Ayurveda management of a patient having bronchial asthma and hemorrhoids- A case report

Abstract

Ayurveda is a holistic science that treats root cause of diseases. One disease can become a causative factor for another disease. This concept is fundamentally described as Nidanarthakar Vyadhi in Ayurveda. In the same way, treating causative diseases is helpful in managing another diseases. However, many published clinical trials on Ayurveda management of Bronchial asthma and Hemorrhoids exist. There is a dearth of published case reports or clinical trials showing an association between Arsha (hemorrhoids) and Shwasa (bronchial asthma). This case report gives important viewpoints about the role of hemorrhoids and its treatment in pathogenesis and treatment of bronchial asthma.

This case report of a 38-year-old female patient known case of bronchial asthma who came to the OPD of Kayachikitsa Government Ayurved College and Hospital, Nagpur with complaints of cough with sputum, breathlessness, chest pain (on/off) for three years. The severity of these symptoms increased for three months. The patient was treated with conventional Shwasghna Chikitsa (treatment of bronchial asthma) for five days, but the response was unsatisfactory. After five days of Shwasghna treatment, the patient gave a history of hemorrhoids. Considering Nidanarthakar Roga (one disease can cause of another disease), treatment was planned. The treatment principle is the treatment of causative disease (Arsha). Hence, Arshoghna treatment was added. Significant increases in peak expiratory flow rate (PEFR), Sustained minimal inspiration (SMI), and Modified Medical Research Council Dyspnoea scale (mMRC) were observed. The respiratory rate was also reduced from 28/min to 18/min. Improvement in the subjective and objective parameters of the patient was observed.

The inclusion of Arsha treatment can be helpful in the management of Tamakshwas (Bronchial Asthma). The need for further research in this direction is warranted.

1. Introduction

Nidanarthakar Roga is a basic fundamental concept in Ayurveda.[1] It is a primary disease or condition that serves as the etiology for another disease and continues to exist in its original form. Nidanarthakar Roga is important in the selection of treatment of disease. It is a condition in which primary disease is a causative factor for other disease. A disease can become an etiological factor of another disease. In such cases, treating causative diseases can be useful in managing the disease. For example, Jwar is a causative factor of Raktapitta Vice versa. Hence, Jwar treatment is useful in Raktapitta.

Bronchial asthma is a chronic inflammation of the lower respiratory tract. It can be correlated with Tamakshwas. [2] Hemorrhoids damage to submucosal vascular tissue of the anal canal, and it is compared with Arsha (Hemorrhoids-vitiated Dosha affecting the skin, flesh, fat and causing sprout–like growths of flesh in various patterns in the anal region) [3]. Arsha is included in Mahagada (disease difficult to treat) [4]. Shwasa and Shushka Arsha both have a predominance of Kapha Vata Dosha [5,6].

Arsha causes Udavarta (disorders of reversed or altered visceral movement) [5]. Udavarta is a causative factor for Shwasa (dyspnoea) [4]. In Udavarta, there is Pratiloma Gati (Upward movement of eructation's or Vata) of Apana Vayu (A subtype of Vata Dosha seated in the pelvic region and its vicinity. It exerts a downward force. It controls functions like defecation, micturition, parturition, menstruation and ejaculation) in Pakwashaya (large intestine-primary functional area of Vata Dosha) [7]. In Tamakshwasa, there is also Pratiloma Gati of Vayu [4]. Udavarta and Shwasa are the Upadrava of Arsha. [5] Shwasa is an Amashaysamudbhava. [8].

2. Patient information

A 38-year-old female patient with a known case of bronchial asthma came to the OPD of Kayachikitsa with the complaints of cough with sputum, breathlessness, chest pain (on/off) for three years. Increase in the severity of these symptoms for three months. Initially, she was treated by a conventional medicine physician for six months, but the patient did not get complete relief. She discontinued modern medicine treatment. When symptoms aggravated in the last three months, she was admitted to the IPD of Kayachikitsa GACH Nagpur. The patient used to take tab Deriphyline 400 mg occasionally by her own, but she did not take the medicine for the last six months. The patient had a known case of hemorrhoids for 15 years, but she gave a history of hemorrhoids on the 5th day of treatment. For hemorrhoids, she took Ayurvedic medicine for up to 1 year. After that, she discontinued treatment as relief in symptoms occurred.

