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.
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
4.
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.
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
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
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
54. • Ajatodaka avasta which is achirotpanna, anupadrava, anudakaprapti are
sadhya.
• Jalodara with upadrava – Asadhya
• If person is balavaan, jatambu navothitam- yatnasadhyam
54
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
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
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
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
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.
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