The Gerson Institute of Ayurvedic Medicine

Scott Gerson, M.D., Ph.D. (Ayurveda) Medical Director, Jupiter Medical Center Dept. of Integrative Medicine Division of Education and Research

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Ulcerative Colitis: The Ayurvedic View

Ulcerative Colitis

Ulcerative colitis (UC) is a chronic inflammatory disease of the colonic mucosa characterized by small ulcerations and bloody diarrhea. The most common area affected is the sigmoid colon and rectum but it can affect the entire colon. Except for a minority of cases which affect the lower part of the ileum, the small intestine is rarely involved.

The cause of ulcerative colitis is unknown. Current theories implicate an immune response to a virus or to a native protein (autoimmune disease). Like Crohn's disease (CD), ulcerative colitis is an inflammatory bowel disease (IBD), however unlike CD which penetratess the entire intestinal wall, UC generally stays limited to the mucosa, epithelium and lamina propia. Ulcerative colitis is not caused by infection, food sensitivities, emotional factors, or physical activities although these may triggers symptoms in some individuals.

Ulcerative colitis occurs equally in men and women most frequently at ages 15-35, but there's another smaller peak incidence at age 55-70. It is unclear whether there is a familial pattern of inheritance.

Diagnosis

Bloody diarrhea of varying duration and amount is the overt symptom (vyakti) of ulcerative colitis which brings most patients to the doctor. However preceding this presentation a careful medical history usually reveals an insidious and unrecognized progression of the condition months or years before a disease entity is recognized.

Many people report a variety of interspersed "pre"-symptoms (purvarupas) which include: periods of urgency to defecate, very mild intermittent abdominal cramps, mucous in the stools, unexplained fatigue, dullness of the complexion, nervousness, mild vertigo, intolerance, unpleasant body odor, weight loss, occasional brief but sharp rectal pain, dark yellow urine, premature ejaculation, low sperm count, longer duration of menstruation, and a sensation of fullness in the lower abdomen. It would be difficult for a physician operating within the conventional allopathic paradigm to connect these preliminary symptoms to the beginning of ulcerative colitis, but very much possible for the Ayurvedic physician aware of the concepts of samprapti and sat kriyakala.

Usually these purvarupas are ignored or treated (i.e. suppressed) symptomatically, but the report of bloody diarrhea triggers a sigmoid- or colonoscopy and biopsy (chronic inflammation, crypt atophy) which confirms the diagnosis. Blood tests (looking for anemia, elevated WBC counts, CRP, and ESR) and barium enemas (outlining ulcerated areas) are also sometimes performed.

Natural History

The common observation is a life of repeated exacerbations and remissions. About 5-10% of individuals have an initial attack which is uncontrollable and progresses rapidly to massive hemorrhage and sepsis. Another 5-10% of people have a complete recovery and no other episodes after their first encounter. The remaining 80% of affected individuals develop a chronic relapsing/remitting pattern of bloody diarrhea, low grade fever, mild nausea, and/or crampy lower abdominal pains, with 30% ultimately undergoing surgery (partial colectomy).

According to Ayurveda, ulcerative colitis is primarily a disease of Pitta dosha with varying degrees of Vata involvement. The latter determines how extensively the inflammatory process will spread proximally and the development of extraintestinal manifestations.

The natural qualities and actions of Pitta are manifested wholly or partially and can be observed.

The inherent paittika qualities are: heat, sharpness, liquidity, light, slight unctuousness, sour or pungent smell, acidic or sour taste, red, yellow, and dark blue colors.

The natural actions of Pitta include: burning sensation, heat, pus formation (suppuration), perspiration, putrification, itching, bleeding (raktasrava), anger, and intensity.

The excessive consumption of paittika ahara (Pitta-aggravating foods) and Pitta-aggravating regimens initially damages both rakta dhatu and mamsa dhatu. Vata dosha in the lower colon is also aggravated and in the early stages blocks the Pitta and Kapha channels causing further inflammation, mucous accumulation and edema.

Treatment

There are two major forms of treatments in Ayurveda for ulcerative colitis, Vasti therapy (enemata) and oral medications. Normally, vasti therapy is administered first and followed by several months of oral medications. Panchakarma Therapies of varying duration are also strongly advised.

Vasti Therapy

" There is no causative factor greater than Vata in the manifestation of diseases in the peripheral tissues (sakha), viscera of the thorax and abdomen (kostha), marma (vital points), upper region of the body (urdhva), travelling throughout the entire body (sarvavayava), and those effecting individual parts (anga)." CS, Siddhi Sthana 1:38

Vasti (enema therapy) is regarded by all the ancient vaidyas as the most important panchakarma procedure. The reason in part is that vasti promotes the elimination of excess Vata dosha from the body, and Vata dosha is the root of the majority of diseases which afflicts mankind. It is the moving force in the physiology which governs the formation, interaction, spread, and elimination of all biological substances and waste products. It is also the force which propels the other doshas out of their normal seats and shrotas into the peripheral tissues. Being the principal treatment of this most influential of biological energies, Vasti Karma is of paramount importance in any regimen of panchakarma.

Two types of vastis are always used: anuvasana (oil-based) and niruha (decoction-based). They are given for a period of either eight or sixteen days in alternating order (see Schedule of Administration below).

