A review article on Udara Chikitsa according to Charaka Samhita

Vol.01, Issue-04, October 2024

Author: Dr. Manish Singh Tomar, MD, PhD Ayurveda

Abstract

Udara refers to a group of disorders characterized by abdominal distension due to the accumulation of doshas (bodily humors), fluids, or other pathological substances in the abdominal cavity, as described in the ancient Ayurvedic text Charaka Samhita. Acharya Charaka provides a comprehensive understanding of Udara, including its etiology, pathogenesis, classification, clinical features, prognosis, and therapeutic approaches. This article explores the Ayurvedic concept of Udara Chikitsa (treatment of abdominal disorders) as presented by Charaka, correlating it with modern medical knowledge on conditions such as ascites, hepatosplenomegaly, peritonitis, and other causes of abdominal distension. By integrating traditional insights with contemporary science, we aim to enhance the understanding of these conditions and promote holistic management strategies.

Introduction

Abdominal distension is a common clinical presentation associated with various pathological conditions. In modern medicine, it can result from fluid accumulation (ascites), organomegaly, intestinal obstruction, tumors, or other causes. Managing such conditions requires a thorough understanding of the underlying etiology and pathophysiology to provide effective treatment.

In Ayurveda, abdominal distension is referred to as Udara, which encompasses a group of disorders leading to enlargement of the abdomen. Acharya Charaka, one of the principal contributors to Ayurvedic literature, elaborates on Udara in the Chikitsa Sthana (treatment section) of the Charaka Samhita. He provides detailed insights into its causative factors, pathogenesis, types, clinical features, prognosis, and therapeutic interventions.

This article delves into the Ayurvedic understanding of Udara, analyzing its etiopathogenesis, classification, clinical features, prognosis, and treatment principles as outlined by Acharya Charaka. By correlating these traditional concepts with modern medical knowledge, we aim to offer a comprehensive perspective that can inform current practices and promote integrative healthcare approaches.

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Etiology (Nidana) of Udara

Ayurvedic Perspective

Acharya Charaka identifies various causative factors leading to Udara, primarily focusing on the impairment of Agni (digestive fire) and the accumulation of Doshas (Vata, Pitta, and Kapha) and waste products (Malas).

Key Etiological Factors:

1. Impaired Digestion (Agnimandya):
   • Consumption of unwholesome, heavy, oily, sour, salty, and incompatible foods.
   • Overeating and eating before previous meals are digested.
   • Consumption of excessively hot, pungent, and rough foods.
2. Lifestyle Factors:
   • Suppression of natural urges (Vegavidharana).
   • Excessive physical exertion.
   • Irregular eating habits and improper convalescence.
3. Pathological Conditions:
   • Diseases like hemorrhoids (Arsha), splenomegaly (Plīha), and chronic diarrhea (Grahani).
   • Injury to vital organs (Marma Upaghata).
   • Worm infestations.
   • Blockage of channels (Srotorodha).
4. Psychological Factors:
   • Stress and anxiety affecting digestive functions.

Shloka References:

• “Atyuṣṇa-lavaṇa-kṣāra-vidāhi-amla-garāśanāt | Mithyā-saṁsarjanāt rūkṣa-viruddhāśuci-bhojanāt ||” (Verse 12)
• “Plīhārśo-grahaṇī-doṣa-karśanāt karma-vibhramāt | Kliṣṭānām apratīkārād raukṣyād vega-vidhāraṇāt ||” (Verses 13)

Modern Correlation

The Ayurvedic etiological factors of Udara can be correlated with modern concepts:

1. Dietary Causes:
   • High intake of spicy, salty, and fatty foods leading to liver dysfunction.
   • Consumption of contaminated food causing infections.
2. Lifestyle Factors:
   • Sedentary lifestyle leading to obesity and metabolic disorders.
   • Suppression of bowel movements causing constipation and intestinal obstruction.
3. Medical Conditions:
   • Liver diseases such as cirrhosis leading to ascites.
   • Heart failure causing abdominal fluid accumulation.
   • Renal dysfunction leading to fluid retention.
   • Malignancies in the abdomen.
4. Infections and Infestations:
   • Parasitic infections causing abdominal distension.
   • Tuberculosis peritonitis leading to ascites.

