Nephrolithiasis ashmari

1. Nephrolithiasis - Ashmari

2. Etiology Low urine volume Hypercalciuria Hyperoxalouria Hyperuricosuria Low fluid intake Fluids such as apple juice, grape fruit, sodas increases the risk High NaCl intake High protein intake Low calcium intake H/o prior kidney stone Hyperoxalouria (enteric hyperoxaluria , short bowel syndrome) Type I Renal Tubular Necrosis Patients may be occassionally diagnosed on radiology of abdomen done for other cause.

3. pathophysiology Normally soluble solutes ( e.g -calcium) supersaturates in the urine(site like end of collecting ducts) crystallization occurscrystal aggregatesbecomes large in shape and sizeanchoring of crystals occurs at epithelial cell injury site caused by crystal itself or by infection– acting as Nodus (charged particle)attracts unsoluble solutes towards it calculi formation

4. Types Calcium oxalate (more common) Calcium phosphate (less common) Uric acid, struvite (Mg, Ammonium Phosphate) Cystine stones Combination of different stones can exist in single stone

5. Clinical features Pain in the lumbar region (kidney stones), Renal Punch test postive Pain radiating from Loin to Groin ( ureteric stone) Pain onset when stone descends in the ureter Spasmodic pain occuring in waves or paroxysm, mostly at night Nausea and vommitting Hematuria - microscopic or gross or absent

6. Investigation Urine routine and Microscopic- shows crystalls USG abdomen & Pelvis Xray KUB IVP Non contrast enhanced CT/MRI

7. Treatment Acute colic- IV hydration Nonnarcotic analgesics ( eg , Acetomenophen ) PO/IV narcotic analgesics ( eg , codeine, butorphanol , morphine sulfate , oxycodone /APAP, hydrocodone /APAP, meperidine , nalbuphine ) NSAIDS ( eg , ketorolac , ketorolac intranasal, ibuprofen) Uricosuric agents ( eg , allopurinol ) Antiemetics ( eg , metoclopramide ) Antidiuretics ( eg-desmopressin acetate ) Antibiotics ( eg , ampicillin , gentamicin , ticarcillin / clavulanic acid, ciprofloxacin, levofloxacin , ofloxacin ) Alkalinizing agents ( eg , potassium citrate, sodium bicarbonate): For uric acid and cysteine calculi Corticosteroids ( eg , prednisone, prednisolone ) Calcium channel blockers ( eg , nifedipine ) Alpha blockers ( eg , tamsulosin , terazosin )

8. Surgery Stones that are 7 mm and larger are unlikely to pass spontaneously and require some type of surgical procedure, such as the following: Stent placement Percutaneous nephrostomy Extracorporeal shockwave lithotripsy(ESWL) Ureteroscopy Percutaneous nephrostolithotomy (PCNL) Open nephrostomy

9. Ashmari - ayurvediya concept तत्र संशोधनशीलस्यापथ्यकारिणः प्रकुपितःश्लेष्मा मूत्रसम्प्रुक्तो s नुप्रविश्य बस्तिमश्मरी जनयति// (सु.नि.४) विशोषयेद् बस्तिगतं सशुक्रं मूत्रं सपित्तं पवनं कफ़ं वा/ यदा तदा s श्मर्युपजायते तु क्रमेण पित्तेष्विव रोचना गोः// (च.चि.३६) Due to improper purification of the body and by following the Apathya , kapha dosha gets vitiated in the urine and reaches in the basti to form ashmari . According to charakacharya - the shukra dhatu in the basti gets dried up along with Pitta or Kapha dosha by Vata forms Ashmari like how Gorochana forms in Gallbladder of cow.

10. एवमेव प्रवेशेन वातः पित्तः कफ़ो s पि वा/ मुत्रयुक्त उपस्नेहात् प्रविश्य कुरुते s श्मरीम्// अप्सु स्वच्छास्वपि यथा निषिक्तासु नवे घटे/ कालान्तरेण पंकः स्यादश्मरीसम्भवस्तथा// संहन्त्यपो यथा दिव्या मारुतो s ग्निश्र्च वैद्युतः/ तव्दद्बलासं बस्तिस्थमूष्मा संहन्ति सानिलः/ (सु.नि.२४-२६) Vata -Pitta- kapha dosha enters into basti like how mutra enters into basti from Pakwashaya and with Upasneha nyaya Ashamari is formed in Basti. When clear water is placed in a new mud pot, after sometimes some particles precipitates into the water, similarly in the basti ashmari develops- this explains the stagnation of the urine in the bladder due to bladder outlet obstruction like BPH etc can form calculus in the bladder.

11. Third shloka explains the crystallization process- when dry air along with the static electricity in the clouds forms the crystalls of water present in the cloud, similarly ashmari develops.

12. Purvaroopa तासां पूर्वरुपाणि- बस्तिपिडारोचकौ मुत्रक्रुच्छ्ं बस्तिशिरोमुष्कशेफ़सां वेदना ज्वरः क्रुच्छावसादौ बस्तगन्धित्वं मूत्रस्येति // Pain and discomfort in the bladder, urethra,testicles /external genital organs. Anorexia, dysuria , fever, debility, smell of goat’s urine. Colour of urine appears like that of individual doshas and pain accordingly. urine appears non-clear, increased specific gravity.

13. Types Kaphaja Vataja Pittaja shukraja

14. Samanya lakshana Pain in the umbilicus,bladder , perineum, external genitals eithr in any one of them while passing urine. Obstruction to the urine stream Hematuria Urine appears clear as Gomeda or some crystals can be seen in urine. Discomfort or pain while performing the activities like running, swimming, hanging, swimming,riding on back of horse,camel .

