Understanding Udararoga w.s.r to Jalodara vis-à-vis Ascites

Rightly diagnosed is half cured so thorough examination of the patient is very much essential for the diagnosis and management of udara roga. Here an attempt made to understand udara roga in parlance with modern science which will be helpful for treating the patient at right time.

1. 1

2. Understanding Udararoga w.s.r to J alodara vis-à-vis Ascites By Dr. Amritha. E. Pady 2 nd year PG scholar Dept., of PG studies in Kayachikitsa SKAMCH&RC, Bangalore. 2 Guided by Dr. Muralidhara HOD & Professor in the department of PG studies in Kayachikitsa SKAMCH&RC

3. The Great Pacific Garbage Patch Giant collection of fishing nets, plastic containers and other discarded items called a ‘ticking time bomb’ as large items crumble into micro plastics

4. Contents Introduction Udara Nidana Panchaka of udara Bheda & Lakshana Critical analysis of Samprapti of Jalodhara Upadrava Sadyasadhyata Chikitsa sutra of jalodhara Ascites Etiology and pathology Evaluation of ascitic patient Investigation-complication-prognosis Discussion Conclusion 5

5. Udara roga is one among the astamahagada . Because of Utseda Sadharmya it is considered as a type of Shotha . उदरोत्सेद साधर्म्याद् उदरम् The diseases that are manifested in the abdominal cavity causing the distension of the abdomen – udara roga . In this condition Agni plays a major role in the manifestation of disease where the aprakrutha ahara paka mala, and all malaswaroopa is accumulating in the udara leads to this ghora vyadhi where mandagni,malinabhojana and mala sanchaya are considered as main nidanas . Introduction

6. Ayurveda emphasizing on being healthy gives the detailed description about the initiation of the diseases step by step. If one pays special attention to the changes happening inside and out side of the body, any one can be healthy and its easy to get healed early stages.

7. ( vachaspati ) Diseases which manifests in udara is termed as Udara . 8 UDARA

8. 9 Udara nidana Ch.chi 13/12

9. 10 Aharaja-Nidana

10. 11 Viharaja-Nidana

11. Pleeha arsho grahani Dosha karshanath 12 Baala shakruth rodha antra sphutana bhedanath

12. 13 Poorvaroopa

13. 14

14. 15 Samanya roopa ||As.hru.ni 12/4||

15. 16

16. 17 Samprapthi Dhatwagnipaka not happening properly so utpathi of malaswaroopa of all dhatu getting increased. Nidana sevana

17. 18

18. 19 When the person indulging more on vishesha nidanas the vyadhi will attain its bhedavastha .

19. 20 Udara bheda

20. 21 Vatodara lakshanas

21. 23 Pithodara lakshanas

22. 25 Kaphodara lakshanas

23. 27 Sannipathodara / dooshyodara On pareeksha - Nanavarna raji sira vyaptam , Sarva varna-nakhadi

24. 28 Pleehodara / yakrudodara Rasa Rakta dushti and vrudhi due to vata prakopa Pleeha becomes Katina and ashteelavath

25. 29 Sa upakshita Kramena kukshim jataram agnyadhishtanam Parikshipan udaram abhinivarthayate - vamaparshwa vrudhi-pleehodara -

26. 30 Yakrudodara - Dakshina parshwavrudhi Tulya hetu linga oushada of pleehodara On pareeksha - pleeha / yakrut will be sparshagamya kachapasamsthanavath , katina and ashteelavath

27. 31

28. 32 Badhodara / badhagudodara Varcha pitha kapho rudhwa Badha gudodara

29. 33

30. 34 Poorayan gudam antram Janayati udaram Chidrodara

31. 35

32. There are various nidanas and samprapti that will lead to specific udaras . ie , ashtaudara Here the question arises how this different types of udara leading to jalodara ?? If proper intervention is not done to each udara , kalantharena by paripaaka , all udara will transform to jalodara where the manifestation of jalodara as a paratantra vyadhi . 36 Su.ni.7/25

33. Critical analysis of samprapthi of jalodara

34. 38 Neglecting this avastha of udara ( ajadodaka ) leads to…………

35. 39 Ajaatodaka avastha Vayo tu vegam krutwa pranashyati

36. 40 If neglecting Ajatodaka avastha Pichotpathi

37. 41 Neglect this stage leads to jalodara

38. 42 Jalodaravastha

39. 43 Jalodara lakshanas

40. 44 Later stages if neglected

41. 45 Jalodhara as swatantravyadhi

42. 46 Nidana and samprapthi Jalodara lakshana

43. Understanding Kapha + Udaka Sammorchana Due to above nidanas tridosha prakopa happens- vata accumulates in udakavaha srotho moola sthana causes obstruction of the udakavaha srothas leading to udaka and kapha moorchana Kapha will become abadhavastha and asthiratwa Vidagdata of kapha - gets lavana rasa. Udaka vrudhi happens. 47

