Introduction

Due to Continuous alterations in the food and life style, more than a few people are suffering from a number of disorders of digestion and the resultant clinical conditions. The most common abdominal condition experiencing in the primary health care, is dyspepsia.[1] Gastric dyspeptic disorders are mainly caused by the unfriendly dietetic pattern, mental stress and strain, mishandling of certain drugs etc. which are directly or indirectly affecting our digestion or its mechanism. [2] Ayurveda has given utmost importance to optimal dietary regimen and its variation as per the season, Agni, Prakriti, type of the intaken food and the disease condition. [3] The unaccustomed variations in the same, may lead to the diseases of the Koshtha or the GI tract. Depending on the three Doshas, which gets disturbed with the pathology, the condition or the disease varies and is named accordingly, in the classics.

Charak and Kashyap have clearly discussed that the Grahani Dosha and Amlapitta occurs in the person, who could not verify the temptation of food in their life. [4] The Nidana or the etiological components create Agnimandya or depleted digestive mechanism and thus Ajirna is developed and leads to the formation of Amavisha or substances which are not supportive in nature or even harmful to the body. This Amavisha mixed with the Doshas, mainly the Pitta Dosha and gets accumulated in the Amashaya, then gradually resulting in the diseases like Amlapitta.[5]

As per the available studies, more than 50% of the people with Hyper-Acidity symptom seldom consult a physician, although they may undertake over the counter medications, on the arousal of the symptoms for the relief, making the computing of the exact prevalence of the condition, as composite. Significant job absenteeism and disability are reported among these, than the people without these symptoms. The most reported or dominant cause of hyper-acidity in the society are the Functional Dyspepsia (FD) and the Irritable Bowel Syndrome (IBS). The prevalence of FD has noted to vary between 11-29.2% as per available studies. [6] Currently, the possibilities of available pharmacological agents in the management of the FD are still having its own limits; however, the experience of administering prokinetics, tricyclic antidepressants, Selective Serotonin Reuptake Inhibitors (SSRIs), Proton Pump Inhibitors (PPIs), and other several alternative techniques have been accumulated and tried as well. [7] The present available protocols, have their own limited areas in the studied efficacy. World is looking ahead to the alternative systems for their contribution to these patients, so as to provide them with a superior prospective and Ayurveda is the best answer for it.

Aim and objective- To detailed review of Ayurvedic Management of Amlapitta

Material & method: References regarding Amlapitta and its Chikitsa were collected from Bruhatrayi, Laghutrayi Modern textbooks and Research articles and analysed them.

Ayurveda has three basic categories of Chikitsa regarding the management of any disease. The combinations of these are used in the treatment of the condition, accordingly.

1) Nidana Parivarjana

Removal of all the alleviating factors of both Ahara and Vihara which are responsible for causation of the disease, is to be performed.

Samanya Nidana

Acharya Charak is narrating the mechanism of digestion and absorption very effectively, while explaining the Chikitsa of Grahani. This is because Grahani is such a condition where, the proper transformations of Dhatu is affected. Chakrapani says that by the term Grahani, the Doshas of Agni located in the Grahani, is being explained. [8] Here the transformation and metabolism of the Dhatus are dealt with seriously also with the stage of metabolism of the food. The etiological factors for Agnidushti are mentioned thereafter.

These all leads to alteration in the functioning of Agni, altered digestive mechanisms and the resultant disorders like Ajeerna or in the later stages, diseases such as Amlapitta. [9] The resulting Ajeerna or Amadosha is acting as a toxin or the causative factor, for the choice of resultant diseases. If it does not get subsided at that level, the pathogenesis progresses further. The Ama or toxin when associated with Pitta, results in conditions like Daha, Trishna, Mukha Roga, Amlapitta etc. [10]

It is to be advised to the patient to avoid such type of factors which are responsible for. Even in the days of Kashyap, Acharya advises to avoid the food materials which are processed. While explaining the Sadhyasadhyata, he adds that the diseases like Amlapitta becomes Sadhya in those who are not greedy towards their food habits. [11] The ancient people were not as careless as we people, as far as the food habits are concerned. Still the restrictions are mentioned by them, to be followed. That points towards the seriousness of dietary restrictions, in GI conditions like Amlapitta, in their management.

2) Apakarshana

         Apakarshana or Sodhana Chikitsa is the unique methodology of Ayurveda as far as the approaches of all the medical systems are considered. [12] Sodhana is the management protocol for the Prabhoota Dosha in any condition. While selecting the concerned Sodhana, mainly 3 factors are to be considered. i.e., the status of Dosha, localization of the Doshas or the Sthanasamshraya and Bala of the patient. In Amlapitta, even though it is a Pitta dominant disorder, the Sthanasamshraya is in the Amasaya, which is the Kaphasthana. The primary route of Sodhana mentioned in Vyadhi affecting the Amasaya is the Urdhwa Sodhana, Vamana. The Sodhana which eliminates the Doshas through the easiest route is always considered as the ideal one. [13]

Vamana and Virechana in Amlapitta:

