RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

KARNATAKA, BANGALORE-560009

REGISTRATION OF SUBJECT FOR DISSERTATION

BY

Dr. LATHA.K

FOR THE DEGREE OF AYURVEDA

DHANVANTARI

M.S (AYURVEDA) IN SHALYA TANTRA

TITLE OF THE TOPIC:

A STUDY ON EFFICACY OF “TILAADI KSHARA AND

TILANALA KSHARA” IN THE MANAGEMENT OF

MUTRASHMARI W.S.R TO UROLITHIASIS.

GOVERNMENT AYURVEDA MEDICAL COLLEGE

DHANVANTARI ROAD

BANGALORE – 09

KARNATAKA

From,

Dr. LATHA.KI M.S.(Ayu)., Dept. of PG Studies in Shalyatantra,Government Ayurveda 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 SHALYATANTRA

GOVERNMENT AYURVEDA MEDICAL COLLEGE,

BANGALORE-560009

Respected Sir,

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

With referenced to above subject, I request you to kindly register the below

mentioned subject against my name for Dissertation by the Rajiv Gandhi University

of Health Sciences, Bangalore for the partial fulfilment of M.S (Ayu) in Shalyatantra.

TITLE OF THE DISSERTATION:

A STUDY ON EFFICACY OF “TILAADI KSHARA AND TILANALA KSHARA” IN THE MANAGEMENT OF MUTRASHMARI W.S.R TO UROLITHIASIS.

I am here with enclosing the completed proforma for registration of subject for Dissertation.

Thanking you,

Yours faithfully,

Place: Bangalore

Date: (Dr.LATHA.K)

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA.

ANNEXURE II

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1 NAME OF THE CANDIDATE AND ADDRESS

Dr. LATHA.KD/O J. KRISHNA MURTHY NO-7 ,9TH MAIN ,KALAPPA BLOCK, SRINAGARA, BANGALORE – 560050,KARNATAKA

2NAME OF THE INSTITUTION

GOVERNMENT AYURVEDA MEDICAL COLLEGE, DHANVANTARI ROAD,BANGALORE-09

3COURSE OF STUDY AND SUBJECT

AYURVEDA DHANVANTARI.MS (AYU),SHALYA TANTRA

4DATE OF ADMISSION TO THE COURSE

17/10/2012

5TITLE OF DISSERTATION

A STUDY ON EFFICACY OF ” TILAADI KSHARA AND TILANAALA KSHARA” IN THE MANAGEMENT OF MUTHRASHMARIW.S.R TO UROLITHIASIS.

6. BRIEF RESUME OF THE INTENDED WORK :

6.1 NEED FOR THE STUDY

Ashamari is one among the Muthravahasrotho vikara. Acharya Sushruta has

mentioned it as one among Astamahagada and calls it as “Antakapratima” which

means swaroopa of Yama. Madhavakra also mentioned it as “Yamopama” - The God

of death.

The oldest evidence regarding Ashmari vyadhi can be found right from vedic period

itself. (I.e. Atharvaveda1/3/6, 7, 8, 9). During samhitakaala explanations regarding

aetio-pathogenesis, classification, clinical features, prognosis and treatment modalities

are found.

Many kalpas with Ashmari bhedaka property have been mentioned by various

authors. However Sushruthaacharya says in tarunavasta it is oushadhasadya and in

pravruddavasta, chedana should be done.

Various Ghrutha, kshara, kashaya, ksheera and uttharabasthi are the main line of

treatment, if disease does not get alleviated, chedhana is ultimate treatment.

Prevalence rate of Urolithiasis varies according to geographical distribution, sex and

age and are more commonly seen in subjects residing in countries with dry and hot

climate. About 12% of people suffer from kidney stone once in their life time.The

prevalence of kidney stone is seen more commonly in male as compared to females

(12% of male & 5% of female).