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Pathogenesis (Samprapti) of Udara

Ayurvedic Perspective

The pathogenesis involves the impairment of Agni, leading to the accumulation of undigested food (Ama) and Doshas, which obstruct the channels (Srotas) and result in abdominal distension.

Sequence of Pathogenesis:

1. Mandagni (Weak Digestive Fire):
   • Leads to improper digestion and accumulation of Ama.
2. Dosha Accumulation:
   • Vitiated Doshas accumulate in the abdomen due to obstruction of channels.
3. Obstruction of Vata:
   • Accumulated Doshas obstruct Vata, leading to its abnormal movement and causing distension.
4. Fluid Accumulation:
   • Vitiated Pitta and Kapha contribute to the accumulation of fluid in the abdominal cavity.
5. Organ Involvement:
   • Enlargement of spleen (Plīha) or liver (Yakrit) due to Dosha imbalance.

Shloka References:

• “Mandē ‘gnau malinair bhuktair apākād doṣa-saṁcayaḥ | Prāṇāgnyapānān sandūṣya mārgān ruddhvā’dharottarān ||” (Verse 10)
• “Tvaṅ-māṁsāntaram āgamya kukṣim ādhmāpayan bhṛśam | Janayaty udaraṁ tasya hetuṁ śṛṇu sa-lakṣaṇam ||” (Verse 11)

Modern Correlation

• Ascites Formation:
  • Portal hypertension due to liver cirrhosis leads to fluid accumulation.
  • Hypoalbuminemia reduces oncotic pressure, causing fluid leakage into the peritoneal cavity.
• Obstruction of Lymphatic Drainage:
  • Tumors or infections obstruct lymph flow, leading to chylous ascites.
• Organomegaly:
  • Enlargement of liver and spleen due to various pathologies contributes to abdominal distension.
• Malabsorption and Malnutrition:
  • Impaired digestion and absorption lead to protein deficiency and edema.

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Classification of Udara

Ayurvedic Perspective

Acharya Charaka classifies Udara into eight types:

1. Vataja Udara:
   • Caused by aggravated Vata Dosha.
2. Pittaja Udara:
   • Caused by aggravated Pitta Dosha.
3. Kaphaja Udara:
   • Caused by aggravated Kapha Dosha.
4. Sannipataja Udara:
   • Caused by the aggravation of all three Doshas.
5. Plīhodara:
   • Enlargement of the spleen causing abdominal distension.
6. Baddha Gudodara:
   • Obstruction in the rectum leading to accumulation of feces and gases.
7. Udakodara:
   • Accumulation of fluid (ascites) in the abdomen.
8. Parisarpa Udara (Chidrodara):
   • Perforation of the intestines causing leakage of contents into the abdominal cavity.

Shloka Reference:

• “Pṛthag doṣaiḥ samastaiś ca plīha-baddha-kṣatodakaiḥ | Sambhavanti udaraṇy aṣṭau teṣāṁ liṅgaṁ pṛthak śṛṇu ||” (Verse 22)

Modern Correlation

• Vataja Udara:
  • Resembles conditions with intestinal obstruction due to gases.
• Pittaja Udara:
  • Correlates with inflammatory conditions like peritonitis.
• Kaphaja Udara:
  • Similar to ascites due to congestive heart failure or renal failure.
• Sannipataja Udara:
  • Represents complex cases with multiple organ involvement.
• Plīhodara:
  • Enlargement of the spleen due to portal hypertension or hematological disorders.
• Baddha Gudodara:
  • Intestinal obstruction leading to fecal impaction.
• Udakodara:
  • Ascites due to liver cirrhosis or nephrotic syndrome.
• Chidrodara:
  • Perforation of the intestines leading to peritonitis.

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Clinical Features (Lakshana) of Udara

General Symptoms

Patients with Udara may present with:

• Abdominal distension.
• Loss of appetite.
• Weakness and emaciation.
• Indigestion and flatulence.
• Swelling in the limbs.
• Altered bowel movements.

