Basti treatment improved faecal calprotectin and faecal elastase of a patient of inflammatory bowel disease with sarcoidosis - a case report

Abstract

Inflammatory Bowel Disease (IBD) and sarcoidosis are both chronic inflammatory disorders which in some rare instance can co-exist. The treatment with conventional medicines such as sulfasalazine, mesalamine, and steroids is challenge to patients and may not alleviate the disease completely. Ayurvedic treatments in this regard are often revolutionary and help in compressive management of all symptoms. We present a report of a 40-year-old male with IBD, diagnosed with sarcoidosis having abdominal pain, diarrhoea, and significant weight loss. Dadimadi Ghrita, Matra Basti and modified Piccha Basti were the line of treatment aimed at treating gastrointestinal inflammation and restoring normal bowel functions. The treatments improved the imbalance of Vata and Pitta doshas, that can effectively treat Pittadhik Vata Grahani. The effects of treatment was analysed by stool examination, weight gain and biomarkers useful to assess gastrointestinal health and disease (faecal calprotectin and faecal elastase).

1. Introduction

Sarcoidosis and Inflammatory Bowel Disease (IBD) are two chronic inflammatory diseases that impact different organ systems. While sarcoidosis is a systemic illness characterized by non-caseating granulomas that frequently affect the lungs and lymph nodes, IBD typically affects the gastrointestinal (GI) tract and often, IBD includes Crohn's disease (CD) and ulcerative colitis (UC). There is some evidence of an association between both conditions despite their different clinical manifestations [1]. Patients with sarcoidosis also have a noteworthy but relatively low prevalence of IBD, suggesting a possible correlation between the two conditions. Research indicates that compared to the general population, people with sarcoidosis have a 1-2-fold greater prevalence of IBD. This raises the possibility that the immune-mediated processes underlying both disorders are similar [2].

IBD is frequently treated with anti-inflammatory drugs such as Sulfasalazine (SAAZ) and Mesalamine (Mesacol), which are typically used in cases with mild to moderate symptoms. Despite its efficacy in many patients, there is a significant failure rate in which patients do not achieve remission or sustain disease control. Evidence shows that as many as 30–40 % of patients may not benefit enough from these medicines [3]. This might require the patient to move to a stronger medications like corticosteroids or biologics or alternative therapies.

Digestive system diseases affecting the small intestine, are linked to inflammatory bowel disease or IBD-like symptoms. The symptoms of inflammatory bowel disease resemble the description of Grahani Roga in ayurvedic texts. Abdominal pain, diarrhoea, and weight loss are typical symptoms of Grahani Roga. The other classical markers include malabsorption, discomfort in the digestive tract, and irregular bowel movements which are considered manifestations of an imbalance in the digestive fire (Agni) and an increase in the doshas, particularly Pitta and Vata [4]. The suggested approach of Ayurveda in treating Grahani Roga is by addressing underlying digestive imbalances. Matra Basti(enema) with Dadimadi Ghrita (medicated ghee prepared of Punica granatum) is one of the suggested treatments for this. Its anti-inflammatory, digestive, and rejuvenating qualities are thought to be responsible for its efficacy; they aid in the restoration of digestive function and the reduction of IBD symptoms [5]. By lowering inflammation and regaining function, Pichha Basti, a medicated enema, seeks to detoxify and revitalize the gastrointestinal system. These treatments in combination provide a comprehensive approach to treating IBD symptoms by restoring digestive fire (Agni) and balancing doshas, two fundamental Ayurvedic principles [[4], [5], [6]].

We treated a case of IBD with preexisting sarcoidosis resistant to conventional treatment with the holistic approach of Ayurveda. In this report we describe our success in the treatment in this rarely cooccurring diseases resulting in symptomatic cure and restoring normal faecal calprotectin and faecal elastase levels. Gut dysbiosis plays major role in the pathogenesis of IBD [7]. Toll-like receptors (TLRs) act as possible targets for therapeutic intervention of inflammatory diseases. [8]. Dadimadi Ghrita Matra Basti and modified Pichha Basti may have a possible role in addressing gut dysbiosis by restoring the said digestive imbalances in IBD.

