RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

KARNATAKA, BANGALORE

SYNOPSIS BYDr. ADARSH JANGATE

FOR THE DEGREE OF AYURVEDA DHANVANTARIM.S (AYURVEDA) IN SHALYA TANTRA

TITLE OF THE TOPIC

“ A STUDY ON THE EFFICACY OF SHIGRU MULA KWATHA IN THE

MANAGEMENT OF MUTRASHMARI W. S. R. TO UROLITHIASIS ”

GOVERNMENT AYURVEDIC MEDICAL COLLEGE,

DHANVANTARI ROAD,

BANGALORE – 09,

KARNATAKA

1

From,Dr. ADARSH JANGATEI M.S., Dept of P G Studies in Shalya tantra,Government Ayurvedic Medical College,Bangalore – 560009.

To,THE REGISTRAR,Rajiv Gandhi University of Health Sciences,Bangalore – 560041

Through:

THE PRINCIPAL AND H.O.D OF PG STUDIES IN SHALYATANTRAGovernment Ayurvedic Medical College, Bangalore- 560009

Respected Sir,

Sub: - Submission of completed proforma for registration of subject for Dissertation.

I request you to kindly register the below mentioned subject against my name for

the submission of dissertation to the Rajiv Gandhi University of Health Sciences,

Bangalore for the partial fulfillment of M.S (Ayu) in Shalyatantra.

TITLE OF THE DISSERTATION:

“A STUDY ON THE EFFICACY OF SHIGRU MULA KWATHA IN THE MANAGEMENT OF MUTRA ASHMARI W. S. R. TO UROLITHIASIS ”

Herewith I am enclosing completed proforma for registration of subject for dissertation.

Thanking you,

Place: Bangalore Your’s Sincerely,

Date: Dr. ADARSH JANGATE

2

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA.

ANNEXURE II

PROFORMA FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

1NAME OF THE CANDIDATE AND ADDRESS

Dr. ADARSH JANGATES/O APPASAB JANGATEAt Po: HUNNARGICHIKKODI TALUKBELGAUM DISTRICTKARNATAKAPIN-591275

2 NAME OF THE INSTITUTION GOVERNMENT AYURVEDA MEDICALCOLLEGE,DHANVANTARI ROAD,BANGALORE-09

3 COURSE OF STUDY AND SUBJECT

AYURVEDA DHANVANTARI.MS (AYU),SHALYA TANTRA

4 DATE OF ADMISSION TO

THE COURSE 29/10/2011

5 TITLE OF DISSERTATION

A STUDY ON THE EFFICACY OF SHIGRU MULA KWATHA IN THE MANAGEMENT OF MUTRA ASHMARI W. S. R. TO UROLITHIASIS

3

4

6. BRIEF RESUME OF THE INTENDED WORK:

6.1 Need for the study:

The word Ashmari denotes a calculi. Sushruta has mentioned it as Antakapratima, because at times it gives unbearable pain.

The earliest reference regarding Nidana, Samprapti, Lakshana and Chikitsa of Mutrashmari is available from Sushruta Samhita (1500BC) . However there is an evidence regarding the description of Urinary Calculi found in an Ezyptian mummy at E-amrah-Ezypt 4800 BC.

In Ayurveda, Mutrashmari is considered as Mahagada . Many kalpas invariably under the action of Ashmaribhedaka have been mentioned by various authours . However the ultimate treatment mentioned by Sushruta is Shastrakarma which is not in practice since more than 2000 years, because of the surgical complications. For the purpose of study, the term Mutrashmari is considered as Urolithiasis (calculus in urinary system). A calculus is a concretion usually composed of inorganic materials formed in a cavity or tissue of the body.