The Urolithiasis occurs more commonly between 3rd to 5thdecade in both sex, and

rarely occurs after 5thdecade. The recurrence rate of urolithiasis is around 50% in 5 –

10 years. In India, approximately 5 to 7 million people suffer from urinary calculus

and at least 1/1000 of Indian population needs hospitalization due to kidney stone

disease.

A calculus is a concretion usually composed of inorganic materials formed in a cavity

or tissue of the body , due to imbalance between the promoters and inhibitors of

crystallization in urine. It presents with clinical features like renal pain, ureteric

colic, haematuria and presence of calculi. Thus with all these features Mutrashmari

can be correlated to Urolithiasis. (Calculus in urinary system)

The treatment principle of urinary calculus in modern science varies depending upon

size, position of calculi etc. conservative treatment includes flush therapy in case of

stones up to 5mm, medical expulsive therapy using alpha-antagonists or calcium-

channel blockers. Non surgical management includes ESWL &Dormia basket

procedure.

Operative treatment includes advanced techniques like PCNL, Ureteroscopy,

Pyelolithotomy, Nephrolithotomy, Partial Nephrectomy, Nephrectomy,Nephrostomy

etc.

Due to increasing incidence of urolithiasis and complications faced ,the study on

Mutrashmari with management of Tilaadikshara as mentioned in Astanga Hridaya

chikitsasthana, chapter-11, shloka-31 is been taken up for the present study, where

kshara is said to have bhedana, lekhana, mutrala and tridoshaghna.

To evaluate significance of Tilaadikshara in the management of Mutrashmari,

Tilanaalakshara has been taken up which is an established one.

6.2 REVIEW OF LITERATURE:

AYURVEDIC REVIEW ON ASHMARI

Vyuthpati:

AzqÉÉlÉÇUÉÌiÉSSÉÌiÉrÉÉ||1(pra. Kh. p.141)

The word meaning of Ashmari is “That which gives stone”

Nidana:

iɧÉÉxÉÇvÉÉåkÉlÉvÉÏsÉxrÉÉmÉjrÉMüÉËUhÉÈmÉëMÑüÌmÉiÉÈvsÉåvqÉÉ

qÉÔ§ÉxÉÇÇmÉëÑ£üÉå ÅlÉÑmÉëÌuÉvrÉ oÉÎxiÉqÉvqÉUÏÇeÉlÉrÉÌiÉ ||

In person who does 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.p.483.)

Purvarupa:

iÉÉxÉÉÇ mÉÔuÉïÃmÉÉÍhÉ – euÉUÉå oÉÎxiÉmÉÏQûÉUÉåcÉMüÉæ qÉÔ§ÉM×ücNíÇû oÉÎxiÉÍzÉUÉåqÉÑwMüzÉåTüxÉÉÇ uÉåSlÉÉ M×ücNíûÉuÉxÉÉSÉå oÉxiÉaÉÎlkÉiuÉÇ qÉÔ§ÉxrÉåÌiÉ || rÉjÉÉxuÉuÉåSlÉÉuÉhÉïçÇ SÒ¹Ç xÉÉlSìqÉjÉÉÌuÉsÉqÉç | mÉÔuÉïÃmÉåÅzqÉlÉÈ M×ücNíûÉlqÉÔ§ÉÇ xÉ×eÉÌiÉ qÉÉlÉuÉÈ ||

Their premonitory symptoms are as follows-fever, pain in urinary bladder, anorexia,

dysuria, pain in head of urinary bladder, scrotum and penis; pain full malaise and

goat’s smell in urine. in the prodromal stage of calculus the person passes vitiated,

viscid and turbid urine with difficulty along with respective pain and colour4.