2. Case report

2.1. Patient details

A 40-year-old male patient reported at the outpatient department (OPD) of the Panchakarma Department at Dr. BRKR Government Ayurvedic Medical College in Hyderabad. He had been experiencing symptoms including coughing, bloating, severe weight loss, blood in his stool, diarrhoea, and difficulty passing stool for past 1 year. He followed a vegetarian diet. Significant medical conditions including diabetes mellitus and hypertension have not been present in the past. According to patient he was working as an employee in a private company and was operating in different shifts due to which his food habits were untimely with inclusion of spicy food items According to Ayurveda, Ratrijagaran (late night work) and spicy food habits (Amla, Lavana, Katu, Vidahi Aahara) are the causes for vitiation of Vata and Pitta which led to Grahani.

2.2. Timeline

The following Table (1) lists the related prior symptoms, investigations, and interventions in chronological order up until the patient's report to the panchakarma department at Dr. BRKR Government Ayurvedic Medical College in Hyderabad.

Table 1.

Timeline of the case.

Period	Clinical events and intervention
Since March 2022	Cough, fatigue, weight loss, loss of appetite
Since August 2022	Lower abdomen pain and increased frequency of loose stools
21-8- 2022 and 5-9-2022	PET-CT, colonoscopy, biopsy- diagnosed as IBD
September 2022 to january 2023	Sulfasalazine and mesalanamine for 16 weeks- discontinue due to no improvement in GI symptoms
24-4- 2023 and 5-5-2023	CT, colonoscopy, biopsy- diagnoised as IBD with sarcoidosis
June 2023	Treatment with immunosuppressants for I month and stopped treatment owing to severe GI discomfort
14-8-2023	Patient visit to ayurvedic hospital in view of alternate treatment options
15-8-2023 to 13-09- 2023	Ayurvedic management (Dadimadi ghrita matra basti for 15 days and modified piccha basti for 15 days)
15-10-2023	Symptomatic relief and faecal calprotectin and faecal elastase assessment
16-10-2023 to 16-1-2024	On prophylaxis by using kutaja Ghana vati, bilwadi vati, musta arista
16-2-2024	One month after completion of therapy

3. Clinical findings

His past medical records showed that the patient was diagnosed IBD following a positron emission tomography-computed tomography (PET-CT) scan and colonoscopy aided biopsy. The patient was previously treated with anti-inflammatory drugs such as Sulfasalazine (16 weeks) and Mesalamine (6 weeks) but his GI symptoms nor his weight improved and the patient discontinued the treatment.

Over time, the patient developed lower abdominal pain, decreased urine output, and a higher frequency of loose stools (8–10 per day). Investigations were repeated including CT, colonoscopy, biopsy, enteroscopy and biopsy along with liver function test (LFT), faecal elastase and faecal calprotectin. The diagnosis was confirmed as sarcoidosis and the treatment regimen was then changed to immunosuppressant (Mycophenolate sodium) and steroid (Wysolone) considering the GI symptoms were manifestation of sarcoidosis. The symptoms of the patient did not improve after modifying the treatment regimen post which the patient reported Ayurvedic treatment.

3.1. Physical examination

Pain and tenderness were noticed in the lower abdomen during a gastrointestinal examination. There were no signs of aberrant cardiovascular, or nervous system function.

4. Diagnostic assessment

A combination of clinical evaluation, lab testing, imaging studies, and endoscopic procedures are usually included in this assessment that are listed in Table 2. Endoscopy, particularly colonoscopy with biopsy, is essential for directly seeing the mucosal surface of the colon and acquiring tissue samples to confirm the diagnosis histologically. Together, these diagnostic tools provide a full assessment of the disease's severity, extent, and activity, guiding the patient's suitable treatment methods (see Table 3).

Table 2.

Chronological order of prior symptoms, investigations, and interventions.