Incidence rate of Urolithiasis varies as per geographical distribution, sex and age group. In India, 5 to 10 in 1000 hospital admissions is due to urinary calculus. The highest incidence of Urolithiasis occur between the age of 30 to 50 years. In 50% of cases recurrence of Urolithiasis occurs in 5 to 10 years. In India, approximately 5 to 7 million people suffer from urinary calculus. 12% of people have stone in their lifetime, 12% of men and 5% of women will suffer from kidney stone by the age of 70.

The treatment principle of urinary calculus in modern science is flush therapy in case of stones up to 5mm. In larger stones, the advanced techniques like PCNL, ESWL, Ureteroscopy, Pyelolithotomy, Nephrolithotomy, Partial Nephrectomy, Nephrectomy, Nephrostomy, etc are done. But these procedures have their own disadvantages as they may lead to complications, they are expensive, have limitations in various aspects and many times cannot be met by common man.

In Ashmari Chikitsa, Bhavaprakasha has mentioned Shigrumula (Moringa Oliefera) kwatha as Ashmari nashaka. Shigrumoola is easily available and less expensive and free from side effects. The Invitro studies conducted in KLE College of Pharmacy, Belgaum has also shown that Shigru mula extractions have Antiurolithiatic property. The scientific studies conducted by Johns Hopkin’s school of medicine, USA has also shown that Moringa oliefera root extracts helps to reduce or to eliminate urinary calculi.

Considering various drawbacks in the above mentioned methods of treatment particularly the surgical methods of management, This study on the efficacy of Shigrumula kwath in the management of Mutrashmari which is free from the above mentioned drawbacks have been taken up.

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To evaluate the significance of Shigrumula kwatha in the management of Ashmari, another study with Pashanabhedadi kwatha in this management has been taken up which is an established study with 80% of success rate.

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6.2 REVIEW OF LITERATURE:

AYURVEDIC REVIEW ON ASHMARI

Vyuthpati:

AzqÉÉlÉÇ UÉÌiÉ SSÉÌiÉ rÉÉ||1 (pra. Kh. p.141)

The word Ashmari is derived from the word Ashma which means that which resemble

stone.

Nidana and samprapti:

iɧÉxÉÇzÉÉåkÉlÉzÉÏsÉxrÉÉ mÉjrÉMüÉËUhÉÈ mÉëMÑüÌmÉiÉÈ zsÉåwqÉÉ qÉÔ§ÉxÉÇmÉ×£üÉåÅlÉÑmÉëÌuÉzrÉ oÉÎxiÉqÉzqÉUÏÇ eÉlÉrÉÌiÉ||

In person who do not undergo purification regularly and who indulges in

unhealthy food and activities, kapha gets aggravated, combines with urine, reaches the

urinary bladder, and stays there, to produces Calculi (stones).2 (Ni. ch.3 sl.4)

ÌuÉzÉÉåwÉrÉå¯ÎxiÉaÉiÉÇ xÉzÉÑ¢Çü qÉѧÉÇ xÉÌmɨÉÇ mÉuÉlÉ: MüTÇü uÉÉrÉSÉ iÉSÉÅzqÉrÉÑïmÉeÉÉrÉiÉå iÉÑ ¢üqÉåhÉ ÌmɨÉåÎwuÉuÉ UÉåcÉlÉÉ aÉÉã:|| When vayu dries up semen or urine, pitta or kapha, the ashmari (calculus) arises

gradually like gall stone in cow.3 (chi. ch.26.sl. 31)

Lakshana:

AjÉ eÉÉiÉÉxÉÑ lÉÉÍpÉoÉÎxiÉxÉåuÉlÉÏqÉåWûlÉåwuÉlrÉiÉqÉÎxqÉlÉç qÉåWûiÉÉå uÉåSlÉÉqÉÔ§ÉkÉÉUÉxÉ…¡ûÈ xÉÂÍkÉUqÉÔ§ÉiÉÉ qÉÔ§ÉÌuÉÌMüUhÉÇ गोमेदप्रकाशमत्यावि लमं

xÉÍxÉMüiÉÇ ÌuÉxÉ×eÉÌiÉ; kÉÉuÉlÉsÉ…¡ûlÉmsÉuÉlÉmÉ׸rÉÉlÉÉåwhÉÉkuÉaÉqÉlÉæ¶ÉÉxrÉ uÉåSlÉÉ pÉuÉÎliÉ ||

