Agni is deranged by fasting, eating during indigestion, over-eating, irregular eating, intake of unsuitable food...faulty adaptation to place, time and seasons and suppression of natural urges. Agni thus deranged becomes unable to digest even light food and the food being undigested gets acidified and toxic. (1).
In this article we will specifically discuss urdvaga amlapitta or upward moving acidity, which leads to symptoms of heartburn, acid reflux, headaches, nausea and loss of appetite (2). It may, in association with kapha, also give rise to post-nasal drip, sinusitis and asthma (3). We will consider the presentation and clinical management of three typical cases of amlapitta--in a stressed out engineer, in a smoker and in a woman with a history of bulimia.
Amlapitta, currently known in America as GERD (gastro-esophageal reflux disease) is an extremely common condition worldwide which may affect as much as 20% of the American adult population with weekly symptoms of heartburn (4, 5). The condition is often self-managed with over-the-counter antacid preparations, with as much as 15% of the adult population consuming antacids at least more than once a week (6). Established causes of GERD fall into two main categories--foods and drugs that lower the pressure of the lower esophageal sphincter and those that irritate the gastric mucosa. Fatty foods, peppermint, onions, coffee, alcohol, smoking, progesterone and many medications fall into the first category, while citrus, tomato, spicy foods, coffee, tea, colas, aspirin and NSAIDs (non-steroidal anti-inflammatory drugs) fall into the second category (7). Obesity is a significant risk factor for GERD (8), while psychological stress is known to exacerbate acid reflux conditions (9). Bulimia that expresses in vomiting food can also lead to an array of symptoms and complications of GERD (10).
Patient A is a fifty-eight-year-old female smoker, V1P2K3, complaining of acid reflux and burping which had been present on and off for the past year. She also struggled with depression following a traumatic childhood. She had a family history of peptic ulcers. Obesity was significant in the etiology of her condition; she weighed 230 lb at a height of 5'7" and with an optimum weight of 150 lb. She had smoked since the age of 25 with a total of about sixteen pack-years. Her diet was irregular. For breakfast she took protein shake with bananas and her other meals consisted of soup, salad, toast, crackers and cookies. Smoking, diet, stress and obesity may all have played a part in her persistent amlapitta condition.
Patient B is a fifty-year-old engineer, V1P3K2, with a high stress job involving a great deal of international travel. He complained of pitta skin rashes that came on at the change of seasons, as well as acid reflux, which he noticed during his last international flight. Endoscopy showed esophageal scarring from reflux. His abdomen was sore and distended and he experienced a lot of gas. A weight of 186 pounds at 5'11" made him overweight although not obese. A less-than optimal waist hip ratio may have been a contributing factor in his condition. He drank coffee daily, an important exacerbating factor. His diet consisted of bagel and cream cheese for breakfast, soup and sandwich for lunch and a main meal at night, either prepared by his wife, or, when travelling, restaurant food. Severe stress was the greatest component in creating his pitta condition, although weight, diet and caffeine intake were all significant factors.
Patient C is a twenty three year old female military officer, V3P12K2, complaining of bulimia and acid reflux. Her eating disorder had been persistent for the last ten years. After being teased by classmates for childhood obesity she developed anorexia nervosa in her early teens and got down to 80lb at 5'5". After a while her symptoms shifted to bulimia nervosa and she began throwing up every time she ate. Currently she was bingeing and throwing up each night in the pitta time of night. Inevitably she was experiencing reflux symptoms, for which she took Prevacid. She did not currently take caffeine. She had recently changed her diet and become vegetarian. For brunch she ate vegetables and salad and for dinner salad with tofu or hummus. She snacked on fruit or crackers. Each night at around 11 p.m. she binged on cookies, soy chips, candy and hot chocolate, which she then threw up.
Patient A was counseled to stop smoking using an Ayurvedic herbal smoking mix (see http://www.alandiashram.org/school/school_html/reviews/tobacco-addiction.html) and was encouraged to modify her diet for kapha by avoiding wheat and cow dairy and eating lower fat foods such as berries and vegetables. A combination of Brahmi and Bacopa was recommended for her depressive condition. In addition, Brahmi is highly effective against H pylori, an important causative factor in peptic ulcers and bacopa monniera also shows significant ulcer healing properties (11). This was particularly important in light of her family history of peptic ulcers. Aloe vera gel was the anupan of choice for all three patients.