              Kashyap has described Vamana as the first line of treatment, followed by Langhana and Laghu Bhojana. [14] i.e., even though the Amlapitta is a Paittika disease, the most effective Sodhana is Vamana. Kashyap opines that just like a tree with its trunk and branches are destroyed by striking the blow at its root. He says that, peculiarly for the chronic conditions; Vamana is to be done definitely. He also gives another example for the relevancy of Sodhana. If we are pouring pure milk in a vessel in which we have already kept Takra and not properly cleaned, the milk even though fresh, is having a chance to become fermented. In fact, the Shamana drugs applied after doing Vamana, will have the expected effect. The Amashaya with the Doshas associated with the Ama is defective in absorbing the drugs even though Shamana drugs are being advised, without proper Shodhana. Such a significance is there for Shodhana, in the context. As per the Chakradatta and Yogaratnakara, the second line of treatment is to perform Mridu virechana. [15, 16] Drugs used for Vamana are Lavanambu, Sukhosna-Dugdha, Ikshurasa, Madhudaka or Tiktadravyas and for the Virechana Triphala, Trayamana, Katuki along with Trivrit is mentioned. [17]

            According to Bhavaprakasha, the decoction of Patola, Nimba, and Madanaphala with Saindhava Lavana should be used for Vamana in Amlapitta. [18] Nishotha Churna and Amalaki are prescribed for the Virechana. Avipathi Choorna is one of the most commonly used Yogas for Virechana, which is mentioned by Vaghbata. [19]

Basti in Amlapitta

            The next regimen consists of administration of Anuvasana followed by Asthapana, in the chronically afflicted patients. The drugs such as Tiktaka Gritha, Indukanta Gritha, Aragwadhadi Gana Gritha etc. are usually used for the purpose of Anuvasana. Madhuyashtyadi Taila and Ksheerabala Taila are also used in thisregard. [20] After Anuvasana, in chronic cases, Nirooha is mentioned. Usually, Ksheeravasthi is the ideal one to be administered here. [21] Instead of plain Ksheera, Ksheera Kwathas with Guduchyadi Gana, Tiktaka Kwatha, Indukanta Kwatha, Aragwadhadi Gana is usually used. Plain Gritha is observed to cause Utklesha in these patients.

Raktamokshana in Amlapitta:

             Yogaratnakar added Raktamokshana as a tool if Amlapitta is not cured by both of the Sodhana procedures, Vamana and Virechana. [22] Vaghbat explains the diseases occurring due to Raktadushti. Even though, Amlapitta is not mentioned as such, the symptoms resembling the disease are mentioned as Katu and Amla Udgara may happen in one with the vitiation of raktha. [23] Moreover in some of the patients with Amlapitta, symptoms of Rakta Dhatu Dushti are also observed. So, in such a condition, Raktamoksha is having significant role, the technique being decided by considering all the related factors.

3) Prakritivighata

                 Prakritivighata refers to the use of drugs which suppress the elevated Dosha, such treatment is also termed as the Shamana therapy. [24] Kashyap opines that after Vamana, if the Doshas persist, the physician should resort to the Shamana Chikitsa with the aid of Laghu Bhojana, Shamana and Pachana. It is forbidden by Acharyas to give Drava Aushadhi if the Doshas are in condition of Utklesha, because if Vamana is not done, the Drava Aushadhi will not be metabolized. When the Dosha Utklesha has reduced with the help of Ahara and Vihara, physician can advise Ama Pachana and Bhedana drugs. Once the Doshas have been expelled and Amashaya is devoid of vitiated Doshas, the physician should direct the patient to take care of the Agni. The Doshas lodged in the Pakvashaya, is removed with the help of Sansrana drugs, which is selected as per the condition. Mainly Tikta Rasa, Laghu, Snigdha Guna, Katu or Madhura Vipaka and Sheeta veerya drugs are advocated by all the Acharyas, for Amlapitta. Use of Shamana drugs opposite to quality of Pitta and to an extent Kapha, is beneficial for Amlapitta.

Discussion

We have to consider the associative Dosha, while prescribing the Shamana drug. We can use combinations like Drakshadi Kwatha in Vata-pitta condition, Guduchyadi Gana in Kapha-Pitta condition and Tiktaka Kwatha for Pitta condition. Likewise, we can select Gritha Yogas as well. Indukanta Gritha is ideal for Vata-Kapha condition, Mahatiktaka Gritha for Vata-Pitta condition and Aragwadhadi Gritha for Pitta-Kapha condition. The drug of any format is usually selected according to the Dosha. Choornas like Avipattikar can be used both as a Shamana as well as a Shodhana drug. The Yogas can also be used in a different format, if the condition demands. The Ghrita Yogas can be administered in the form of Kwatha, if we know that Ghrita must not be administered, but the combination is ideal for use. [25] For eg. Mahatiktaka Yoga when administered in the Ghrita form is much more Vata Pitta in action, while if it is being administered as Kwatha, it is more Pitta Kapha Shamana in action.

Conclusion

Modern era's changing life style along with changing food culture and depending upon one’s body constitution Amlapitta is one of the most common disease. There is no permanent cost-effective treatment for Hyper-Acidity in modern medicine. So, we have to see for Ayurvedic Management. In this way through Ayurveda, we can manage Amlapitta specifically with Shodhan Chikitsa as Vaman, Virechana, Basti and Rakta-Mokshan along with Shaman Chikitsa and additionally by following Dincharya and Ritucharya effectively.