Sl.no	Symptom/Investigation/Intervention	Duration
1	Cough, fatigue, weight loss, loss of appetite	1 year
2	Investigations including PET-CT, colonoscopy, biopsy	7–14 days
3	Diagnosis as IBD	–
4	Treated with anti-inflammatory Sulfasalazine (1000 mg, thrice a day)	16 weeks
	Mesalamine (800 mg, thrice a day)	6 weeks
5	Treatment discontinued due to severe GI disturbance	2 weeks
6	Developed lower abdominal pain, decreased urine output, and a higher frequency of loose stools (8–10 per day)	6 months
7	Investigations repeated (CT, colonoscopy, biopsy, LFT, faecal elastase, faecal calprotectin)	7–14 days
8	Diagnosed sarcoidosis with IBD	–
9	Treatment with steroids (wysolone 20 mg, once a day) and immunosuppressant (mycophenolate sodium 360 mg, twice a day)	4 weeks

Table 3.

Diagnostic assessment.

Investigation/Examination	Signs and Symptoms/Findings	Interpretation
Physical examination	Pain and tenderness were noticed in the lower abdomen during a gastrointestinal examination. A visual analogue scale (VAS) pain intensity levels shows moderate pain. Bristol stool form scale showed Type7- liquid consistency with no solid pieces (severe diarrhoea)	Pittadhik Vata Grahani
Abdomen computed tomography	Distal jejunal and proximal ileal loops showed discontinuous segments of circumferential smooth increase in wall thickness with post contrast hyper enhancement, narrowed lumen and adjacent mesenteric fat stranding	Suggestive of infla mmation
Colonoscopy and biopsy of polyp	1cm sigmoid colon polyp at sigmoid colon	Inflammatory polyp upon biopsy
Enteroscopy	Enteroscopy passed up to proximal ileum showed dilated small bowels with increased friability and no ulcerations with inflammatory areas near ileum. Random small bowel biopsies done and sent for histopathology report	Suggestive of inflammation
Random Biopsies of small bowel (Histopathology)	Sections shows that villi are lined by enterocytes and goblet cells. Lamina propria is edematous with moderate inflammation composed of lymphocytes, plasma cells, eosinophils(10–12/hpf) focally	Suggestive of inflammation
Liver function test (LFT)	Serum glutamic-pyruvic transaminase (SGPT) – 130 U/L (normal range: 7–56 U/L)	Mild transaminitis (Hepatic involvement of sarcoidosis ?)
	Antinuclear antibody (ANA) – 1:35 (Normal range: Titres <1:40)	Normal
Stool test	Faecal elastase −110 μg/g (normal range: >200 μg/g)	Mild pancreatic insufficiency
	Faecal calprotectin – 132 mg/kg (normal range: <50 mg/kg)	Mild intestinal inflammation

5. Therapeutic intervention

The rationale for treating IBD with Matra Basti and Modified Pichha Basti is they offer an effective approach that addresses IBD's inflammation and vata imbalance. Matra Basti is a mild oil enema that can be used for an extended period of time since it effectively soothes the colon, reduces inflammation, and improves gut motility without having a severe purgative impact. It relieves symptoms including cramps and diarrhoea while restoring the integrity of the mucosa. With its astringent and anti-inflammatory herbs, Modified Piccha Basti having Yasthimadhu (Glycyrrhiza glabra Linn.) and Mocharasa (Resin of Salmalia malabarica Schott & Endl.) preserves the walls of the intestines, minimizing irritation and managing symptoms like diarrhoea and rectal bleeding [9,11].

Ayurvedic formulations such as Kutaja, Bilwadi Vati, and Mustaarista are useful in the prevention of remission of IBD. Kutaja lowers inflammation and stops IBD flare-ups by stabilizing the intestinal mucosa [10]. Bilwadi Vati has anti-inflammatory and digestive properties; Mustaarista balances digestive fire (Agni) and doshas, promoting remission through its antispasmodic and digestive effects [9,11]. Collectively, these formulations tackle essential pathogenic processes in inflammatory bowel disease (IBD), including inflammation, dysbiosis, and reduced mucosal integrity. As such, they are useful as prophylactic regimen for achieving sustained remission.