(Ni.ch.3.sl.5,6.p.26)

Lakshana:

AjÉeÉÉiÉÉxÉÑlÉÉÍpÉoÉÎxiÉxÉåuÉlÉÏqÉåWûlÉåwuÉlrÉiÉqÉÎxqÉlÉç qÉåWûiÉÉå uÉåSlÉÉ| qÉÔ§ÉkÉÉUÉxÉXçaÉÈ xÉÂÍkÉUqÉÔ§ÉiÉÉ qÉÔ§ÉÌuÉÌMüUhÉÇ aÉÉåqÉåSMümÉëMüÉvqÉirÉÉÌuÉsÉqÉçxÉÍxÉMüiÉÇÌuÉxÉ×eÉÌiÉ kÉÉuÉlÉsÉÇbÉlÉmsÉuÉlÉ mÉÚ¹rÉÉlÉÉåwhÉÉkuÉaÉqÉlÉæ¶ÉÉxrÉ uÉåSlÉÉpÉuÉÎliÉ||

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

penis and other areas near by during micturation, interruption of stream of 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); there is pain during running, jumping, swimming, riding, exposure to

sunlight, long walk etc.2(Ni. ch.3 sl.7.p.484.)

Samprapthi:

ÌuÉvÉÉåwÉrÉåSè oÉÎxiÉaÉiÉÇ xÉzÉÑ¢Çü qÉÔ§ÉÇ xÉÌmɨÉÇ mÉuÉlÉÈMüTüÇ uÉÉrÉSÉ iÉSÉÅvqÉrÉÑïmÉeÉÉrÉiÉå iÉÑ ¢üqÉåhÉÌmɨÉåÎwuÉuÉ UÉåcÉlÉÉ aÉÉåÈ||

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.p.424)

Chikithsa:

AvqÉUÏSÉÂhÉÉåurÉÉÍkÉUliÉMümÉëÌiÉqÉÉå qÉiÉÈ|AÉæwÉkÉæxiÉÂhÉÈxÉÉkrÉÈmÉëuÉ×®zNåûSqÉWïûÌiÉ ||

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.p.340)

iÉxrÉ mÉÔuÉåïwÉÑ ÃmÉåwÉÑ xlÉåWûÉÌS¢üqÉ CwrÉiÉå |iÉålÉÉxrÉÉmÉcÉrÉÇ rÉÉÎliÉ urÉÉkÉåqÉÔïsÉÉlrÉzÉåwÉiÉÈ||

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.p.340)

bÉ×iÉæÈ ¤ÉÉUæÈ MüwÉÉrÉæ¶É¤ÉÏUæÈ xÉÉå¨ÉUoÉÎxiÉÍpÉÈ |rÉÌSlÉÉåmÉzÉqÉÇ aÉcNåûcNåûSxiɧÉÉå¨ÉUÌuÉÍkÉ: ||

If it does not get alleviated by application of ghrutha, alkali, decoctions, milk and

urethral douche, the next step is surgical operation.4(chi.ch. 7 sl.27.p.344)

ÌiÉsÉÉmÉqÉÉaÉï MüSsÉÏmÉsÉÉzÉrÉuÉxÉqpÉuÉÈ |¤ÉÉUÈ mÉårÉÉåÅÌuÉqÉÔ§ÉåhÉ zÉMïüUÉxuÉzqÉUÏwÉÑcÉ ||

Kshara of Tila, apamarga, kadali, palasa and yava consumed with sheep’s urine is

good for both gravel and stone. 5 (chi.ch.11 sl.31.p.376)

Kshara preparation:

¤ÉÏUuÉפÉxrÉ MüɸÉÌlÉ zÉÑwMüÉhrÉaÉëÉæ mÉëSÏmÉrÉåiÉç lÉÏiuÉÉ iÉ°xqÉ qÉ×imÉɧÉå ͤÉmiuÉÉ lÉÏUå cÉiÉÑaÉÑïhÉåÌuÉqɱï kÉÉUrÉåSìɧÉÉæ mÉëÉiÉUcNÇû eÉsÉÇ lÉrÉåiÉç ||iɳÉÏUÇ YuÉÉjÉrÉå²»ûÉæ rÉÉuÉixÉuÉïÇ ÌuÉzÉÑwrÉÌiÉ iÉiÉÈ

mÉɧÉÉixÉqÉÑÎssÉZrÉ ¤ÉÉUÉå aÉëÉ½È ÍxÉiÉmÉëpÉÈ ||cÉÔhÉÉïpÉÈ mÉëÌiÉxÉÉrÉïÈ xrÉÉimÉårÉÈ xrÉÉiYuÉÉjÉuÉÎixjÉiÉÈ