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After manifestation, the person has pain in the area of the umbilicus, bladder,

raphae, penis and other areas near by during micturation, inturrpution of stream o

urine, urine mixed with blood, urine scattering (spreading in many streams); urine

resembling gomedaka (dolomite stone) in colour (light yellow), very turbid, and

containing sand (gravel); their is a pain during running, jumping, swimming, riding,

exposure to sunlight, long walk etc.2 (Ni. ch.3 sl.7)

कदम्ब पुष्पाकृवि�रश्म�ुल्या श्लक्ष्णा वि�पुट्यप्यथ ाअविप qÉײÏM | qÉѧÉxrÉ cÉålqÉÉaÉïqÉÑmÉæÌiÉ ÂSèkuÉÉ qÉѧÉÇ ÂeÉÇ iÉxrÉ करोवि� oÉxiÉÉæ || xÉxÉåuÉÌlÉqÉåWûlÉoÉÎxiÉzÉÑsÉÇ ÌuÉÍzÉlÉïkÉUÇ cÉ MüUÉåÌiÉ qÉÔ§ÉqÉçç | qÉÚSèlÉÉÌiÉ qÉåRíÇû xÉ iÉÑ uÉåSlÉÉiÉÉåï qÉÑWÒûÈ zÉMÚülqÉÑlcÉÌiÉ qÉåWûÌiÉ cÉ || ¤ÉÉåpÉÉiÉç ¤ÉiÉå qÉѧÉrÉÌiÉWû xÉÉxÉÚMçü iÉxrÉÉÈ xÉÑZÉÇ qÉåWûÌiÉ cÉ urÉÉmÉÉrÉÉiÉç ||

When the calculus simulating Kadamba flower, stony, smooth, prismatic, or

soft comes in the passage of urine, it obstructs the flow of the urine and thus causes

pain in bladder. Urine is passed in divided streams and with pain in suture, penis in

bladder. The patient, with agonising pain, presses the penis and sometimes passes

stool and sometimes urine. If the passage or bladder is injured by irritationof the

calculus urine is passed with blood (haematuria). When the calculus shifts from the

passage , the patient passes urine with ease.3 (chi. ch.26.sl 32-34)

Chikitsa:

AzqÉËU SÉÂhÉÉå urÉÉÍkÉUliÉMümÉëÌiÉqÉÉå qÉiÉ:|AÉæwÉkÉæxiÉÂhÉÈ xÉÉkrÉÈ mÉëuÉ×kSzNãûkÉqÉWïûÌiÉ ||

Ashmari (calculus) is a disease severe like the god of death. It can be cured

with drugs when newly arisen but in advanced stage it requires surgical operation.4

(Chi. ch.7 sl.3)

iÉxrÉ mÉÔuÉåïwÉÑ ÃmÉåwÉÑ xlÉåWûÉÌS¢üqÉ CwrÉiÉå|| iÉålÉÉxrÉmÉcÉrÉÇ rÉÉÎliÉ urÉÉkÉåqÉÔïsÉÉlrÉzÉåwÉiÉ:|| In its early stage, unction etc; Regimen is applicable by which the root causes of

the disease get eliminated.4 (Chi. ch.7 sl.4)

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ÌmÉoÉå²ÂhÉeÉÇ qÉÔsÉÇ YuÉÉjÇÉ iÉiMüsMüxÉÇrÉÑiÉqÉç|YuÉÉjÉ¶É ÍzÉaÉëÑqÉÔsÉÉåijÉç: MüOÒûwhÉÉåÅzqÉËUlÉÉzÉlÉ:||