Shloka Reference:

• “Kṣunnāśaḥ svādvatisnigdha-gurvannaṁ pacyate cirāt | Bhuktaṁ vidahyate sarvaṁ jīrṇājīrṇaṁ na vetti ca ||” (Verse 16)

Symptoms Based on Dosha Predominance

1. Vataja Udara

• Symptoms:
  • Abdominal pain and distension.
  • Gurgling sounds in the abdomen.
  • Constipation and flatus retention.
  • Dryness and emaciation.
  • Blackish discoloration of nails, eyes, skin.
• Shloka Reference:
  • “Tasya rūpāṇi—kukṣi-pāṇi-pāda-vṛṣaṇa-śvayathuḥ, udara-vipāṭanam…” (Verse 25)

2. Pittaja Udara

• Symptoms:
  • Burning sensation in the abdomen.
  • Fever, thirst, and delirium.
  • Yellowish discoloration of skin, eyes, urine, and feces.
  • Loose stools and fainting.
• Shloka Reference:
  • “Tasya rūpāṇi—dāha-jvara-tṛṣṇā-mūrcchā-tīsāra-bhramāḥ…” (Verse 28)

3. Kaphaja Udara

• Symptoms:
  • Heaviness and stiffness in the abdomen.
  • Loss of appetite and indigestion.
  • Swelling in hands, feet, and scrotum.
  • White discoloration of nails, eyes, skin.
• Shloka Reference:
  • “Tasya rūpāṇi—gaurava-ārocaka-avipāka-aṅgamardāḥ…” (Verse 31)

4. Sannipataja Udara

• Symptoms:
  • Combination of symptoms from all three Doshas.
  • Variegated discoloration of skin, nails, eyes.
  • Severe and difficult to treat.
• Shloka Reference:
  • “Tasya rūpāṇi—sarveṣām eva doṣāṇāṁ samastāni liṅgāni…” (Verse 34)

5. Plīhodara

• Symptoms:
  • Enlargement of the spleen palpable in the left hypochondrium.
  • Weakness, indigestion, anemia.
  • Abdominal distension progresses over time.
• Shloka Reference:
  • “Tasya plīhā kaṭhino ‘ṣṭhīla iva adau vardhamānaḥ…” (Verse 37)

6. Baddha Gudodara

• Symptoms:
  • Obstruction in the rectum causing constipation.
  • Abdominal pain and distension.
  • Foul-smelling breath and body odor.
• Shloka Reference:
  • “Tasya rūpāṇi—tṛṣṇā-dāha-jvara-mukhatālu-śoṣa…” (Verse 41)

7. Udakodara

• Symptoms:
  • Fluid accumulation in the abdomen.
  • Swollen and tense abdomen with fluid thrill.
  • Loss of appetite, thirst, weakness.
• Shloka Reference:
  • “Tasya rūpāṇi—anannakāṅkṣā-pipāsā-guda-srāva-śūla…” (Verse 47)

8. Chidrodara (Parisarpa Udara)

• Symptoms:
  • Perforation in the intestines causing leakage.
  • Severe abdominal pain and distension.
  • Symptoms of infection and sepsis.
• Shloka Reference:
  • “Tasya rūpāṇi—tad adho nābhyāḥ prāyo ‘bhi-vardhamānam…” (Verse 44)

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Prognosis (Sadhya-Asadhya) of Udara

Ayurvedic Perspective

• Curable (Sadhya):
  • Newly developed Udara in strong individuals without complications.
  • Vataja, Pittaja, and Kaphaja Udara in early stages.
• Difficult to Cure (Kricchra Sadhya):
  • Plīhodara and Baddha Gudodara due to organ enlargement or obstruction.
• Incurable (Asadhya):
  • Sannipataja Udara and Udakodara with complications.
  • Chidrodara due to perforation and severe infection.

Shloka References:

• “Janmanaivodaraṁ sarvaṁ prāyaḥ kricchratamaṁ matam | Balinas tad ajātāmbu yatna-sādhyaṁ navotthitam ||” (Verse 54)
• “Upadravaṁ tu nirvṛttaṁ pratyākhyeyaṁ vijānatā ||” (Verse 74)

Modern Correlation

• Good Prognosis:
  • Early-stage ascites due to reversible causes.
  • Manageable with appropriate treatment.
• Guarded Prognosis:
  • Chronic liver diseases with manageable complications.
• Poor Prognosis:
  • Advanced cirrhosis with refractory ascites.
  • Malignant ascites and peritonitis.
  • Multi-organ failure.