Preparation of Anuvasana Vasti

Anuvasana vastis are basically enemas consisting of herbalized oils. For this study, the formula used is as follows:

* Haritaki (Terminalia chebula, Linn.)-------------1/4 cup
* Haritaki Paste-------------------------------------------1 cup
* Sesame Oil-----------------------------------------------4 cups
* Water----------------------------------------------------16 cups

These ingredients are combined in a small pot and brought to a boil. The heat is then reduced and a gentle rolling boil is maintained until all the water was boiled off. The remaining oil is strained through a cheese cloth and the residual haritaki residue disgarded. The herbalized oil is allowed to cool down until warm before administration. The above formula will provide sufficient quantity for eight days of anuvasana basti. Store in refrigerator at 34-38 F.

Preparation of Niruha Vasti

Niruha vasti consists of the introduction of kwathas, or decoctions, made with appropriate herbal medicines into the rectum. It is also known as asthapana vasti. The preparation is made as follows:

First the kwath is prepared. One hundred and twenty (40 grams each) of licorice root (Glycerrhiza glabra, Linn.), sariva (Hemidesmus indicus, Linn.) and bael (Aegle marmelos Linn.) are added to a pot containing two (2) liters of cold water (a 1:16 ratio). This is boiled until reduced to 1/4 of its original volume, or 500 ml.. Then strain the kwath through cheesecloth to remove the particulate matter.

To 400 ml of the resulting filtered kwath add ghee in the amount of 1/8 the volume of the decoction, or 50 ml.

To summarize, the Niruha Vasti consists of:

* Herbal Kwatha----------------400 ml (2000ml. reduced to 500ml. and 400ml. of this is used)
* Ghee--------------------------------50 ml (1/8 the volume of the kwatha)

By increasing the above quantities, the herbal kwath can be made in sufficient quantity for eight days. It should be stored in a refrigerator at 34-38 F remove aliquots of 450 ml. each day and gently re-warm and supplement with required amount of warm ghee (50 ml.)

Determination Of The Dosage (Volumes) Of Anuvasana and Niruha Vastis

The volume of anuvasana vasti is determined from the volume of niruha vasti. The standard volume of niruha vasti is 450 ml.

Anuvasana vasti can be 1/4, 1/8, or 1/16 of the Niruha volume. In ulcerative colitis, we should use 1/4 the niruha volume (approximately 110 ml.) as the anuvasana volume.

Therefore the dosages (volumes) given of each vasti is as follows:

* Niruha Vasti-----------------------------------450 ml.
* Anuvasana Vasti------------------------------110 ml.

Schedule of Administration

The physician will decide whether to administer an 8- or 16-day regimen. The schedule should be as follows.

Eight-day Regimen: A N A N A N A A

Sixteen-day Regimen: A N A N A N A N A N A N A N A A

(Note that each regimen begins with an anuvasana treatment and ends with two.)

Oral Medications

These herbal-based Ayurvedic medicines can be started beginning on the day after the last anuvasana basti treatment. Although all of the medicines below are appropriate, the physician will select the specific medicines, dosages, and schedules based on the roga- and rogipariksha.

  • Combine equal quantities of the powders of jatiphala (i.e. nutmeg), jiraka (cumin seed), and dried bilva fruit (bael). Dosage: 3-6 grams with limewater morning and evening 30-60-minutes before food.
  • Prepare a decoction from equal amounts of the powders of vidanga, ativisa, mustaka, dhanyaka, and bilva. Mix well. Add 4 ounces of this herbal powder to ½ gallon (64 oz.) of water. Boil over a low flame until liquid is reduced to 1 pint (32 oz.). Dosage: 1 ounce morning and evening 30-60 minutes before food.
  • Prepare a decoction from equal amounts of the powders of punarnava, guduchi, vacha, chirata, indrayava (kurchi seed), and haritaki. Mix well. Add 4 ounces of this herbal powder to ½ gallon (64 oz.) of water. Boil over a low flame until liquid is reduced to 1 pint (32 oz.). Dosage: 1 ounce morning and evening 30-60 minutes before food. Alternatively, this powder can be taken as a powder in the dosage of 3-6 grams with 1 tsp. honey and warm water morning and evening 30-60 minutes before food.
  • Add ½ tsp pippali, bilva, jatiphala, and kutaja to 6 oz. goat's milk. Add 1 tsp honey. Mix and allow to stand (covered) for 60 minutes. Drink every day 15-30 minutes after noontime meal.
  • Combine 4-6 oz Dadima juice (pomegranate) with 1 tsp. yastimadhu powder (licorice root). Drink morning and evening on empty stomach.
  • Combine powder of yastimadhu (licorice root) two parts, rakta chandana (red sandalwood) one part, and shatavari one-half part. Take 3-6 grams morning and evening with 4 oz. goats milk on an empty stomach.
  • Combine powder of shallaki (boswellia) two parts, haridra (turmeric) one part, yastimadhu (licorice root) two parts, and shatavari one-half part. Take 3-6 grams morning and evening with 4 oz. goats milk on an empty stomach.

Diet

Pathya: The following specific foods are generally recommended in Ayurveda for patients of ulcerative colitis. However, not all patients will tolerate all of these food items. Your physician can provide a more individualized nutritional plan.

Old basmati rice (>3 months), barley, mung dal, urad dal, saffron, coriander, cumin, fennel, barley sprouts, navy beans, kidney beans, green lentils, cow's milk and butter, goat's milk and butter, almonds, water chestnut, pomegranate, banana, mango, limes, wheat grass juice, and kiwi fruit.

Apathya: Foods to be reduced or avoided:

All leftovers, spicy foods, white sugar, wheat, pasta, red grapes, vinegar, mustard, salty and acidic foods.