3. Examination

In local clinical examination, an external sentinel tag was observed at 12 o’clock position. No secretion was observed at this site. It was Shushka Arsha with a predominance of Vatkapha Dosha.. Ashtavidha, Dashavidha Parikshan, and a general and systemic examination of a patient mentioned in Fig. 2.

Fig. 2.

Patient assessment during treatment.

3.1. Strotas Parikshan

It was observed that Pranvaha (channels in the body which originate from the heart and carry and circulate vital life (Prana) throughout the body), Annavaha (the pathway for the food in the process of the digestion), Rasavaha (Channels carrying nutrient fluids. The pathway mediates and distributes the primary circulating nutrients and fluids to the body tissues. Entitles related to this channel are the heart and vessels carrying primary circulating nutrient fluids), Medovaha (channels carrying fat. Entitles related to these channels are Kidneys and omentum), Purishvaha (channels in which faeces is formed and excreted. Entitles related to these channels are large intestine and rectum) were disturbed

3.2. Investigation

All blood tests and urine tests were within normal limits. ECG findings within normal limits. Pulmonary function test shows bronchial asthma, moderate obstruction with good reversibility. Investigations reports are attached with supplementary material. Details of investigations with dates are given in Table no 1.

3.3. Clinical findings

The patient presented with clinical symptoms of cough with sputum, breathlessness, chest pain, and these symptoms aggravated during night. Breathlessness is assessed by the mMRC [9](modified medical research council) dyspnoea scale, which was very high, which is mentioned in graph 1 (Fig. 1).

Fig. 1.

Shows Ashtavidha, Dashavidha Parikshan, and a general and systemic examination of a patient.

3.4. Diagnostic assessment

The patient was a known case of bronchial asthma. The assessment was done based on clinical findings, measurement of peak expiratory flow rate (PEFR) (Fig. 1-Graph 2), sustained minimal inspiration(SMI), inspiration time, expiration time, and breathe holding time mentioned in Graph 3. mMRC dyspnoea is used in respiratory diseases to assess the degree of baseline functional disability due to dyspnoea. mMRC dyspnoea scale includes 5 questions along with gradation [10].

3.5. Therapeutic intervention

Considering an Alpa Bala of patient, Shwasghna Shaman Chikitsa (conservative therapy – that aims to mitigate the diseases by pacifying Dosha) was planned. Formulations indicated for Shwasa treatment in classical Ayurveda text were used. Up to 5 days of treatment; There was no improvement in clinical symptoms. After five days of Shwasaghna treatment, the patient gave history of hemorrhoids; after that, treatment was planned considering Nidanarthkar Roga (∼one cause for many diseases). In such cases, the treatment principle is the treatment of causative disease. Hence, we added Arshoghna Chikitsa. Aushadha (medicine), Kshara, Shastra (Surgery), Agnikarma (cautery) are used sequentially in management of Arsha. The treatment principle is Anuloman and increasing the Agni Bala (∼digestive, metabolic factor) [11]. Treatment was planned to consider Vatkapha Dosha, specifically Vitiation of Apana Vayu, Dushta Mansa treatment was planned.

After that, Arshoghna Chikitsa was added and mentioned in Table 1. Anuwasan Basti (Therapeutic oil enema) of Jatyadi Tail was used for 8 days. Basti (Therapeutic enema) of Dashmularishta was given immediately when we observed a sudden increase in symptoms. Arishta Kalpana mitigates Kapha (one of the three regulatory functional factors responsible for stability, unctuousness, lubrication, immunity and cohesion) and Vata Dosha (Regulating movement and cognition). Also acts as a laxative, does not work against Pitta Dosha and is useful in chronic hemorrhoids [12]. 500ml luke-warm Dashamularishta Basti was given; prepared by adding 100ml of Dashmularishta in 400ml of hot water. Basti was administered on an empty stomach (considering Niruha Basti). Basti retention time was 15 minutes. Duration of the course of treatment, along with important events, is summarized in the timeline.

