Understanding Udararoga w.s.r to Jalodara vis-à-vis Ascites
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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.
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Understanding Udararoga w.s.r to Jalodara vis-à-vis Ascites
- 1. 1
- 2. Understanding Udararoga w.s.r to Jalodara vis-à-vis Ascites By Dr. Amritha. E. Pady 2nd 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
- 5. 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
- 6. • Udara roga is one among the astamahagada. • Because of Utseda Sadharmya it is considered as a type of Shotha. • उदरोत्सेद साधर्म्ााद् 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
- 7. • 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.
- 8. (vachaspati) Diseases which manifests in udara is termed as Udara. 8 UDARA
- 13. 13 Poorvaroopa
- 17. • Due to nidanas • Due to other vyadhi • Ajeernaadi Su durbala agni • Causing tridosha prakopa. • Arambhaka dosha dushti in rasa,sweda • ambuvaha srotas Chirath mala sanchaya • Leading to Prana Agni Apana sandushti Adha urdhwa marga rodha 17 Samprapthi Dhatwagnipaka not happening properly so utpathi of malaswaroopa of all dhatu getting increased. Nidana sevana
- 18. Through upasneha vat Annasara repeatedly oozes out through anuthama srotas Koshtaat annasaaro nisruthya Because of dushta anila preritha takes these dushta annasara in between twacha and mamsa of udara Into udara pradesha • Vi • vardha mano jataram • Udara Causing shanai: samunn atha 18
- 19. 19 •When the person indulging more on vishesha nidanas the vyadhi will attain its bhedavastha.
- 21. 21 Vatodara lakshanas Aniyato cha vridhi hraasa, • Kukshi-parshwa shula, • Udavartha • Angamarda • Parvabheda Shushka kasa Karshya dourbalya • Arochaka • Avipaka Adhoguruthwa, • Vatavarcha mootra sanga, • Urdhwadha tiryak sashoola shabda
- 22. on Pareeksha Aadmadamdruti shabda Kukshi-pani- pada- vrushana- shwayathu Shyava/arunatwa of nakha- nayana-vadana- twak-mootra- varcha Tanu asita raaji sira
- 27. Durbala agni, apathyanna, virodhibhojana, gurubhojana All tridosha linga sheeghrapaakam Sthreedatha bhojana- raja,roma,vit,mootra,asthi nakhadi Samprasakta moorcha Garadooshivisha, dushtambu, Shosha- kanta,taalu,mukha 27 Sannipathodara/dooshyodara On pareeksha-Nanavarna raji sira vyaptam, Sarva varna-nakhadi
- 28. Athisankshobha ashana, yana, aticheshtitabhara adhwa vamana, vyadhikarshana Pleeha chyuti/pleeha vrudhi Kachapasamsth anavath udara- 28 Pleehodara/yakrudodara Rasa Rakta dushti and vrudhi due to vata prakopa Pleeha becomes Katina and ashteelavath
- 29. 29 Sa upakshita Kramena kukshim jataram agnyadhishtanam Parikshipan udaram abhinivarthayate- vamaparshwa vrudhi- pleehodara-
- 30. 30 Yakrudodara- Dakshina parshwavrudhi Tulya hetu linga oushada of pleehodara On pareeksha- pleeha/yakrut will be sparshagamya kachapasamsthanavath ,katina and ashteelavath
- 31. Dourbalya Arochaka Avipaka, Varchamootragraha, Mrudu jwara Anaaha, Agninasha, Atipandu Karshya, Asyavairasya, Parvabheda, Koshta vata shoola, Neela –harita-haridra- raji Tamapravesha, Pipaasa, Angamarda, Chardi, Moorcha, Angasaada Kasa Shwasa 31
- 32. 32 Badhodara/badhagudodara Pakshma- baala- ashma sahanna, udavartha, arsha, other gudanirodhaka hetu Antra samurchana- Badhayane gude • Apana marga samrodhatwath Agnim kupito anila Varcha pitha kapho rudhwa Badha gudodara
- 33. Trushna, daha, Jwara Mukha-taalu-shosha Kasa-shwasa dourbalya Arochaka avipaka Varcha-mootra sanga Adhmana Chardi –with vitgandhi Shira-hrudaya- nabhi-guda-shoola Moodavatam On pareeksha - Shwayathu Sthiram Aruna-neela raji- over nabhi upari Gopuchavath 33
