Restoring gut harmony - Role of Grahani Chikitsa in the management of irritable bowel syndrome - a case report

Abstract

In contemporary society, the prevalence of irregular lifestyles, particularly nocturnal habits, coupled with sub optimal dietary patterns and heightened psychological stress, has significantly contributed to gastrointestinal disturbances. Irritable Bowel Syndrome (IBS), a multi factorial disorder, is often precipitated by stressors such as depression or systemic illnesses. Conversely, IBS itself may serve as a precursor to psychological disorders, underscoring the intricate gut-brain axis interplay. A symptomatic approach to management is insufficient, rather a focus on addressing the underlying pathophysiological mechanisms is imperative for sustained gastrointestinal health and overall well-being. Epidemiological data indicate that IBS affects approximately 12%–15% of the Indian population, with a female predilection, being three times more prevalent in women than men. Ayurveda views Grahani as both an organ and a functional entity, where Grahani Dosha refers to its impaired functioning. If this dysfunction progresses, it leads to Grahani Roga, which is characterized by chronic gastrointestinal symptoms. A comprehensive understanding of Grahani, in its context as an organ, Dosha, and Roga, is necessary to systematically analyze gastrointestinal disturbances. This case study discusses a 25-year-old male with a two-year history of poor appetite, weight loss, nausea, abdominal pain, frequent bowel urges, and alternating episodes of constipation and diarrhea, along with persistent insomnia. A structured treatment protocol was implemented to strengthen the gut-brain axis and manage Grahani Roga through internal and external purification therapies (Antar and Bahir Parimarjana Chikitsa). Over just 10 days, significant improvements were observed in the Rome IV criteria and scales related to IBS and anxiety. The findings highlight that Grahani, which involves altered bowel habits and nutritional deficiencies due to malabsorption, can be classified as a syndrome that results from a complex interaction of various disorders, making it one of the Ashta Mahagada.

1. Introduction

Irritable Bowel Syndrome (IBS) is a persistent condition that can be continuous or episodic, marked by recurrent and unexplained symptoms such as abdominal pain, bloating, and irregular bowel movements. It is regarded as the most prevalent gastrointestinal (GI) disorder in India with an estimated prevalence ranges from 12% to 15%, with women being three times more affected than men [1]. Western research suggests that population-based IBS prevalence typically falls between 10% and 15%. It is widely accepted that IBS is common in both Eastern and Western countries, with no significant difference in prevalence between the regions [2]. By a variety of measures, the median prevalence of IBS in Asia ranges from 6.5% to 10.1%. Although IBS is more prevalent in women overall, this pattern is not exclusive to them. In terms of IBS sub-types, the prevalence of constipation-predominant IBS ranges from 12% to 77%, while the prevalence of diarrhea-predominant IBS varies greatly, ranging from 0.8% to 74.0% [3]. According to the Rome III criteria, irritable bowel syndrome (IBS) is considered a biopsychosocial disorder. This implies that the dysfunction of the bowel is a result of the brain-gut connection, influenced by social, environmental, and psychological factors, with the prevalence rates of depression and anxiety disorder being 37.1% and 31.4%, respectively [3,4].

In this case, notable clinical improvements were observed within the first 10 days of treatment. The patient experienced a significant improvement in appetite, along with normalisation of bowel habits. Remarkably, sleep quality improved from the very first day of intervention, and by the fourth day, the patient was able to sleep without any Bahir Parimarjana Chikitsa or medication. A marked reduction in anxiety symptoms was also noted, indicating a positive impact of Ayurvedic management on both somatic and psychological domains.

Grahani Roga, as described in Ayurveda, shares clinical similarities with Irritable bowel syndrome (IBS). It is considered a result of imbalances in the doshas (bodily humors) and disturbances in multiple physiological systems or srotas. The systems primarily affected include the Annavaha Srotas (digestive tract), Purishavaha Srotas (excretory system), Manovaha Srotas (psychological channels), as well as factors related to Ahara (diet), Vihara (lifestyle), Agni (digestive/metabolic fire), and Kostha (gut environment). These elements interact in a dynamic and interdependent manner, necessitating a holistic system-based approach for understanding and managing the condition. Clinical features commonly observed include altered bowel patterns such as constipation or diarrhea, changes in frequency, and symptoms like abdominal pain, burning sensation, foul-smelling stools, bloating, poor appetite, and general weakness [5].