44. Dosha - Tridosha –prana agni apana Dooshya - rasa,udaka , sveda Agni - Jataragni , dhatvagni Ama - Jataragnimandhyajanya dhathwagnimandhyajanya Srothas - rasavaha , swedavaha , ambuvaha Sanchara - siras Srotho dushti prakara – sanga , vimargagamana Udbava sthana - amashayodbhava Vyaktha sthana - Udara - twak mamsantara Adhishtana - udara Marga - Abhyanthara , baahya 48 Samprapti ghataka

45. Lakshana Dosha involvement Gamane ashakti , dourbalya , Vata vrudhi -prana dushti Shotha , udaka vrudhi Kapha - dravya vrudhi Vatapurisha sanga Apana dushti Paka pitha-ushna guna vrudhi Daha pitha-ushna guna vrudhi Shushkavaktrata Ambuvaha srotodushti - kshaya Karshya Vata - rooksha guna vrudhi 49 Kapha-sthira kshaya -guru vrudhi - pichila guna vrudhi - lavana rasa- vidagda kapha Pitha - ushna - teekshna guna vrudhi Vatha karma kshaya and rooksha guna vrudhi

46. Samanya samprapthi Lakshana Udbhava - koshta Kshunnasha Agnimaandya kruta-jeernajeerna aparinjana Bhuktam vidahyate Sahate na athisouhityam Sanchara - siras Upasnehavat – yatha anubhi:bahirsrothobhi bahisravad drushyate . Ashraya - udara - twak mamsanthara Srothodushti - rasa, sweda , ambuvaha Dosha – Tridosha Dushya - sweda , ambu , rasa Dominated with- prana- apana - samana Pachakapitha Kledaka kapha Kapha abadhata 50 Samprapthi lakshana sambanda and amshamsha kalpana

47. 51

48. 52 Sadhyasadhyata

49. 53 Param param Kruchrutharam

50. Ajatodaka avasta which is achirotpanna , anupadrava , anudakaprapti are sadhya . Jalodara with upadrava – Asadhya If person is balavaan , jatambu navothitam - yatnasadhyam 54

51. 55 Chikitsa sutra of jalodara || cha.chi 13/93|| अपां दोषहराण्यादौ प्रदद्यादुदकोदरे||९३|| मूत्रयुक्तानि तीक्ष्णानि विविधक्षारवन्ति च| दीपनीयैः कफघ्नैश्च तमाहारैरुपाचरेत्||९४|| द्रवेभ्यश्चोदकादिभ्यो नियच्छेदनुपूर्वशः | (Ca.Chi.13/93-94) दोषातिमात्रोपचयात् स्रोतोमार्गनिरोधनात्| सम्भवत्युदरं तस्मा न्नित्यमेव विरेचयेत्|| ६१|| (Ch. Chi. 17/61)

52. उदराणां मलाड्यत्वाद्वहुश: शोधन्ं हितम् ||( Ca.Chi.13/93-94 ) उदीर्यते भृशतरं मार्गरोधाद्वहज्जलम्| यथा तथाऽनिलस्तस्य मार्गं नित्यं विशोधयेत्|| (Ch. Chi. 17/122)

53. Nityameva udaranaam samprapthi praapnothi = Nityameva virechanaath . GOAL- Apaam dosha haranam , Srothoshodhanam Removing of accumulated fluids without harming the bala of Rogi . दुर्बलोऽपि महादोषो विरेच्यो बहुशोऽल्पशः| मृदुभिर्भेषजैर्दोषा हन्युः ह्येनमनिर्हृताः | | (Ch. Kal . 12/69) Restoring the Agni by expelling “BAHU DOSHA” stoka stoka nirharanam and preventing further accumulation

54. Correcting prana- agni - apana by inducing vatanulomana . Once apana starts moving its prakruta marga all other vata comes into normalcy. Removal of apaam dosha by mootrayukta teekshna ksharadi oushadhis The abadha - asthira kapha samoorcha with udaka gets broken by rooksha teekshna ushna gunas of mootra and enhances the agni . With the combination of hareetaki which does vatanulomana , deepanam pachanam further supports for samprapti vighatana .