CÌiÉ ¤ÉÉU²rÉÇ kÉÏqÉÉlÉÑ£üMüÉrÉåïwÉÑ rÉÉåeÉrÉåiÉç ||

Dried wood of trees which exude milky sap are burnt to ashes in fire. The ash thus

obtained is dissolved in four times of water in a mud pot and kept over night. Next

morning the clear supernatant water is decanted out into a clean vessel and boiled till

all the water evaporates, leaving of a fine white powder at the bottom this is known as

ksara (alkali). It is used in two ways i.e. “Pratisarya”(external application) and “Peya”

( internal potion along with suitable vehicles.6(Ma Kh.ch.11.sl.101-104.p.156)

MODERN REVIEW ON UROLITHIASIS:

Aetiopathogenesis:

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.

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

of calcium, formation of calcium oxalate stones.

Dietary factor:

Diet rich in red meat, fish, eggs can give rise 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.

Metabolic causes:

Hyperparathyroidism increases serum calcium levels resulting in

Hypercalcinosis and pelvic stones.

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

Immobilisation: Paraplegic patients secrete large amount of calcium in the

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

Urinary pH low: When citric acid levels decrease, it promotes precipitation of

urinary calcium. Citrate excretion under hormonal control.

Inadequate urinary drainage as in case of horseshoe kidney, Unascended

kidneys are more vulnerable for development of stones due to stasis.

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

to pylorospasm. pain worsen on movements.

Haematuria is common

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 .

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)

Treatment:

The treatment of renal stones can be divided into non operative treatment and

operative treatment.

Non operative treatment

1. Conservative: A small stone 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 to pass the stones spontaneously.

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

(Double J stent) 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)

Abbreviations :

Ni.-Nidanasthana

Chi.-Chikitsasthana

Ch.-Chapter

Ma.-Madhyama

Kh.-Khanda

Sl.-Shloka

Pra.-Prathama

Ma.-Madyama

P.- Page number

pp. -printed pages

Previous dissertation work done:

1. SanjeevLJahagirdhar-A Study on mutravahasrothas W.S.R to effect of

Tilanalakshara in the management of vataja Mutrashmari. BNM Ayurvedic coll; 2010

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. Dharmapaj S.L –Effect of Tilanaala ksharayoga in management of Mutrashmari.

SDM Hassan.2001-2002

5. Ashok M. L - Role of Palashakshara in mutrashmari, SDM Hassan .2000

6.3 OBJECTIVES OF THE STUDY :

To evaluate efficacy of Tilaadikshara in the management of

Mutrashmari.

To evaluate the efficacy of Tilanaalakshara in the management

Mutrashmari.

To study the comparative effect of Tilaadikshara and Tilanalakshara

in Mutrashmari, there by finding out the significance of Tilaadikshara.

7. METHODOLOGY:

7.1 SOURCE OF DATA:

The patient suffering from classical features of Mutrashmari 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 patient suffering from Mutrashmari having the features of pain in the renal angle ,

pain in hypochondrium, pain in lumbar region, radiating pain from loin to groin, pain

in scrotum and inner aspect of thigh, haematuria, dysuria and the presence of calculi

confirmed by ultrasonography shall be selected for the study.

INCLUSION CRITERIA:

1. Patient complaining of pain in the renal angle , pain in hypochondrium, pain in

lumbar region and radiating pain from loin to groin, scrotum and inner aspect of

thigh or pain in at least any two of these sites.