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Treatment Principles (Chikitsa Sutra)

Ayurvedic Perspective

The treatment of Udara involves:

1. Nidana Parivarjana (Avoidance of Causative Factors):

• Correcting dietary habits.
• Avoiding incompatible foods and lifestyle practices.

2. Shodhana (Purification Therapies):

• Vamana (Emesis): In Kapha predominant conditions.
• Virechana (Purgation): In Pitta predominant conditions.
• Basti (Enema): In Vata predominant conditions.
• Raktamokshana (Bloodletting): In conditions with blood involvement.

3. Shamana (Pacification Therapies):

• Administration of herbal formulations to balance Doshas.
• Use of digestive stimulants and carminatives.

4. Diet and Lifestyle Modifications:

• Consuming easily digestible, light foods.
• Avoiding heavy, oily, and difficult-to-digest foods.
• Regular physical activity appropriate to strength.

Specific Treatment Approaches:

• Vataja Udara:
  • Oleation and sudation therapies.
  • Mild purgation with oily substances.
  • Administration of medicated enemas.
• Pittaja Udara:
  • Purgation with cooling and bitter herbs.
  • Use of milk and ghee preparations.
  • Bloodletting if necessary.
• Kaphaja Udara:
  • Emesis to expel Kapha.
  • Use of pungent, bitter, and astringent herbs.
  • Administration of diuretics.
• Plīhodara and Yakritodara:
  • Treatment similar to Vataja Udara.
  • Specific herbs targeting liver and spleen.

Shloka References:

• “Vātodaraṁ bala-mataḥ pūrvaṁ snehair upācaret | Snigdhāya sveditāṅgāya dadyāt sneha-virecanam ||” (Verses 59-60)
• “Pittodare tu balinaṁ pūrvam eva virecayet | Durbalaṁ tv anuvāsyādau śodhayet kṣīra-bastinā ||” (Verses 68)

Modern Correlation

• Addressing Underlying Causes:
  • Treating liver diseases, heart failure, or renal dysfunction.
  • Use of diuretics to reduce fluid accumulation.
• Paracentesis:
  • Removing excess fluid from the abdominal cavity.
• Dietary Management:
  • Low sodium diet to reduce fluid retention.
  • Adequate protein intake to prevent muscle wasting.
• Medications:
  • Diuretics like spironolactone and furosemide.
  • Antibiotics for infections.
  • Vasoconstrictors in portal hypertension.
• Surgical Interventions:
  • Transjugular Intrahepatic Portosystemic Shunt (TIPS) in refractory ascites.
  • Liver transplantation in end-stage liver disease.

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Herbal Formulations and Medications

Ayurvedic Preparations

1. Trivritadi Ghrita

• Ingredients:
  • Trivrit (Operculina turpethum), Haritaki (Terminalia chebula), Pippali (Piper longum), Ghee.
• Benefits:
  • Acts as a purgative to eliminate Doshas.
  • Useful in Vataja and Pittaja Udara.
• Shloka Reference:
  • “Sañjāta-bala-kāyāgniṁ punaḥ snigdhaṁ virecayet | Payasā sa-trivṛt-kalkena urubūka-śṛtena vā ||” (Verse 69)

2. Panchakola Siddha Ghrita

• Ingredients:
  • Pippali, Pippali Mula, Chavya, Chitraka, Ginger, Ghee.
• Benefits:
  • Stimulates digestion and reduces abdominal distension.
• Shloka Reference:
  • “Pippalī-pippalī-mūla-cavya-citraka-nāgaraiḥ | Sa-kṣārair ardha-palikair dvi-prasthaṁ sarpiṣaḥ pacet ||” (Verses 112-113)

3. Narayana Churna

• Ingredients:
  • Trivrit, Danti (Baliospermum montanum), Shankhini (Evolvulus alsinoides), Triphala, Haritaki, Bibhitaki, Amalaki.
• Benefits:
  • Acts as a strong purgative.
  • Effective in all types of Udara.
• Shloka Reference:
  • “Etan nārāyaṇaṁ nāma cūrṇaṁ roga-gaṇāpaham | Nainat prāpyātivartante rogā viṣṇum ivāsurāḥ ||” (Verses 128-129)

Modern Correlation

• Herbal Supplements:
  • Use of natural diuretics like Punarnava (Boerhavia diffusa).
  • Milk thistle (Silybum marianum) for liver support.
• Nutraceuticals:
  • Supplements containing essential amino acids.
• Caution:
  • Herbal medications should be used under medical supervision due to potential toxicity.