55. Takra prayoga - Swadu takra+sa vyosha Ksheeraprayoga - chaga paya , karabha paya , gavya paya Ksheeranupaanam for gomutraprayoga 7 days mahisha mootra followed by ksheera - no anna 1 month- oushtra paya 3 month- chaga paya Along with vyosha Mootraprayoga - for seka paana Gomutrahareetaki - for the shesha dosha nirharanaartham Nagaraadi ghrutha Patolaadi choorna peya Katuki churna . 59

56. Udara vyadha in jathodaka - tapping As pashchat karma – Udara veshtana Peya without sneha and lavana For 6 months ksheeravruthi - 3 months ksheerapana 3 months ksheeraanna and paana 60

57. Pathya Apathya Raktashaali Odaka anoopaja mamsa / shaaka Yava Pishtakrutha Mudga Tilaan Jangalarasa Vyayama , adhwa Paya Divaswapna Mootra Yaana yaana-ashwadi Arishta Asava Ushna / amla / lavana / vidahi /guru/ abhishyandi - bhojana Madhu , seedhu , sura Toyapaanam Alpa – amla / sneha / katu + panchamoola sadhita Yavagu / odana / yusha . 61

58. Askites  a Greek word which means ‘bag’ or ‘sac’. Accumulation of fluid within the peritoneal cavity. Small amounts of fluid will be asymptomatic. Increase in amount of fluid cause abdominal distention and discomfort, anorexia, nausea, heartburn, flank pain and respiratory distress. 62 Ascites

59. 63 Etiological factors Portal vein thrombosis splenic vein thrombosis Massive spleenomegaly Cirrhosis Alcoholic hepatitis Massive hepatic metastasis Hepatic sinusoidal obstruction Budd- chiari syndrome Inferior venacaval webs

60. Hypoproteineamias Nephrotic syndrome Malnutrition Protein losing enteropathy Hepatic venous occlusion Buddchiari syndrome Venous occlusive disease Perforation Pancreatitis Meig’s syndrome Ovarian torsion, rupture 64

61. 65 Pathogenesis of ascites According to Starling’s hypothesis the exchange of fluids between the blood and tissue spaces is controlled by the balance between two factors; Capillary blood pressure Osmotic pressure of plasma proteins (plasma colloid osmotic pressure/oncotic pressure) Capillary blood pressure & Plasma colloid osmotic pressure  Ascites

62. 66 Theories behind the pathology

63. HYPOVOLAEMIA Kidney feels  Body is under filled & require more salt and water Stimulates JG cell to release RENIN angiotensinogen  anginsioten -I ACE lung capillaries convert Angiotensin II Releases aldosterone from the zona glomerulosa Increase the reabsorption of sodium and water & excretion of potassium from the DCT ASCITES 67 Underfill theory

64. 68 Overfill theory Peripheral arterial vasodialation theory When a portal pressure increases above a critical threshold, nitric oxide levels increase leading to vasodilatation As the state of vasodilatation worsens  plasma levels of vasoconstrictor, sodium retentive hormones increase and renal function deteriorates ASCITES The combination of portal hypertension and circulating hypervolemia results in over flow from the congested portal system to the peritoneal cavity, to produce ascites

65. 69 Portal hypertension Splanchic arterial system vasodialation Increased portal inflow Increase splanchic pressure Arterial under filling Activation of renin- angiotensis -aldosterone Increase in fluid accumulation and extracellularfluid volume Sodium retention Formation of ascites Pathogenesis of ascites with portal hypertension Increase splanchic lymph

66. 70 Evaluation of an ascitic patient

67. Age child : Tuberculous ascites and nephrosis Middle age : cirrhosis of liver Old age : malignancy Sex Female : Meig’s syndrome, pelvic tumors and infection, ovarian tumors Order of Development of Ascites Cardiac causes : Leg oedema precedes ascites . Kidney causes : Puffiness of face precedes ascites . Cirrhosis of liver : Ascites is the first feature . 71 HISTORY

68. Severe anaemia : Ascites of haematologic origin . Periorbital oedema , puffiness of face and oedema associated with ascites : acute nephritis , nephrotic synd. Associated jaundice : Cirrhosis of liver . Enlarged lymph nodes : Suggestive of TB , leukaemia , malignancy , and lymphomas . Dyspnoea , orthopnoea , and oedema : congestive cardiac failure . 72 General examinations

69. Abdominal Examination Inspection Abdomen is distended . Umbilicus is everted and slit transversely (laughing umbilicus) The distance between umbilicus and xiphi sternum is more than the distance between umbilicus and pubic symphysis . Flanks are full. Nearly 1500 mL of fluid is required to make the flanks full . Veins are dilated over the abdomen . Scrotal oedema indicates nephrotic syndrome 73

70. Examination of veins over the abdomen Vein obstructed Site of engorged veins Direction of flow of blood Portal vein obstruction Veins around the umbilicus and upper abdominal wall Veins above umbilicus- below upwards . Veins below umbilicus- from above downwards Caput medusa Hepatic vein obstruction Lower thorax and upper abdomen From above downwards Inferior vena cava obstruction Lower third of abdominal wall and flanks From below upwards