2. Patient information

A 25-year-old male who is an IT employee, visited the OPD of Kayachikitsa of Sri Jayendra Saraswathi Ayurveda College and Hospital, Nazarathpet, Chennai – 600123. He complained of poor appetite for 2 years along with weight loss of 13 kg in 1 year [from 68kg to 55kg], pain in the abdomen, bloating sensation and nausea after taking a meal. He also complained of sour belching immediately after taking food and no faecal urgency with decreased appetite and difficulty in falling asleep for a year. One week, he complained of mixed bowel movements. His complaints get aggravated after eating food and relieved after food digestion.

2.1. History of present illness

The patient was well before 1 year, he started to work in night shift continuously between the years 2021 and 2022. Because of this, his routine was hampered and at the same time in the year 2021 his grandmother passed away, and which made him disappointed and depressed. Thereafter he lost his interest in eating food and gradually his appetite got diminished and he suffered from difficulty to sleep due to psychological stress, due towhich he lost 13 kgs within the same year and since 1 week he had mixed bowel movements.

2.2. History of past illness

There is no infection or any pathological conditions.

2.3. Family history

No relevant family history.

2.4. Medical history

Nothing specific.

2.5. Psycho-social history

He was depressed due to his failed relationship and grandmother's death.

2.6. Surgical history

Nothing specific.

2.7. Personal history

The patient consumed a mixed diet and reported a poor appetite. Sleep was disturbed. Bowel habits were irregular, characterized by alternating episodes of constipation and diarrhea. Micturition is normal. The patient consumes tea three times daily and had no history of addictions.

2.8. Examinations

On general examination, the patient's vital signs were within normal limits. Blood pressure was recorded as 110/80 mm Hg, pulse rate was 75 beats per minute, and respiratory rate was 18 rpm. The patient weighed 55 kg, and the body temperature was 35.9 °C. On systemic examination, cardiovascular system revealed S1 and S2 heart sounds were heard normally. Respiratory system examination showed normal vesicular breath sounds (NVBS) present bilaterally. Central nervous system examination revealed that the patient was conscious, alert, and well-oriented to time, place, and person. Abdominal examination elicited pain in the lower abdomen. Overall, the patient's vital parameters were stable at the time of examination.

2.9. GI examinations

On abdominal examination, inspection revealed no visible abnormalities and appeared normal. On palpation, the abdomen was soft, with tenderness/pain noted in the lower abdomen, particularly in the umbilical region. Auscultation revealed normal bowel sounds, indicating normal intestinal activity. On percussion, there was no evidence of organomegaly or palpable masses, and the percussion notes were within normal limits. Overall, the abdominal examination was unremarkable except for pain localized to the lower abdominal (umbilical) region.

2.10. Ashtavidha Pareeksha

On Ashtavidha Pareeksha, the patient's Nadi was assessed as Vata-Pitta predominant. Mootram was found to be Samyak. Malam exhibited a pattern of Muhur Baddham Muhur Dravam, indicating alternating episodes of constipation and loose stools. Jihwa was Liptam (coated tongue). Sabda was Madhyama, while Sparsha was Anushnasheeta, suggesting a normal tactile temperature. Drik was assessed as Avara, and Aakruti was of Madhyama build.

2.11. Dashavidha Pareeksha

On Dashavidha Pareeksha, the patient was found to have a Vata Prakruti with Pitta Dosha predominance in the Vikruti state. The affected Dhatus were identified as Rasa, Rakta, and Mamsa. Assessment of Mala revealed Pureeshaja involvement, characterized by Muhur Baddham Muhur Dravam (alternating constipation and loose stools). The patient exhibited Sarva Sara, and Pravara Samhana, Pramana was assessed as Avara. The patient was Satmya to all six tastes (Sarvarasa Satmya) and possessed Madhyama Satva. Both Aharashakti and Vyayamashakti were found to be Avara. The patient belonged to the Youvana Avastha.