Patient B was placed on a pitta soothing diet and was also given a Brahmi Bacopa combination to help his stress-related condition. Important herbs for his amlapitta included Shatavari, Guduchi and Bhringaraj. In amlapitta, Shatavari has been shown to reduce symptoms of heartburn and nausea and to lower total gastric acidity and gastric emptying time (12, 13, 14). Guduchi is an important gastro-intestinal protective (15). Bhringaraj has also been shown to be effective in reducing gastric acidity (12, 16).
Patient C was suspected to have addictive allergies to the foods she binged on and was advised to do an elimination trial of wheat and soy. She was also referred for therapy for her eating disorder. We encouraged her to eat more nourishing foods during the day to avoid the intense hunger that led to her nightly binges. She was given tulsi-brahmi tea to help with her emotional issues. Tulsi is also an important herb for dyspepsia (17). Her formula included Shatavari and also Licorice root, which has important anti-ulcer and anti-inflammatory properties in amlapitta (18).
As an alternative to consumption of antacid patent medicines, proton pump inhibitors and surgical interventions, Ayurveda offers a holistic approach of dietary and lifestyle changes and herbal remedies that can address not only the symptoms but also the causes of amlapitta.
1. Charak Samhita chikitsa sthana ch 15 v 42-44 tr. P.V. Sharma, Chaukhambha Orientalia Varanasi 1994
2. ibid v 45-46
3. ibid v 47-48
4. Locke G R III, Talley N J, Fett S L, Zinsmeister A R, Melton J III. Prevalence and clinical spectrum of gastroesophageal reflux: A population-based study in Olmsted County, Minnesota. Gastroenterlogy. 1997; 112: 1448-1456.
5. Shaheen N, Provenzale D. The epidemiology of gastroesophageal reflux disease. Am J Med Sci. 2003 Nov; 326(5):264-73
6. Diseases of the Gastroesophageal Mucosa. The Acid-Related Disorders Edited by J W Freston. New Jersey: Humana Press, 2001, $99.50, pp 200. ISBN 0 986 03965 p 123
7. ibid 127
8. ibid 128
9. T. Kamolz; F. A. Granderath; T. Bammer; M. Pasiut; R. Pointner Psychological Intervention Influences the Outcome of Laparoscopic Antireflux Surgery in Patients with Stress-related Symptoms of Gastroesophageal Reflux Disease , Volume , Issue August 2001 , pages 800 - 805
10. Laura M. Lasater and Philip
S. Mehler Medical
complications of bulimia nervosa Eating
2, Issue 3, Autumn 2001, Pages 279-292
11. Ingrid Kohlstadt, editor Food and Nutrients in Disease Management Boca Raton, FL, CRC Press/Taylor & Francis Group, 2009 ISBN-13: 978-1-4200-6762-0 CH 11.
12. Lakshmi Chandra Mishra, Scientific basis for Ayurvedic therapies, CRC Press 2004 Ch 19
13. SS Dalvi, PM Nadkarni, KC Gupta Effect of Asparagus racemosus (Shatavari) on gastric emptying time in normal healthy volunteers J Postgrad Med. 1990 Apr;36(2):91-4.
14. K. Sairam, S. Priyambada, N. C. Aryya and R. K. Goel, Gastroduodenal ulcer protective activity of Asparagus racemosus: an experimental, biochemical and histological study Journal of Ethnopharmacology Volume 86, Issue 1, May 2003, Pages 1-10
15. T. S. Panchabhai, U. P. Kulkarni, N. N. Rege Validation of therapeutic claims of Tinospora cordifolia: a review Phytotherapy Research Volume 22, Issue 4, pages 425-441, April 2008
16. Chaturvedi, G.N. and R.N. Singh Treatment of hyperchlorhydria with an indigenous drug Eclipa alba Current Medical Practice 8, 283 1968
17. P. Prakash And Neelu Gupta Therapeutic Uses Of Ocimum Sanctum Linn (Tulsi) With A Note On Eugenol And Its Pharmacological Actions: A Short Review Indian J Physiol Pharmacol 2005; 49 (2) : 125-131.
18. Asl MN, Hosseinzadeh H. Review of pharmacological effects of Glycyrrhiza sp. and its bioactive compounds