- 34. Sharkara, Truna,kaashta,asthi, kantaka anna samyuthai: Bhidyet antram • During bhukta/jrumbhaya/ atyashanena Paka of rasa which oozed out from the antra 34 Poorayan gudam antram Janayati udaram Chidrodara
- 35. Yathabalam cha doshanam roopani darshayati( udakodara roopam darshayathi) Varcha with-Ama- salohita-saneela- sapeeta- pichila- kunapagandhi Hikka shwasa Kaasa Trushna prameha, Arochaka Avipaka dourbalya 35
- 36. • 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
- 37. Critical analysis of samprapthi of jalodara
- 38. UdakodaraPichotpathi Anudaka prapthi 38 Neglecting this avastha of udara (ajadodaka) leads to…………
- 39. Sashabda, sirajaalagavakshitam Sadagudugudayashcha Nabhi vishtambhya Alpa mootra pravruthi Ishat shotha arunabhasa Shoola- hrut,nabhi,vankshana, kati,guda, Karkashe srujato vatam Na ati mande paavake Na asya vairasya 39 Ajaatodaka avastha Vayo tu vegam krutwa pranashyati
- 40. • swa • sthanaa t • apavrut a • pari pakaat Dosha • Srothaamsi upakledayati • Sveda-bahya • srotho • prathihata Dravi bhoothat Accumu lates pichoda ka in udara- (foam) Avatishta in tiryak gata marga 40 If neglecting Ajatodaka avastha Pichotpathi
- 41. Udara looks like mandalakruthi Guru,sthimita Akotitha ashabdam Mrudusparsha Apagata raajeekam aakrantam nabhyaame upasarpathi 41 Neglect this stage leads to jalodara
- 42. Triggers vata- acts on klomni- ambuvahasrothoavarodha by kapha + udaka sammoorchana Vardhayetham thadevaambu swasthanaat udaraaya tu 42 Jalodaravastha
- 43. Udakapurna druthi sankshobha, samsparsha Nanavarna raji sira Kuksherathimatra vrudhi Anannakanksha Shwasa kasa dourbalya Gudasrava 43 Jalodara lakshanas
- 44. 44 Later stages if neglected Sarva marmotha shwayathu Shoona aksha Kutila upastha Bala-shonita- mamsa-agni- pariksheenam Upaklinna tanu twacha Shwasa- hikka- aruchi-trut Moorcha- chardi- atisaara
- 46. Snehapeetasya mandagne Atyambu panaat nashtaagne Ksheenasya atikrushasya va Triggers vata- acts on klomni- Ambuvaha srotho avarodha by kapha + udaka sammoorchana Vardhayetham thadevaambu swasthanaat udaraaya tu 46 Nidana and samprapthi Jalodara lakshana
- 47. 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
- 48. • 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
- 49. 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
- 50. 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
- 54. • Ajatodaka avasta which is achirotpanna, anupadrava, anudakaprapti are sadhya. • Jalodara with upadrava – Asadhya • If person is balavaan, jatambu navothitam- yatnasadhyam 54
- 55. 55 Chikitsa sutra of jalodara ||cha.chi 13/93|| अपाां दोषहराण््ादौ प्रदद््ादुदकोदरे||९३|| मूत्र्ुक्तानि तीक्ष्णानि विविधक्षारित त च| दीपिी्ैः कफघ्िश्च तमाहाररुपाचरेत्||९४|| द्रिेभ््श्चोदकाददभ््ो नि्च्छेदिुपूिाःैः| (Ca.Chi.13/93-94) दोषानतमात्रोपच्ात्स्रोतोमार्ानिरोधिात्| सर्मभित््ुदरां तस्मात ित््मेि विरेच्ेत्||६१|| (Ch. Chi. 17/61)
- 56. • उदराणाां मलाड््त्िाद्िहुः: ःोधि्ां दहतम ्||(Ca.Chi.13/93-94) • उदी्ाते भृःतरां मार्ारोधाद्िहज्जलम्| ्था तथाऽनिलस्तस्् मार्ं नित््ां विःोध्ेत्|| (Ch. Chi. 17/122)
- 57. • Nityameva udaranaam samprapthi praapnothi = Nityameva virechanaath. • GOAL- Apaam dosha haranam, Srothoshodhanam • Removing of accumulated fluids without harming the bala of Rogi. • दुर्ालोऽवप महादोषो विरेच््ो र्हुःोऽल्पःैः| मृदुभभभेषजदोषा ह ्ुैः ह््ेिमनिर्हाताैः|| (Ch. Kal. 12/69) • Restoring the Agni by expelling “BAHU DOSHA” stoka stoka nirharanam and preventing further accumulation
- 58. • 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.