2. With or Without Haematuria in context of USG showing calculi in urinary

tract

3. With or Without Dysuria in context of USG showing calculi in urinary tract.

4. Presence of calculi up to 9 mm size.

5. with or without mild hydroureternephrosis confirmed by USG abdomen.

6. Calculi present in kidney, ureter, and urinary bladder.

7. Patient with solitary or multiple stones.

8. Patient with age between 20 to 60 years.

EXCLUSION CRITERIA:

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

moderate and severe hydroureteronephrosis, acute urinary tract infection and

other diseases of urinary system.

2. Patient with other systemic disorder.

3. Presence of calculi during pregnancy and lactation.

4. Stag horn calculi.

Note: The diseases mentioned in the exclusion criteria will be ruled out by

necessary investigations.

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

shall be included for the study. These 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

MATRA

GROUP A Tilaadikshara

with Avimutra

Abhyanthara

21 days

250mg bid

after food

GROUP B Tilanalakshara

with madhu

Abhyanthara 2

1 days

250mg bid

after food

Note: During the course of study, if patient is not regular for follow up, non

compliant with medication and develops urosepsis or severe hydro

ureteronephrosis, such cases will be excluded from the study. Patients with

complications will be referred immediately to urologist.

Observations regarding the changes in the clinical features during study period will be

done on every 7th day and shall be recorded in the specific case sheet. For observing

the possibility of recurrence in case where total relief would be obtained, duration of

six months will be fixed. Suitable pathya and apathy shall be advised to the patient

during and after the treatment.The result obtained shall be statistically analysed and

conclusion shall be draw.

ASSESSMENT CRITERIA:

Subjective parameter

1. Pain

2. Haematuria

3. Dysuria

Objective parameter

1. Size of the calculi .

2. Descent of the calculi .

3. Number of calculi .

4. Tenderness.

7.3 INVESTIGATION:

1. USG - Abdomen and Pelvis- done before and after treatment.

7.4 ETHICAL CLEARANCE:

Ethical clearance shall be obtained from ethical committee, Government

Ayurveda Medical College, Bangalore.

8. BIBILIOGRAPHY:

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

publishers; 2003.Prathamakhanda. pp .315

2) Sushruta. Sushrutasamhita- translated by prof. K.R.ShrikanthaMurty.1st ed.

Varanasi: Chaukambh orientalia; 2000. vol 1.pp.656

3) Charaka. Charakasamhita- translated in english by Prof. Priya Vrata Sharma.

Varanasi: Chaukambha Orientalia;2003. vol 2.pp.879

4) Sushruta. Sushrutasamhita- edited and translated by Prof. Priya Vratha Sharma. Varanasi: Chaukambha Vishwabharati oriental publishers and distributer; 2005.vol 2.pp.695

5) Vagbhata. AstangaHrudayam-Translated by Prof.K.R.Srikanthamurthy.5thed. Varanasi: Chowkhamba krishnadas academy,Chowkamba oriental publisher and Distributer;2003.vol.2.pp.596

6) Sarangadhara .SarangadharaSamhita –translated in English by Prof .K.R. Srikantha murthy. 5 thed.Varanasi :Chaukamba Orientalia;2003.pp.335

7) Rajgopalshenoy K, AnithaNileshwar. Manipal manual of surgery.3rded.

New Delhi: CBS publishers and distributors Pvt. Ltd.;2010.pp. 969

8) Sriram Bhat M. SRB’s manual of surgery. 3rded. New Delhi:Jaypeebrothers

medical Publishers (p)Ltd.;2009. pp.1198

9. SIGNATURE OF CANDIDATE

10. REMARKS OF GUIDE

11. NAME AND DESIGNATION OF

GUIDE

DR. M.G NARMADA BAMS. MD (AYU)

PROFESSOR

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

11.4 REMARKS OF PRINCIPAL

12. SIGNATURE