3. Clinical findings

Rome IV criteria:The patient presented with a history of recurrent abdominal pain for the past one year, which was associated with alterations in stool frequency and bowel habits. Over the last one week, the symptoms had become more pronounced, with features suggestive of Mixed Irritable Bowel Syndrome (IBS-M), characterized by alternating episodes of constipation and diarrhea. The abdominal pain was recurrent in nature and closely related to changes in bowel movements.

4. Diagnostic assessments

Samyak Langita Lakshana, like Laghutvam (Feeling of lightness in the body), Sudha Nadi (Pulse becomes clean and balanced), Agni Dipti (Increase in digestive fire (Agni) and appetite). Sudha Utklesa (Proper elimination or control of waste products), Dourbalya Abhava (No weakness; the person doesn't feel overly fatigued.) and Utsaha (Improved enthusiasm and mental clarity).

4.1. Scales used

The IBS-QOL questionnaire, Hamilton Anxiety Rating Scale, IBS symptoms severity scale, IBS-VAS scale and Bristol Stool Chart were used.

4.2. Investigation

Since the patient has been clinically diagnosed with IBS(M), an objective investigation was not needed.

4.3. Differential diagnosis

Malabsorption Syndrome, Anorexia Nervosa, Shokaja Atisara (SeeTable 2 for the reasons).

Table 2.

Reason for inclusion and exclusion of DD

Differential Diagnosis	Inclusion	Exclusion
Malabsorption Syndrome	Both conditions present with chronic bowel disturbances, irregular stools, abdominal discomfort, weight loss, weakness, and impaired digestive function. Grahani is often correlated with malabsorption due to Agnimandya and defective nutrient assimilation.	Malabsorption syndrome typically demonstrates objective evidence of nutrient deficiency such as steatorrhea, anemia, hypoalbuminemia, vitamin deficiencies, and laboratory abnormalities. In Vataja Grahani, the primary pathology is Agni Dushti and Grahani dysfunction without definitive biochemical evidence of malabsorption.
Anorexia Nervosa	Patients may present with reduced appetite, weight loss, weakness, and gastrointestinal complaints, which can resemble features seen in Grahani.	Anorexia nervosa is primarily a psychiatric disorder characterized by intentional food restriction, distorted body image, and an intense fear of gaining weight. These psychological features are absent in Vataja Grahani, where digestive impairment and bowel irregularities are the predominant manifestations.
Shokaja Atisara	Both conditions may present with altered bowel habits, frequent loose stools, abdominal discomfort, and involvement of Vata Dosha. Chronic emotional stress can also aggravate symptoms in both disorders.	Shokaja Atisara is predominantly characterized by diarrhea precipitated by grief, emotional trauma, or psychological distress and is usually acute or directly linked to a specific emotional event. In contrast, Vataja Grahani is a chronic disorder resulting from Agnimandya and Grahani Dushti, presenting with Muhur Baddham Muhur Dravam Mala Pravritti (alternating constipation and diarrhea) rather than persistent diarrhea alone.

Although Malabsorption Syndrome, Anorexia Nervosa, and Shokaja Atisara share certain clinical features with Vataja Grahani, they were excluded based on the absence of characteristic findings such as laboratory evidence of malabsorption, psychiatric features suggestive of anorexia nervosa, and a clear history of grief-induced diarrhea. The patient's presentation of chronic recurrent abdominal pain, irregular bowel habits, and Muhur Baddham Muhur Dravam is more consistent with Vataja Grahani.

4.4. Provisional diagnosis

Vata Pradhana Sannipataja Grahani. There is no such type explained, hence it is considered under the broad category of Grahani Roga (Vataja Grahani) and managed according to the general Grahani Chikitsa, with special focus on pacifying Vata and correcting Agni.

4.5. Final diagnosis

Vataja Grahani.

