. 1994.11. Dore MP, Leandro G. Gastroenterology on Helicobacter Pylori Therapy. Mediline

News. 2000.

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