- 59. • 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
- 60. • 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
- 61. 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/abhish yandi- bhojana Madhu, seedhu ,sura Toyapaanam Alpa – amla/sneha/katu+ panchamoola sadhita Yavagu/odana/yusha. 61
- 62. •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
- 63. 63 Etiological factors Pre hepatic Hepatic Post hepatic • Portal vein thrombosis • splenic vein thrombosis • Massive spleenomegaly • Cirrhosis • Alcoholic hepatitis • Massive hepatic metastasis • Hepatic sinusoidal obstruction • Budd-chiari syndrome • Inferior venacaval webs
- 64. • Hypoproteineamias Nephrotic syndrome Malnutrition Protein losing enteropathy • Hepatic venous occlusion Buddchiari syndrome Venous occlusive disease Perforation Pancreatitis Meig’s syndrome Ovarian torsion, rupture 64
- 65. 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; 1. Capillary blood pressure 2. Osmotic pressure of plasma proteins (plasma colloid osmotic pressure/oncotic pressure) Capillary blood pressure & Plasma colloid osmotic pressure Ascites
- 66. 66 Theories behind the pathology Under fill theory Overfill theory Vasodilatation theory
- 67. 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
- 68. 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
- 69. 69 Portal hypertension Splanchic arterial system vasodialation Increased portal inflow Increase splanchic pressure Arterial under filling Activation of renin- angiotensis-aldosteroneIncrease in fluid accumulation and extracellularfluid volume Sodium retention Formation of ascites Pathogenesis of ascites with portal hypertension Increase splanchic lymph
- 70. 70 Evaluation of an ascitic patient
- 71. • 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
- 72. • 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
- 73. 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
- 74. 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
- 75. • 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
- 76. 76 1.Fluid wave / thrill 1.Bulging flanks 1.Puddl e sign. 1.Flank dullness or horse-shoe dullness 1.Shiftin g dullness FIVE CLASSICAL PHYSICAL SIGN
- 77. 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+
- 78. •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)
- 79. 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
- 80. 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
- 81. 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.
- 82. 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
- 83. Complications of ascites 1. 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
- 84. • GOAL-To achieve ascites-free status -To maintain it thereafter INDICATION FOR HOSPITALIZATION 1. If there is no response to outpatient management for 4-6 weeks. 2. Tense (grade III) ascites with respiratory embarrassment. 3. Spontaneous bacterial peritonitis 4. Refractory ascites Management of ascites
- 85. 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
- 86. 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 .
- 87. • अतनिदोषा मिुष््ाणाांरोर्सङ्ाैःपृथतनिधाैः| मलिृद्््ा प्रिता ते विःेषेणोदराणण 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
- 88. • 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.
- 89. • 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.
- 90. • 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
- 91. Thank You Let our life flow smoothly, naturally without any obstruction