5. Therapeutic intervention

The primary therapeutic objectives were Deepana and Pachana, Vatanulomana and Grahi. The patient was administered Deepana-Pachana medications to correct Agnimandya and facilitate Ama Pachana. Grahi and Sangrahi formulations were employed to regulate bowel habits and restore the functional integrity of Grahani. Vatahara measures were incorporated to alleviate abdominal pain, bloating, and irregular bowel movements. Appropriate Pathya Ahara and lifestyle modifications were advised to support Agni and prevent further aggravation of Vata. The treatment was periodically reviewed and modified based on the patient's clinical response. At the same time, Pitta, the Sthanika Dosha, was treated with Guduchyadhi Kashayam. Pada Abhyangam was performed in order to lessen his worry and enhance his sleep. The entire Dhanyamla Dhara was carried out as an Ama Pachaka, with Purvakarma preceding Snehapanam. Following the delivery of Snehapanam, Purvakarma Abhyangam, and Patra Pinda Swedam (PPS), Virechanam is performed (seeTable 1 .Table 3.

Table 1.

Represents the timeline of observations and therapeutic procedures.

Procedure	Days	Observation
Dhanyamla dhara	3 Days (02-05-2024 till 04-05-2024)	Samyak Langita Lakshana was observed
Pada abhyangam with ksheerabala tailam	1ST Day (02-05-2024)	The patient was able to sleep for 3 hours continuously
	2ND Day (03-05-2024)	Patient was able to sleep for more than 4 hours
	3RD Day (04-05-2024)	Patient was able to sleep continuously for 6 hours
Snehapanam with dadimathi ghritam	1st Day (05-05-2024)	His capability for digesting ghee was also improved, in 1st day of Snehapana (50ml at 6:30am) he was able to digest within 4 hours (10:15 a.m.) Abdominal pain started to get reduce.
	2nd Day (06-05-2024)	100ml was administered at the same time and he had got his appetite by 1pm. Softness and unctuousness of skin was noted. Abdominal Pain got reduced.
	3rd Day (07-05-2024)	150ml was administered and he got his appetite (Mild) back by 2pm. Samyak Snigdha lakshana has obtained. Stool got normal
Poorvakarma (Abhyangam And PPS) Abhyangam with Balaaswagandadhi Tailam.	1st Day (08-05-2024)	Relief in stiffness and general lightness of the body
	2nd Day (09-05-2024)
	3rd Day (10-05-2024)
Virechanam	1st Day (11-05-2024)	Administered at 8:30 a.m. with Avipati Choornam(40g) in which he had 6 Vegas

Table 3.

Therapeutic Interventions used

S. No	Medicine Names	Dosage	Anupana	Duration
1	Guduchyadi Kashayam	15ml-0-15ml	45ml Lukewarm water	15 days (02-05-2024 till 17-05-2024)
2	T. Shaddharanam (500mg)	1 in the Morning, Afternoon & Night	After food	15 days (02-05-2024 till 17-05-2024)
3	Vaiswanara Choornam	5 gm with buttermilk	11 a.m.	15 days (02-05-2024 till 17-05-2024)
4	Amlapittari Vati (300mg)	1 in the Morning and Night	Before food	15 days (02-05-2024 till 17-05-2024)
5	Syp. Indukantamritam.	2tsp-2tsp-2tsp	After food	15 days (02-05-2024 till 17-05-2024)

Table 1 consist of the treatment plan.

Pathya Apathya: General Pathya Apathya diet was advised for the patient with emphasis on easily digestible, light, and wholesome foods. Particular care was taken to avoid excessively sour, spicy, oily and heavy-to-digest items, which are known to aggravate Pitta and Vata Doshas and disturb Agni. The dietary approach supported the overall management and helped in reducing gastrointestinal symptoms.

5.1. Panchakarma procedure

Day-wise procedures are explained in Table 1 (see ).

6. Follow-up and outcomes

Results before and after treatment are explained in Table 4.

Table 4.

Reduction in Assessment scale.