Decoction of root of Varuna added with the paste of the same root or

decoction of routes of Shigru made slightly warm and consumed destroy urinary

calculi.5 (Ma. Kh. Ch. 37 sl. 65)

mÉÉwÉÉhÉÍpÉSè uÉÂhÉ aÉÉå¤ÉÑUMü EÃoÉMüÉå¤ÉÑSìɲrɤÉÑUMüqÉÔsÉM×üiÉÈ MüwÉÉrÉÈ |SklÉÉ rÉÑiÉÉã eÉrÉÌiÉ qÉÔ§ÉÌuÉoÉÇlkÉzÉÑ¢üqÉÑaÉëÉzqÉUÏqÉÌmÉ cÉ zÉMïüUÉ xÉqÉåiÉÉqÉç ||6 (Ut.sl.1)

The decoction of root of Pashsnabheda, Varuna, Gokshura, Eranda, Bhrahati,

Kantakari, Ekshuraka taken with Dadhi destroys the Mutravibanda, Ugra

Shukrashmari, Sharkara.

MODERN REVIEWS ON UROLITHIASIS

Aetiopathogenesis

1. Infection: Organisms such as Proteus, pseudomonas, klebsiella, produce recurrent

UTI. These organisms produce urea and cause stasis of urine which precipitate stone

formation. Nucleus of the stone may harbour these bacteriae.

2. Hot climate cause increase in concentration of solute, resulting in precipitation of

calcium, formation of calcium oxalate stones

3. Dietary factor

Diet rich red meat, fish, eggs can give rice to aciduria.

Diet rich in calcium- tomatoes, milk, spinach, rhubarb produce calcium oxalate

stones.

Diet lacking in vitamin A causes desqamantation of renal epithelium which

precipitates calcium, alerts it and forms stones.

4. Metabolic causes

Hyperparathyroidism increases serum calcium levels resulting in

hypercalcinosis and pelvic stones.

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Gout increases uric acid levels and causes multiple uric acid stones.

5. Immobalisation: Paraplegic patients secrete large amount of calcium in the

Urine resulting in calcium oxalate stones (they pass skeleton in urine).

6. Decreased urinary citrate: Citric acid ( 300-900 mg / 24 hours ) keeps the

urinary pH low. When citric acid levels decrease, it promotes precipitation of

urinary calcium. Citrate excretion under hormonal control.

7. Inadequate urinary drainage as in case of horseshoe kidney, unascended kidneys

are more vulnerable for development of stones due to stasis.

8. Randall’s plaques: Randall has suggested that initially a small erosion or an ulcer

develops at the tip of the renal papilla on which minute concretions or minor calcium

particles get deposited and give rise to stone formation.7 (p.752-753)

Stages of stone formation

1. Supersaturation

2. Nucleus formation.

3. Crystallisation.

4. Aggregation.

5. Matrix.

6. Stone.8 (p. 955)

Type of renal stones

1. Calcium oxalate stone

2. Phosphate stone

3. Uric acid stone

4. Cystine calculus.7 (p. 753)

Clinical features

Pain – Renal pain is located over renal angle, hypochondrium and lumbar

region. Often severe radiating to groin and testis in male, with vomiting due

pylorospasm. Pain worsen on movements .

Haematuria is common

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Pyuria

Fever

Tenderness in renal angle, with often mass in the loin due to hydronephrosis

which moves with respiration and is bimanually palpable, ballotable, smooth,

soft.

As urinary tract infection.

Incidental finding.

Often hypertension.8 (p. 956)

Complications

1. Calculous hydronephrosis occurs due to back pressure producing renal

enlargement. Stretching of the renal capsule results in pain. In such cases,

an associated palpable kidney mass suggests hydronephrosis.

2. Calculous pyonephrosis: Infected hydronephrosis where in kidney is converted

into a bag of pus.

3. Renal failure: Bilateral staghorn stones may not be symptomatic until they

present with uraemia and renal failure.