71. Shifting dullness is an important sign of free fluid in the peritoneal cavity . It requires nearly 500 mL of fluid to elicit this sign . Fluid thrill is present in tense ascites . If the fluid is small in amount nearly 120 mL , it will be demonstrated by puddle sign Ausculation It is not of much significance in ascites stage. 75 Percussion

72. 76 FIVE CLASSICAL PHYSICAL SIGN

73. GRADING OF ASCITES GRADE SEVERITY SIGNS 1 Mild Puddle sign + USG abdomen+ 2 Moderate Shifting dullness+ No fluid thrill 3 Severe Fluid thrill+ Resp. embarrassment+

74. INVESTIGATION X-Ray CT USG After the diagnosis of ascites is made, its cause should be determined by laboratory analysis. Ascitic fluid study (diagnostic paracentesis)

75. Strawcoloured / Transparent Bloody fluid Opaque / milky Dark -brown Black colour Normal Cirrhosis TB Malignancies Trauma TB peritonitis Pancreatitis Perforation Traumatic tap Chylous ascites Billiary ascites Pancreatic ascites. Colour / appearance of ascitic fluid

76. Determination of - Total protein Albumin content Glucose Blood cell count with differential Gram’s and acid fast stains Cytology Amylase LDH Triglycerides Culture for tuberculosis 80

77. Evaluation through SAAG- SAAG= serum albumin – ascitic fluid albumin Value >1.1g/dl- ascites due to portal hypertension Value<1.1g/dl- ascites due to infectious or other malignant condition.

78. Transudate – (protein<25g/l) Exudate(protein>25g/l) Low plasma protein concentrations Malnutrition Nephrotic syndrome Protein losing enteropathy High central venous pressure Congestive cardiac failure Portal hypertension Portal vein thrombosis Cirrhosis Tuberculous peritonitis Peritoneal malignancy Budd Chiari syndrome Pancreatic ascites Chylous ascites Meig’s syndrome 82 Evaluation of ascitic fluid

79. Complications of ascites Spontaneous bacterial peritonitis ( SBP)- Characterized by the spontaneous infection of ascitic fluid in the absence of an intra-abdominal source of infection 2. Hepatic renal syndrome

80. GOAL-To achieve ascites -free status -To maintain it thereafter INDICATION FOR HOSPITALIZATION If there is no response to outpatient management for 4-6 weeks. Tense (grade III) ascites with respiratory embarrassment. Spontaneous bacterial peritonitis Refractory ascites Management of ascites

81. Dietary sodium restriction <2gm/day Usually put on spirolactone 100-200mg/day as a single dose Frusemide may be added at 40-80mg/day- particularly patients with peripheral oedema In refractive ascites- Large volume paracentesis+ albumin infusion Dietary sodium restriction+ diuretics If ascites re accumulation- go with TIPS, consider liver transplantation, large volume paracentesis with albumin if needed. 85

82. Prognosis of ascites Despite the recent advances in the treatment of ascites , the prognosis is always grave after ascites. The presence of hepatocellular failure, evidenced by jaundice and encephalopathy is a very bad prognostic factor .

83. अग्निदोषान्मनुष्याणांरोगसङ्घाःपृथग्विधाः| मलवृद्ध्या प्रवर्तन्ते विशेषेणोदराणि तु||९|| While mentioning the nidanas , Acharyas have given very much importance to agnidosha plays main role in causing udara vyadhi like “ snehapeetasya mandagne ” The explanation given 300 decades back about the appearance of Udara rogi suggests multiorgan disorders explained under one chapter. 87 Discussion

84. The understanding of jalodara is in paralance with modern science i.e., manifestation of jala in udara pradesha is termed as jalodhara & the accumulation of fluid in peritoneal cavity is termed as ascites. The clinical examination and treatment for jalodara such as anguli thadana (percussion of abdomen), udakapoorna drutisparsha (fluid thrill), akotitamashabdam (dullness), sirajaala gavakshitam (engorged veins), udara vyadhana (tapping of abdomen) are seem to be adopted by modern science which holds good even today also.

85. The chikitsa sutra is based on dosha dushya amshamsha vikalpana which when employed at appropriate time or stage gives us better approach in managing udara in comparison to other streams. Understanding udara as a vyadhi , lakshana , asadhya lakshana , upadrava of some other vyadhi gives a Vaidya more specificity while approaching the patient. The investigative approach of ascites will help us to evaluate the use of oushada and prognosis of the patient.

86. Rightly diagnosed is half cured so thorough examination of the patient is very much essential for the diagnosis and management of udara roga . Jalodara which explained in our classics is very much similar to Ascites. The pathology of ascites in modern is based on certain hypothesis which is still being debated. The samprapthi of jalodara is more specific in our classics which takes place through upasneha nyaaya . Among all udaras - badhodara , chidrodara leading to jalodara needs Shastra chikitsa . 90 Conclusion

87. Thank You Let our life flow smoothly, naturally without any obstruction