Symptoms	Before Treatment	After Treatment
Rome 4 criteria	Positive	Negative
The IBS-QOL questionnaire	64	5
Hamilton Anxiety Rating scale	22	8
IBS symptoms severity scale	4	0
IBS-VAS scale	8/10	0/10
Bristol Stool Chart	Type 1(Separate hard lumps)	Type 4 (Normal)

Follow-up: Since his workplace was in Hyderabad, he was unable to visit our hospital immediately after completing one month(18-06-2024) of medication. Hence, follow-up was maintained through telephonic consultations over the subsequent four months (July 19, 2024, August 21, 2024, September 19, 2024, October 18, 2024). During this period, the patient consistently reported sustained relief, with absence of anxiety, normal sleep pattern, regular bowel habits, and no recurrence of abdominal pain. Symptom severity, as assessed subjectively during each follow-up, remained at minimal levels, indicating continued therapeutic benefit.

Interventions Adherence and Tolerability: The patient demonstrated good adherence to Bahya and Abhyantara Chikitsa and he was able to tolerate Virechanam along with mild dietary modifications.

Adverse and unanticipated events: There is no such adverse reactions were noted during the treatment period.

7. Discussion

In Grahani disorders, Mandagni disrupts Pachaka Pitta and Samana Vayu, impairing digestion and nutrient absorption. Aggravated Kapha, particularly Kledaka Kapha, induces excess mucus secretion and sluggish digestion, while Vata vitiation leads to irregular bowel movements and abdominal discomfort. The accumulation of Ama further obstructs the Srotas, exacerbating the pathological process. Hence the treatment should help in breaking the Samprapti.

Guduchyadhi Kashayam is recognized for its diverse pharmacological properties, including Kashaya, Tikta, and Madhura Rasa, Laghu Guna, Anushna Veerya, and Katu-Madhura Vipaka. This formulation exhibits anti-inflammatory, analgesic, immunomodulatory, antipyretic, and gastroprotective effects. The constituent herbs of Guduchyadhi Kashayam primarily act on the Annavaha Srotas, targeting exogenous pathogens. Guduchi, Arishta, and Dhanyaka play a crucial role in enhancing Agni (digestive fire), while Guduchi and Dhanyaka specifically aid in the digestion of Ama, thereby supporting gastrointestinal health [6,7].

Shaddharana Choorna, as described by Sushrutha in the contexts of Amashayagata Vata and Pakvashayagata Vata, it modulates the pathological state of Grahani, alleviates clinical symptoms, and preserves gastrointestinal mucosal integrity without adverse effects [8]. Pharmacologically, Shaddharana Choorna exhibits Kaphavatahara, Deepana-Pachana, and Anulomana properties, with Laghu-Ruksha-Teekshna Guna, Ushna Veerya, and Katu Vipaka. It possesses anti-inflammatory, antioxidant, antispasmodic, antibacterial, antipyretic, hepatoprotective, anti-ulcerogenic, and dyspepsia-relieving properties, effectively eliminating Ama and enhancing Agni. Its Ruksha nature aids in the removal of Leena Dosha from Dhatus and Srotas, thereby maintaining digestive efficiency and protecting the gastrointestinal tract from infections, inflammation, and microbial overgrowth.

Similarly, Vaishwanara Choorna exhibits Vatakaphahara, Deepana-Pachana, and Anulomana actions and have been advised under many gastrointestinal disorders [9], characterized by Laghu-Ruksha Guna and Madhura Vipaka. It primarily corrects Apana Vayu through the Anulomana action of Haritaki, restoring Samana Vayu and enhancing Agni. Its Deepana effect strengthens digestion, while its Laghu-Teekshna nature regulates Pitta, ensuring metabolic balance. Additionally, it promotes Srotosodhana, Lekhana, Malanulomana, and Shoola Prasamana [10].

Dhanyamla Dhara was initially implemented to regulate metabolism, enhance digestive function, and facilitate the elimination of Ama. Furthermore, it plays a crucial role in restoring the equilibrium of Vata and Kapha Doshas and acts as Srotovisodhanam (Cleaning body channels) Balapradam (Strengthening) etc [11].

Pada Abhyangam promotes overall relaxation, alleviates stress, and strengthens the nervous system while aiding in sleep induction. It nourishes the eyes and contributes to overall physical well-being and enhances the quality of life and Acharya Dalhana has mentioned has Vatashamaka [12] has aggravated Vata causes insomnia [13].