15. Vataja Ashmari Vata and kapha dosha after combining together obstructs the urine and causes pain as a result person bites his teeth, presses navel, external genitals,anus and shouts due to pain. Has to pass urine after putting force. The ashmari formed is Shyava , hard, irregular,rough , it contains thorny structures like of kadamba Pushpa .

16. Pittaja Ashmari Kapha dosha along with Pitta dosha attends compactness and obstructs the urine and produces discomfort like burning sensation in the basti-medhra , feeling of hot air coming out of bladder. Ashmari appears like red,yellow , dark in colour and appears like seed of Bhallataka

17. Kaphaja ashmari The Kapha dosha attends compactness and increases in size and obstructs the urine and produces features like tearing type of pain in bladder, heaviness in the bladder and feeling of cold. Ashmari appears like hen’s egg, pale-white colour , unctous to touch, large in size and like madhuka flower.

18. Madhuka pushpa kukkutanda

19. Shukrashmari Causes = shukraveghdharan or excessive coitus. The vitiated vata causes vimargagaman of shukra into medhra or vrushana and after drying it up forms the shukrashmari . The resultant ashmari obstructs flow of urine and causes dysuria , pain in bladder and external genitals, oedema in legs. On pressing the ashmari it gets broken into pieces easily.

20. Ashmari in children Due to kapha avastha more chances of forming ashmari Occurs in those children who follows life style and diet which increases and vitiates kapha Ashmari can be of any 3 doshas Due to thin bladder wall and under developing basti , ashmari is small in size and can be easily removed with instruments Due to non development of shukra dhatu , there are no chances of forming shukrashmari

21. chikitsa Newly formed ashmari can be treated with medicines Chronic- surgical removal

22. Medicinal treatment Vataja ashmari - pashanbheda,vasuka,shatavari,gokshura,bhruhati , kantakari etc drugs should be used in form of kshaar , yavagu,kwatha,milk,food etc. Pittaja - kusha -kasha- sara - gundra - itkata - morata (sugarcane root),pashanbhedh,vidaari-varahkanda-shaalimoola,gokshura,shyonaka,punarnava,shirisha,lotus seed, evaru (cucumber) etc

23. Kaphaja ashmari - varunadi gana,guggulu,ela,kushtha , devdaru,haridra,maricha,chitraka etc drugs in form of kshar , peya,kshira,yavagu,kwatha . Kshara prepared from tila,apamarga,kadali,palasha and yava kalka with sheep’s urine prevents sharkara formation

24. Use of Ghrita , Kshara,kashaya , kshira and Uttarbasti are advised. If no relief with above medications then surgical extraction of calculus should be performed.

25. Surgical extraction Purvakarma - consent from the king, snehan-swedan-vaman-virechana , food should be given to the patient. Mangala-swastik vachan Collection all required instruments and medicines required during surgery

26. Pradhana karma This technique is Perineal Vesicolithotomy Position is lithotomy postion , head resting in lap of attendant Sneh is applied on nabhi and pressure massaging in done on left lateral region till ashmari decends into Basti. Lubricated middle and index finger is inserted into anal canal of the patient. Calculus is then pushed with those fingers in upward direction towards in between guda and external genital. Ashmari can be seen as nodule

27. While performing this procedure if patient becomes unconscious or goes into shock, in such condition procedure should be hold and extraction shouldn’t be done. Site of incision- vamaParshwa (left lateral) 1 yava (grain) distance from the sevani ( perineal raphe ). Incision should be adequate to remove stone While extracting the calculus, it should be brought out without crushing it. Otherwise it can cause recurrence. Instrument used is अग्रवक्र आहारण यन्त्र (curved forcep )

28. In case of female – uterus should be protected,incision shouldnot be too deep otherwise it causes vrana through which urine oozes out. Avoid damaging important structures like mutravaha,shukravaha,mutrapraseka,sevani,yoni,guda,basti .

29. Damage to- Mutravaha srotas and Basti-death due to extavasation of urine Shukravaha srotas -death or infertility Mushkasrot - dhwajabhanga (erectile dysfunction) Mutraprasek - vesical fistula  urine discharge Sevni and yoni- severe pain Guda and basti - death

30. Paschat karma Patient should be kept in hot water tub, this prevents collection of blood in bladder. If blood gets collected in bladder then Uttarbasti of kshirvruksha kwatha should be administered, it removes the collected blood out of bladder (bladder wash) For mutramargavishodhana – rice mixed with jaggery should be given. After removing from tub, apply honey+ghrita on the incision wound

31. For diuresis - trunapanchamoola,gokshura etc drugs in the form of yavagu is given 2-3 times a day. For rakta-mutra shodhan and vrana kledanartha - jaggery mixed milk along with cooked rice is given in small quantity for 10 days. After 10 days- sour fruit like dadima and jangala mamsa rasa is given. Carefully snehan and drava swedan is performed. Clean wound with kshiravruksha decoction. Apply lepa of rodhra,madhuka,manjishtha,prapaundarika kalka

32. If urine doesn’t come through its normal route and comes out from incision site ( vrana ), then it should be thermally cauterized ( agnikarma ). After urine comes out via normal route, uttarbasti , anuvasan and niruha basti are given prepared from kakolyadi gana or Kshiravrukshadi gana .

33. Obstructed shukrashmari or sharkara should be removed with badisha yantra Avoid coitus, horse-elephant-camel ride climbing mountain, riding chariots, swimming, heavy to digest food for 1 year after healing of the wound.