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Lifestyle and Dietary Recommendations

Ayurvedic Perspective

• Diet:
  • Light, easily digestible foods.
  • Barley, rice, green gram, and lean meats.
• Avoid:
  • Heavy, oily, spicy, and salty foods.
  • Daytime sleep and excessive rest.
• Activities:
  • Gentle physical activity appropriate to strength.

Shloka References:

• “Tasmād bhōjyāni bhōjyāni dīpanāni laghūni ca | Rakta-śālīn yavān mudgāñ jāṅgalāṁś ca mṛga-dvijān ||” (Verse 97)
• “Vyāyāma-ādhva-divā-svapnaṁ yāna-yānaṁ ca varjayet | Tathā uṣṇa-lavaṇāmlāni vidāhīni gurūṇi ca ||” (Verse 100)

Modern Correlation

• Dietary Modifications:
  • Low sodium diet.
  • Adequate protein intake.
  • Avoid alcohol in liver diseases.
• Lifestyle Changes:
  • Regular exercise as tolerated.
  • Avoidance of substances harmful to the liver.
• Monitoring Fluid Intake:
  • Restriction of fluid intake in severe cases.

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Discussion

Integration of Ayurvedic and Modern Perspectives

Acharya Charaka’s description of Udara provides a comprehensive understanding of abdominal distension and its management. The holistic approach emphasizes the importance of treating the underlying causes, balancing the Doshas, and adopting appropriate dietary and lifestyle practices.

Relevance of Ayurvedic Concepts

• Holistic Healing:
  • Addressing physical, mental, and emotional aspects of health.
• Individualized Treatment:
  • Tailoring therapies based on the patient’s constitution (Prakriti) and Dosha predominance.
• Preventive Measures:
  • Emphasis on diet and lifestyle to prevent disease progression.

Modern Medical Alignment

• Etiological Focus:
  • Importance of diagnosing and treating the root cause.
• Symptomatic Relief:
  • Use of medications to reduce symptoms and improve quality of life.
• Supportive Care:
  • Nutritional support and monitoring for complications.

Potential for Integrative Approaches

• Combining Therapies:
  • Using Ayurvedic treatments as adjuncts to modern medicine under professional guidance.
• Research Opportunities:
  • Investigating the efficacy of Ayurvedic herbs in clinical trials.
• Patient-Centered Care:
  • Incorporating patient’s beliefs and preferences in treatment plans.

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Conclusion

Udara Chikitsa, as elaborated by Acharya Charaka, offers valuable insights into the management of abdominal distension and related disorders. The emphasis on holistic care, including dietary, lifestyle, and therapeutic interventions, aligns with modern approaches to treating such conditions. Integrating Ayurvedic principles with contemporary medical practices can enhance patient outcomes by providing comprehensive care that addresses the root causes and promotes overall well-being.

Further research and collaboration between traditional and modern healthcare systems are essential to fully realize the benefits of such integrative approaches.

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References

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2. Sharma, P. V. (1981). Charaka Samhita: Text with English Translation. Chaukhambha Orientalia.
3. Lad, V. (2002). Textbook of Ayurveda. Ayurvedic Press.
4. Dash, B., & Kashyap, L. (2001). Diagnosis and Treatment of Diseases in Ayurveda. Concept Publishing Company.
5. Murthy, K. R. S. (2012). Astanga Hridaya (English Translation). Krishnadas Academy.
6. Singh, R. H. (1998). Essentials of Ayurveda. Motilal Banarsidass Publishers.
7. Sherlock, S., & Dooley, J. (2002). Diseases of the Liver and Biliary System. Blackwell Science.
8. Runyon, B. A. (2009). Management of adult patients with ascites due to cirrhosis: update 2009. Hepatology, 49(6), 2087-2107.
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10. Schrier, R. W. (2006). Water and sodium retention in edematous disorders: role of vasopressin and aldosterone. The American Journal of Medicine, 119(7), S47-S53.

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