6. Treatment outcome and follow-up

The patient's symptoms considerably improved with the treatment (see Table 4). In addition to the elimination of pain and discomfort in the abdomen during defecation, the frequency of bowel movements decreased from 8 to 10 times per day to 1–2 times per day. On the Bristol Stool Form Scale, there was a noticeable increase in weight from 52 kgs to 65 kgs and a change in stool consistency from liquid (Dravam) to well-formed solid (Samhata pureesha), as shown by a move from Type 7 to Type 3. The level of faecal elastase rose from 110μg/g to 210μg/g, indicating better pancreatic function. Faecal calprotectin reduced from 132mg/kg to 42mg/kg. These results in Table 5 suggest a successful therapeutic outcome with notable reduction in symptoms and restoration of normal bowel function.

Table 4.

Ayurveda treatment protocol.

Sl. No	Treatment Duration	Type of Vasti/Form	Composition & Dosage
1	Day 1–15 (15 days)	Matra Basti As oil enema, given75ml daily in the morning after food for 15 consecutive days	Dadimadi ghrita-75ml (Pomegranate medicated ghee)
2	Day 6–30 (15 days)	Modified Piccha Basti as decoction enema given343ml daily before food in the morning for 15 consecutive days followed by soup of goat meat with rice as diet	Makshika - 25 ml (Honey) Saindhava - 3 g (Rock salt) Dadimadi Ghrita - 40 ml (Pomegranate medicated ghee) Kalka - 25 g (Herbal Paste) [ Yastimadhu (Glycyrrhiza glabra) - 3 g Lodhra (Symplocos racemosa) - 3 g Rasanjana (Berberis aristata) - 3 g Mocharasa (Salmalia malabarica) - 3 g Manjishta (Rubia cordifolia) - 3 g Nagakesara (Mesua ferrea) - 3 g Satapushpa (Anethum graveolens) - 3 g ] Shalmali Kwatha (Bombax malabaricum) - 125 mlMilk- 125ml Total dose-343ml
3	Prophylactic intervention Day 30–120 (90 days)	Kutaja ghana vati Dose- 1 tablet of dose500mg orally twice a day after food with water	48 g Kutaja bark – Holarrhena antidysenterica (connessi bark) 12 g Ativisha – Aconitum heterophyllum (root powder)
		Bilwadi vati Dose- I tablet of dose500mg orally twice a day after food with water	Bilva (Aegle marmelos) - 20 % Shunthi (Zingiber officinale) - 15 % Pippali (Piper longum) - 15 % Dhaniya (Coriandrum sativum) - 10 % Nagarmotha (Cyperus rotundus) - 10 % Mustaka (Cyperus rotundus) - 10 % Dhataki (Woodfordia fruticosa) - 10 % Vasa (Adhatoda vasica) - 5 % Shatavari (Asparagus racemosus) - 5 %
		Mustaarista Dose-15ml of medicine diluted with30ml of water and taken orally twice a day after food	Musta (Cyperus rotundus) - 48 g Parpataka (Fumaria indica) - 48 g Usheera (Vetiveria zizanioides) - 48 g Dhataki (Woodfordia fruticosa) - 48 g Gokshura (Tribulus terrestris) - 48 g Saindhava Lavana (Rock Salt) - 12 g

Table 5.

Follow-up investigations for outcome assessment.