4. Squamous cell carcinoma : Long- standing stones increases the risk of

carcinoma.7 (p.754)

Investigations

Blood: ESR, Serum calcium, phosphate, creatinine, blood urea, uric acid, PTH

level.

Urine: Calcium, Urate, Cystine if suspected only, pH, specific gravity.

Plain X-ray KUB: To see kidney shadow, stones (90% - radiopaque).

IVU to see renal functions and HN.

RGP is required.

U/S abdomen- can detect even radioluscent stones and gives information about

the changes in renal parenchyma.

Urine analysis and C/S to indetify bacteria.8 (p.956-57)

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Treatment

The treatment of renal stones can be divided into nonoperative treatment and

operative treatment.

Nonoperative treatment

1 Conservative: Small stones less than 5mm in size passes off with intake of

copious amount of fluids and at times forced diuretics. Intravenous hydration

followed by intravenous frusemide may help pass the stones spontaneously.

2 Extracorporeal shock wave lithotripsy (ESWL): After cystoscopy a ureteric

stunt (Double J stunt) is placed into the ureter on the side of large renal stones.

Shock waves are generated (around 500-1500shock waves) which blasts the

stones. The stones get crushed and most of the stones will come out by the

side of the stent. Small stones can be removed without prior crushing.

Operative treatment

1 Endoscopic procedures

2 Open procedures

3 Special situation.7 (p.754-755)

Abbrevations

Ni.- Nidanasthana

Ut.- Uttarardha

Chi.- Chikitsasthana

Ch.- Chapter

Ma.- Madhyama

Kh.- khanda

Sl.- Shloka

pra.- prathama

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Previous dissertation work done

1. M. Ramachandra. A clinical study on Mutra ashmari and its management with

Pashanabhedadi kwath (Dissertation). Bangalore University; 1998.

2. Chovatia Shailesh N.Role of Nagaradi Kashaya in the management of Mutrashmari

(Urolithiasis) (Dissertation). Jamnagar: Gujarat Ayurveda University; 2004.

3. Parul Chauhan. To evaluate the efficacy of Paniyakshara in the management of

Mutrashmari.A clinical comparative study (Dissertation). Davanageri: Rajiv

Gandhi university of Health Sciences; 2006

4. Subhash Khan. A study on Trivikrama rasa in management of

Mutrashmari (Urolithiasis) (Diseertation). Udupi: Rajiv Gandhi University of

Health sciences; 2006

6.3 OBJECTIVES OF THE STUDY:

1) To evaluate the efficacy of Shigrumula kwatha in the management of

Mutrashmari.

2) To evaluate the efficacy Pashanabhedadi kwatha in the management

of Mutrashmari.

3) To study the comparative effect of Shigru mula kwatha and Pashanabhedadi

kwatha in Mutrashmari, there by finding out the significance of Shigru mula

kwatha.

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7. METHODOLOGY

7.1 Source of data

The patients suffering from classical features of urinary calculi will be selected

from OPD and IPD of Sri Jayachamarajendra Institute of Indian Medicine

hospital, Bangalore-09.

7.2 Method of collection of data

The patients suffering from urinary calculi having the features of pain in renal

angle, radiating pain from loin to groin, scrotum, inner aspect of thigh, with or

without heamaturia, with or without dysurea, stranguary and the presence of

calculi confirmed by ultrasonography shall be selected for the study.

Inclusion criteria

1. Patients with the feature of pain in the renal angle, radiating pain from loin to

groin, scrotum and inner aspect of thigh or pain in at least two of these sites.

2. With or without heamaturea

3. With or without dysuria

4. With or without stranguary

5. Presence of calculi in kidney or ureter or urinary bladder confirned by USG

abdomen.

6. Size of the calculi stone up to 9mm.

7. Patients with solitary or multiple stones.

Exclusion criteria

1. Patients with retention of urine due to any other pathology, renal failure,

severe hydronephrosis, acute urinary tract infection and other diseases of

urinary system.