Table 1.

Showing treatment plan.

Date	Treatment plan	Anupana And Kal
13/11/2019 To 17/11/2019	1.Shwaskuthar Rasa 150 mg TDS	After meals with honey
	2. Sitopaladi Churna 5 gm
	Yashtimadhu Churna 3 gm
	Pippalimul Churna 1 gm	Continuous with Aadrak Swaras
	Sunthi Churna 1 gm
	Anantmul Churna 1 gm
18/11/2019 To 19/11/2019	1,2 continues
	3. Kanakasav 10 ml BD	After meals with 200 ml lukewarm water
20/11/2019	1.Talisadi Churna 2 gm	After meals with honey
	Yashtimadhu Churna 2 gm
	Tankan Bhasma 250 mg
	Pippali Churna 1 gm
	Ashwagandha Churna 2 gm
	2.Nagguti 250 mg	Before meals with lukewarm water
	3.Aamlaki Churna 2 gm	Before meals with lukewarm water
	Sunthi Churna 3 gm
	4. Triphala Guggul 250 mg BD	Before meals with lukewarm water
	5.Abhayarishta 10 ml
21/11/2019	Hold 1,2,3,4
	1.Abhayarishta 10 ml	After meals with lukewarm water
	2. Dashmularishta 10 l	Before meals with 200 ml lukewarm water
	3.Kravyad Rasa 250 mg	After meals with Haritaki phant 100 ml
22/11/2019 To 24/11/2019	Treatment continues	Kanakasav was added with distilled water in a ratio of Kanakasav: Distilled water- 1:2 & then filtered through filter paper.
	7..Nebulization with Kanakasav BD
25/11/2019	1,2,3,4,5,6,7 continues	After meals
	Dashmul Haritaki Avaleha 10 gm
26/11/2019 To 6/12/2019	1.Dashmularishta 10 ml	Before meals with 100 ml lukewarm water +10 ml Goghrut
	2.Kravyad Rasa 250 mg	Along with meals with lukewarm water
	3. Dashmul Haritaki Avaleha 10 gm	After meals With Abhayarishta 10 ml + 100 ml hot water
7/12/2019 To 17/12/2019	1,2,3,4 continues
	5. Arshkuthar Rasa 250 mg	Before meals with lukewarm water
18/12/2019 To 26/12/2019	1.Sudarshan Churna 5 gm TDS	After meals with lukewarm water
	2.Kravyad Rasa 250 mg	Along with meals with Triphala Ghrut 5 ml
	Arogyavardhini Vati 250 mg
	3. Dashmul Haritaki Avaleha 10 gm	After meals with lukewarm water
	4. Sunthi Churna 5 gm TDS	After meals.

3.6. Follow up and outcome

During treatment, symptoms were not relieved in the initial five days. The patient had symptoms of Udavarta, such as constipation on/off and excessive belching; these symptoms subsided after the addition of Arshoghna treatment. After the addition of treatment for Arsha, a significant increase in PEFR, SMI, mMRC scale was found, which are mentioned in graph 1, 2, and 3 (Fig. 1), respectively. The respiratory rate was 28/min, which reduced to 18/min.