Investigation	Pre- Intervention	Post-Intervention
Pain/Abdominal discomfort	Mild to moderate during defecation	No pain
Frequency of bowel movements	8-10/Per day	1-2/day
Weight gain	Not considerable (52 kgs)	Considerable (65 kgs)
Dravya mala pravritti	3- Dravam/tanu (Liquid stool)	0- Samhata pureesha (Well-formed solid stool)
Bristol stool form scale	Type7- liquid consistency with no solid pieces (severe diarrhoea)	Type3- a sausage shape with cracks over the surface (normal stool)
Faecal elastase	110 μg/g	210 μg/g
Faecal calprotectin	132mg/kg	42mg/kg

7. Discussion

This case report provides a detailed account of how Dadimadi ghrita matra basti and modified Piccha basti were used effectively to manage a 40-year-old male patient with inflammatory Boweabl Disease (IBD) with known sarcoidosis. The patient's chronic symptoms, such as severe diarrhoea, abdominal pain, and significant weight loss, went unresponded adequately to conventional treatments where in ayurvedic intervention was started. The approach taken in this case was based on grahani, with a focus on managing Pittaja Grahani, which aligns with the patient's symptoms of increased bowel movements, malabsorption, and weakened digestive fire.

In this case, Ayurvedic diagnosis of Grahani Roga was made based on both clinical symptoms and the patient's history, and the classical descriptions in Ayurveda in Table 6. Grahani is characterized by dysfunction of the small intestine, where digestion and absorption are disturbed due to impaired agni (digestive fire) and imbalance in Vata and Pitta doshas. Upon examination, the following Ayurvedic parameters were considered: (i) Nadi pariksha revealed a predominance of Vata, supporting the diagnosis of Vata-related digestive disturbances. (ii) The patient's prakruti was identified as Vata-Pitta, which explained the sensitivity of the digestive system to stressors such as irregular food habits and spicy foods, known in Ayurveda as vidahi aahara, which vitiates both Vata and Pitta. (iii) The involvement of anna vaha srotas was confirmed by symptoms like diarrhoea, bloating, and weight loss. The specific type of sroto dushti was labeled as atipravrutti referring to the excessive and uncontrolled bowel movements.

Table 6.

Symptom similarities between Grahani and IBD.

Type of grahani [12]	Symptoms of grahani [12]	Symptoms of IBD [,[13], [14]]
Vataja grahani [12]	Kanta asaya shosha [12]	Dryness of throat and mouth
	Kshudha	Excessive hunger
	Thrishna	Excessive thirst
	Parshwa ruk	Frequent pain in sides of chest, thighs, pelvic region, pain in cardiac region and neck
	Visuchika	Diarrhoea
Pittaja grahani	Loose stools with undigested material which is bluish yellow In color [12]	Diarrhoea
	Hrit kanta daha	Dryness of throat
	Aruchi	Loss of appetite
	Trishna	Excessive thirst
Kaphaja grahani	Udara gauravam	Heaviness in the abdomen
	Muhurbaddam muhur dravam	Stool mixed with mucous and phlegm

The patient had a history of untimely food intake, inclusion of spicy and heavy food, and irregular work shifts, all of which contributed to the aaharaja nidana and viharaja nidana (lifestyle causes). These factors led to weakening of digestion, resulting in the formation of ama and subsequent sthanasanshraya (localization) of the disease in the digestive tract. Samprapti of grahani in this patient involved the following steps: (i) Nidana sevana such as improper diet and lifestyle which weakened the agni. (ii) The formation of ama which led to dysfunction in pittadhara kala (digestive lining). (iii) This resulted in grahani dushti (impairment of the small intestine), causing improper digestion and absorption, manifesting as diarrhoea and weight loss.

Basti karma, a crucial therapeutic intervention, played a pivotal role in addressing gut dysbiosis. Dadimadi ghrita and pichha basti formulations contain ingredients known for their mucosal healing properties, essential for managing IBD. Following basti therapy, notable improvements were observed in the patient's overall condition, alongside symptomatic relief. Notably, levels of faecal calprotectin returned to within normal range, indicating a positive response to treatment.

The observed reduction in the frequency of bowel movements from 8 to 10 times per day to 1–2 times per day, together with the shift from liquid to solid stools that are well-formed, indicates a noteworthy enhancement in bowel function that is consistent with the literature [15]. The intervention's effectiveness in lowering inflammatory markers is supported by the significant increase in faecal elastase and drop in calprotectin levels, which reflect a decrease in intestinal inflammation. This is in line with research demonstrating that efficient IBD therapies reduce faecal calprotectin levels and enhance clinical results [16].