2. Patients with other severe systemic disorders.

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Sampling Design

A total of 40 cases of Mutrasmari after considering the above mentioned

criteria shall be included for the study.

The 40 cases included will be randomly allotted into two groups namely

group-A &group-B with 20 patients in each group.

STUDY DESIGN :

GROUP CHIKITSA PRAYOGA PRAYOGA AVADHI

GROUP A Shigru Mula

quatha 30 ml.

B.D.

Oral

administration

45 days

GROUP B Pashanabhedadi

Kwatha 30 ml.

B.D.

Oral

administration

45 days

Note : In case of severe complications occuring during the management, for eg : impacted ureteric stone, the case shall be referred to Allopathic specialist for needfull and the same shall be discarded for the study.

Observations regarding the changes in the features with the treatment shall be made fixing suitable observation days and same shall be recorded in the proforma of case sheet. For observing the possibility of reccurences in cases where total relief would be obtained, suitable duration shall be fixed.

Suitable pathya and apathya shall be adviced to the patients during the treatment.

ASSESSMENT CRITERIA

Subjective parameter

1. Pain

2. Haematuria

3. Dysuria

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4. Stranguary

Objective parameter

Size of the calculi.

7.3 INVESTIGATION 1. Urine analysis for heamaturia .

2. USG of abdomen and pelvis.

7.4 ETHICAL CLEARANCE

Ethical clearance shall be obtained from ethical committee, Government

Ayurvedic Medical College, Bangalore.

8. BIBILIOGRAPHY 1) Raja Radhakantadev Bahaddur. Shabdakalpadruma. 2nd ed. 2003.Delhi: Naga

publishers; Prathama khanda. pp .315

2) Sushruta. Sushruta samhita- translated by prof. K. R. Shrikantha Murty. 2000.

Varanasi: Chaukambha Orientalia; vol 1. pp.656

3) Charaka. Charaka samhita- translated by Prof. Priyavrat Sharma. 2005.

Varanasi: Chaukambha Orientalia; vol 2. pp.879

4) Sushruta. Sushruta samhita- edited and translated by Prof. Priyavrata Sharma.

2005. Varanasi: Chaukambha Vishwabharati oriental publishers and

distributers; vol 2.

5) Bhavamishra. Bhavaprakash- translated by Prof. K. R. Shrikantha Murty.

2005. Varanasi: Chaukambha krishnadasa academy; vol 2. pp.884

6) Yogaratnakara.Vidhyotini hindi commentary of vaidhya Lakshmipatishastri.

Edited by Shribrahmashankar Shastri. 2005. Varanasi: Chaukamba Sanskrita

16

Samsthana; pp.504

7) Rajgopal shenoy K, Anitha Nileshwar. Manipal manual of surgery.

3rd ed. 2010. New Delhi: CBS publishers and distributors Pvt. Ltd.;

pp. 969

8) Sriram Bhat M. SRB’s manual of surgery. 3rd ed. 2009. New Delhi:

Jaypee brothers medical publishers (p) Ltd.; pp.1198

9. SIGNATURE OF CANDIDATE

10. REMARKS OF GUIDE

11. NAME AND DESIGNATION OF

GUIDE

DR. R. VIJAYASARATHI

BSAM.BAMS.MD (AYU)

PROFESSOR & HOD,

DEPARTMENT OF P.G. STUDIES IN

SHALYA TANTRA,

G.A.M.C., BANGALORE - 560 009.

11.1 SIGNATURE

11.2 HEAD OF THE DEPARTMENT Dr.R.VIJAYASARATHI.

BSAM.BAMS.MD (AYU)

PROFESSOR & H.O.D

DEPARTMENT OF P.G. STUDIES IN

SHALYA TANTRA,

G.A.M.C, BANGALORE-560 009.

11.3 SIGNATURE

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11.4 REMARKS OF PRINCIPAL

12. SIGNATURE

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