Snehapana facilitates the movement of vitiated Doshas from the Shakha to the Koshta through mechanisms such as Vriddhi, Vishyandata, Pakata, Strotomukha Vishodhanata, and Vayu Nigrahata. This preparatory process enables the effective elimination of accumulated Doshas through Shodhana. Sneha acts as an excellent medium for the accumulation of toxins and serves as a vehicle for their transportation within the body, ensuring their systematic expulsion during the purification process [14,15].

Abhyanga with Balashwagandadhi Taila was administered with aim of Dhatu Vardhaka and for alleviation of Vata followed by Patra Pinda Sweda which helps in Srotoshuddhi and this acts as Purvakarma for Virechanam.

Virechana Karma primarily acts through systemic circulation while also exerting localized effects on the gastrointestinal tract. Virechana Dravyas, upon systemic absorption, facilitate the expulsion of morbid Pitta Dosha from the Amashaya and Pakwashaya. Through systemic circulation, these drugs reach the body's macro and micro channels, where their Vyavayi Guna ensures rapid absorption at sites of Pitta aggravation [16]. The Vikasi Guna aids in softening and loosening Pitta, while Ushna Guna promotes Dosha Sanghata, leading to Vishyandana. Additionally, the Tikshna Guna breaks down Pitta into finer particles, facilitating its swift elimination. The local irritant effect of Virechana Dravyas on the gastrointestinal tract induces bowel evacuation, thereby expelling morbid Pitta Dosha along with fecal matter. The unique Prabhava of Virechana directs aggravated Pitta towards the lower gastrointestinal tract, enabling its efficient elimination. This process further supports Vatanulomana and enhances Agni, contributing to overall metabolic balance [17]. Avipati Choornam has Katu, Tikta,Madhura Rasa, Ushna Veerya, Laghu, Ruksha, Teekshna Guna with Katu and Madhura Vipaka helps in Amapachana with helping in eliminating the root cause.

7.1. Strengths and limitation of this case

The Ayurvedic line of treatment was tailored to the patient's Prakriti, Vikriti, Agnibala, and Koshta, ensuring individualized care. The case was evaluated and managed with inputs from both Ayurvedic and modern systems, which improved clinical comprehension and facilitated an integrative diagnostic strategy. The simplicity, affordability of Ayurvedic medicines increased patient adherence to treatment.

As this is an individual case study, the conclusions cannot be generalised or statistically confirmed. The relative effectiveness of treatment cannot be definitively proven without a comparative or placebo group. Many Ayurvedic diagnostic and prognostic factors, which are qualitative in nature and may change depending on the clinician's interpretation. Because of limited availability or extent, advanced investigations like colonoscopy, food intolerance testing, or IBS biomarkers were not incorporated to help support results from a modern standpoint. In this case patient was not able to come for proper follow-up after 2 months of medication due to his work pressure.

8. Conclusion

The intricate relationship between IBS, the gut-brain axis, and the Ayurvedic concept of Grahani highlights the profound impact of gut health on both physical and mental well-being. Ayurveda provides a holistic framework for addressing IBS and psychosomatic disorders like Chittodvega (anxiety disorders) by focusing on Agni, Ama, and Dosha balance. Through detoxification therapies, Deepana-Pachana, and a personalised diet and lifestyle tailored to one's Prakriti, Ayurveda offers a sustainable approach to restoring gut health and preventing recurrence. By aligning modern understanding of the gut-brain connection with Ayurvedic wisdom, we can foster long-term digestive harmony and overall well-being.

Informed consent

The patient gave informed consent for both the treatment and the publication of the case report.

Patient perspective

“I am highly satisfied with the treatment. It has relieved my anxiety, restored my normal sleep pattern, and improved my bowel habits. The abdominal pain I was experiencing has also reduced significantly, which has greatly improved my overall well-being.”

Author contributions

Dr Vaishali N -, Writing- Original Draft, Editing, Visualisation, and Follow-up of the patient.

Dr Suvendu Rout- Review, Proofreading and Supervision.

Dr Vijayarajaa P- Conceptualisation, Treating Doctor, Review, Methodology.

Declaration of generative AI in scientific writing

There is no usage of AI generative tools in this manuscript.

Funding sources

There is no supported Financial source.

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.