Although modern medical therapy with anti-rheumatoid drugs is conventionally the first-line option, existing research clearly suggests that drugs like mycophenolate sodium may help a few patients, and that its overall effectiveness in managing IBD is limited and has several possible adverse effects [17]. Steroids are also is not appropriate for long-term maintenance therapy because of adverse effects include weight gain, osteoporosis, hypertension, and an increased risk of infections and likely steroid dependency and decreased efficacy [18].

The current therapy used in line with recent medical literature in Ayurveda. Dadimadi ghrita contains an active ingredient Dadima (Punica granatum), found to have properties as potential inhibitors in ulcerative colitis [19] was considered for Matra basti. Patel MV et al. had elaborated on the role of pitta vata shamana basti, Kutajaghana vati, Musta in successfully treating 43 patients of ulcerative colitis [20]. Likewise, Pooja BA et al. have reported the role of Musta arista in treating a 30-year-old patient to have (diagnosed ulcerative colitis) [21]. Niruha basthi with Balaguduchyadi yoga, combined by Shamana treatment with Rasnerandadi kwatha and Simhanada guggulu have been found effective in curbing the progression of UC [22]. The ingredients of Piccha basti have wound healing properties while Mocharasa (Resin of Salmalia malabarica) acted as Vrana ropaka (∼wound healing) due to its Kashaya rasa and Sheeta virya. There treatemnts were used in a 27-year-old patient with UC who presented with rectal bleeding. These drugs are also group as Shonita sthapaka gana (haemostatics) which are ideal for the cases of UC/IBD with bleeding as a presentation [23]. The probable mode of action of basti in addressing digestive disorder can be summarised in the following ways: Firstly, basti strikes the pakwasaya (main seat of vayu), the very root cause of vata, and further normalizes its function. This can further a hypothesis for reversal of gut dysbiosis. Secondly, the action of basti, may be due to may dimensions: a procedural effect due to uniqueness in the way it is used, a drug effect due direct action of components, a srotsudhi/sodhana effect, and finally a regulating effect on the enteric nervous system or gut brain [24].

The strengths of the case study lie in use of customised formulation for a comprehensive management of IBD case with known sarcoidosis. Appropriately designed clinical trials are indicated to inform clinical guidelines for treatment regimen of IBD alone and when is with other inflammatory conditions.

The intervention (Matra Basti and Modified Piccha Basti) demonstrated significant therapeutic efficacy in managing the patient with Inflammatory Bowel Disease (IBD). The patient experienced significant improvement in symptoms such as abdominal pain, diarrhoea, and weight loss. Biochemical assays revealed a reduction in faecal calprotectin levels, indicating decreased intestinal inflammation, and an increase in faecal elastase levels, suggesting improved pancreatic function. Further treatment of IBD through Ayurvedic intervention can be standardized by good clinical trials with larger sample size.

8. Patient perspective

Following the dosage of Matra Basti with Dadimadi Ghrita and Modified Piccha Basti, the patient reported having regular and effortless patterns of bowel movements. The patient noticed a noticeable improvement in his appetite, frequency of bowel movements, and weight gain. The patient felt extremely satisfied, especially after the Basti.

9. Informed consent

Being a single case study, there is no requirement of an ethical approval committee. Written informed consent from the patient was obtained to publish details of the case.

Author contributions

Ranjith Kumar Kora- conceptualization, methodology, software, validation, Formal analysis, Investigations, resources, Data curation, Writing-original draft, Writing-review and editing, visualization, supervision, Project administration, funding acquisition.

Praveen Kumar Madikonda- methodology, validation, Formal analysis, Investigations, Data curation, Writing-review and editing, visualization, supervision, Project administration,

Bura Johar- Formal analysis, supervision, Project administration.

Declaration of generative AI in scientific writing

The authors declare that they have not used artificial intelligence (AI) tools for writing and editing the manuscript, and no images were manipulated using AI.

Funding sources

This paper did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Conflict of interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.