4. Discussion

Disturbance in the functioning of Agni (metabolic power) causes the formation of Aamdosha (∼state of incomplete digestion, transformation or metabolism). This leads to the vitiation of Amashaya (∼viscera between umbilicus and nebel), which is the seat of Annawaha Strotas [13]. Arsha is caused by the vitiation of all three Dosha (Vata, Pitta, Kapha), mainly Apana Vayu. [5] Excretion is a function of Apana Vayu. Disturbed Apana Vayu and Amashaya (stomach-primary functional area of Kapha and Pitta) Dushti leads to Udavarta [7]. This Udavarta leads into Shwasa [4]. Nidanarthakar Roga means a disease that has become the cause of another disease. In this case study, Arsha (hemorrhoids have become the cause of asthma). Arsha can be cause of many diseases [14]; so from this, it can be said Arsha is a causative factor for Udavarta and Shwasa.

Guda (∼Anus) is a Karmendriya. [15] Its functioning is regulated by Prana (Vata Dosha that provides attributes of life to an organism. It regulates respiration, sneezing, belching, and swallowing) and Apana Vayu. In Udavarta, Prana and Apana Vayu are vitiated. This leads to Mahastrotas (∼central inner cavity of the body from mouth to the anus comprises both stomach and large intestine) Dushti [16], which is site of Pranavaha Strotas.

Pran Vayu's site is at the uppermost part of Mahastrotas, and Apan Vayu's site is at the lower part [17]. Vitiated Apan Vayu, Kapha, Pitta, and Dushta Mansa cause Arsha at the lower part of Mahastrotas [5]. Chronic Arsha leads to Pratiloma gati of Vayu and Amashay (Stomach-primary functional area of Kapha and Pitta) Dushti result into Tamakshwasa [8]. This shows the relationship between the lungs and the large intestine. In this case, Arsha is Hetu for Tamakshwas as it originated from Amashaya. Arsha and Shwas are diseases of Abhyantar Marga [18]. Prana Vayu is responsible for the maintenance of Jatharagni [19] Impairment of Jathragni results in Tamakshwas and Arsha.

Hemorrhoids may trigger systemic inflammation and release of various cytokines that increase bronchial sensitivity and inflammation, leading to acute asthma condition. Mast cells play a important role in the pathogenesis of lung disease by an innate and adaptive immune response to the antigen [20]. Studies suggest that several mast cells are also affected in hemorrhoidal conditions. Hence, proper Ayurvedic treatment of hemorrhoids can lead to a decrease in mast cells and, thereby reduction in acute asthmatic attacks [21]. Different case report have shown that Ayurveda treatment can modulate the immune response through its action on the gut [22]. Per rectal administration of Ayurveda medicine, it can act on respiratory system through the gut-lung axis [23]. Some published articles on the concept of Vyadhisankar (cluster of two or more diseases) and Nidanarthkar Roga (a disease itself a cause for another diseases) [24].

Considering the concept of Nidanarthkar Roga, the treatment principle is treating the original disease. There are so many Ayurvedic clinical trials on bronchial asthma and hemorrhoids [[25], [26]]. But we can not find any published Ayurvedic case report or clinical trial showing the relationship between Tamakshwas and Arsha regarding clinical management.

Result: A significant increase in PEFR, SMI, and mMRC scale was found. The respiratory rate also reduced from 28/min to 18/min.

5. Conclusion

Ayurveda management of Arsha is useful as an add-on treatment for patients having Tamakshwas with Arsha. This case report gives future direction for various studies that impact the management of Arsha in Bronchial asthma and improves patient outcome.

Patient perspective

Initially, patient was uncomfortable when symptoms worsened by Shwasghna Chikitsa. After the addition of treatment for Arsha, she experienced relief in symptoms and got complete relief in two month treatment. The patient was satisfied as no symptoms of Tamakshwas occurred after the treatment. She has also given her consent for the publication of this case report.

Source of funding

Nil

Author Contribution

Conceptualization and Treatment Plan – AN. Rough Draft and Ayurveda formulation preparation – PK, AN.Critical Editing of Draft – PK, AN.Data Collection – PK, AN. Data Presentation – PK, AN.

Declaration of competing interest

Nil.

Declaration about use of Generative AI: Authors declare that they have used generative AI Grammarly for language editing and improvement.

Appendix A. Supplementary data

The following is the Supplementary data to this article: