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A REVIEW ON THE SIGNIFICANCE OF NITYA VIRECHANA IN THE MANAGEMENT OF JALODARA (ASCITES)

Jalodara is a type of Udara roga. It is such type of a disease which is difficult to cure. Its occurrence is increasing day by day in our society. In Jalodara, there is accumulation of fluid in between Tvak and Mamsa of Udara pradesha (abdomen). As a result, there is distension of abdomen. Its main causes are Mandagni, Srota avarodha and Apa dosha etc. Here vitiated Kapha and Vata are mainly involved. In this disease accumulated Doshas are mainly obstruct the Swedavaha and Ambuvaha srotas. It has three stages which are Ajatodakavastha, Picchavastha and Jatodakavastha. Jalodara in its Jatodakavastha is incurable. It can be correlated with Ascites based on its clinical features. Ascites is the abnormal accumulation of free fluid in the peritoneal cavity. Its most common cause is portal hypertension related to hepatic cirrhosis. Ascites is asymptomatic when there is small accumulation of fluid in peritoneal cavity. But when there is larger accumulation of fluid (> 1 lit), it shows symptoms. In this article, Ayurvedic treatment principles for Jalodara have been discussed in details. These include Nidan parivarjana, Nitya virechana, therapies which remove the defects of liquid elements (Apam doshaharanam), Dipana and Shastra karma (abdominal tapping). This article is mainly based on the review of the significance of Nitya virechana in the management of Jalodara (Ascites).


INTRODUCTION
In Ayurveda, there is concept of Ashta mahagada (eight great diseases) which are dreadful and difficult to treat. Udara roga is accepted as one of the Ashta mahagada. The Sanchita doshas by obstructing the Swedavaha and Ambuvaha srotas and affecting Prana vayu, Agni and Apana vayu, produce the Udara roga. [1] It is characterised by abnormal distension or enlargement of abdomen. There are eight types of Udara roga. Jalodara is one among them. Udakodara and Dakodara are its synonyms. In Jalodara, there is accumulation of fluid in between Tvak and Mamsa of Udara pradesha (abdomen). [2] Due to this, there is abnormal increase in abdominal girth of the patient. It is of two types -Swatantra Jalodara (which occurs independently) and Paratantra Jalodara (which arises as a complication of other diseases). [3] It can be correlated with Ascites due to similarity in their clinical features. The term 'Ascites' is derived from Greek word 'Askites' meaning 'bag like'. It is the abnormal accumulation of free fluid in the peritoneal cavity. Technically, it is more than 25ml of fluid in the peritoneal cavity, although volumes greater than 1 lit may occur. [4] The main lines of treatment for Jalodara are Nidana parivarjana (avoidance of etiological factors), Shodhana chikitsa (purificatory therapy), Shamana chikitsa (Palliative therapy) and Shastra karma (Surgical measure). Proper Pathya-Apathya should also be followed along with these treatments. Nitya virechana has been described as one of the most effective Shodhana therapies in the management of Jalodara. AIMS AND OBJECTIVES 1. To discuss about Jalodara (Ascites) in details. 2. To evaluate the significance of Nitya virechana in the management of Jalodara (Ascites).

MATERIALS AND METHODS
As the present study is a review article, different Ayurvedic texts, modern books, published research papers and available materials on internet have been reviewed for this article. Concept of Jalodara (Ascites) Etiopathogenesis of Jalodara As per Acharya Caraka-If there is Atyambupana (excessive intake of water) in the conditions like Snehapitasya (after administration of oleation therapy) or Mandagni (suppressed power of digestion) or Kshinasya atikrishasya (cachexia or excessive emaciation) then Agni loses its power. As a result of this, Vayu located in Kloma (a visceral organ located adjacent to the heart, i.e. right lungs) gets interrupted with Kapha and Udaka dhatu (a liquid element of the body) increases the quantity of water in the obstructed channels of circulation. Both vitiated Kapha and Vayu displace this water from its place and cause its accumulation into the abdomen, due to which Udakodara is caused. [5] As per Acharya Sushruta-The person who is undergoing therapies such as Sneha pana (Oleation), Anuvasana (Oil enema), Vamana (Emesis), Virechana (Purgation) or Niruha (Decoction enema), if he drinks cold water immediately, then channels of water become smeared with fatty materials and give rise to Dakodara. [6] Signs and symptoms of Jalodara [7][8][9] I. Aruchi (Anorexia), Pipasa (morbid thirst), Guda srava (discharge from the rectum), Shula (colic pain), Swasa (dyspnoea), Kasa (cough) and Daurbalya (general weakness). II. The abdomen is Snigdha (unctuous), Mahat (big) and Sthira (static). There is presence of Vritta nabhi (bulging umbilicus). III. Udaram nanavarna raji sira santatamappearance of network of veins having different colour over the abdomen. IV. Udaka purna driti kshobha samsparsha-in percussion and palpation, the physician feel as if the abdomen is a leather bag filled with water.

Stages of Jalodara
There are three Avasthas (stages) of Jalodara which are as follows [10] I. Ajatodakavastha (Accumulation of water does not take place in the abdomen in this stage) II. Picchavastha (Accumulation of Piccha i.e., sticky liquid takes place in the abdomen in this stage) III. Jatodakavastha (Accumulation of water takes place in the abdomen in this stage) These three stages are the progressive conditions of Srota avarodha in Jalodara. Prognosis of Jalodara I. All varieties of Udara roga are considered as Kriccha sadhya (difficult to cure) right from their origin. But it can be cured with proper care soon after its origin when patient is strong and water has not started accumulating in abdomen. [11] II. Jalodara in its Jatodaka stage is Asadhya (incurable) right from its origin. [12] III. Jalodara with complications is also Asadhya (incurable). Gradually, the patient should be prohibited to take water and such other liquids. [14] IV. Takra (butter milk) mixed with Trikatu curna is beneficial in Jalodara. [15] V. Shastra karma (Abdominal tapping)-The physician should puncture the left side of the abdomen below the umbilicus with the help of Vrihimukha shastra. After that fluid should be drained out with the help of Nadi yantra. After draining the fluid, abdomen should be tied tightly with the help of a cloth bandage. [16] VI. Diet regimen after abdominal tapping [17] -Patient should be made to fast after abdominal tapping then he should take Peya (thin gruel) without adding Sneha (fat) and Lavana (salt). Thereafter, he should take following diet for one year.  For first six months -Milk diet.  For next three months -Peya + milk.  For last three months -Cereals like Shyamaka or Kordusha along with milk. These are light for digestion and no salt should be given during this period.
Jalodara can be correlated with Ascites due to similarity in their clinical features. Ascites is the abnormal accumulation of free fluid in the peritoneal cavity. Common causes of Ascites are hepatic cirrhosis, cardiac failure and malignant disease (hepatic and peritoneal). Its other causes are hypoproteinaemia (Nephrotic syndrome), hepatic venous occlusion (Budd-chiari syndrome, venoocclusive disease), pancreatitis, lymphatic obstruction and infection like tuberculosis. It's rare causes are Meigs' syndrome and hypothyroidism. [18] Ascites is asymptomatic when there is small accumulation of fluid in peritoneal cavity. On the other hand with larger accumulation of fluid (> 1 lit), it is manifested with abdominal distension, fullness in the flanks, shifting dullness on percussion and fluid thrill. Other features include eversion of umbilicus, hernia and abdominal striae etc. Dilated superficial abdominal veins may be appeared if it is occurred due to portal hypertension. [18] If ascitic fluid is massive patient will develop shortness of breath. Patients with massive ascites are often malnourished and have muscle wasting. [19] Its treatment includes sodium and water restriction, administration of diuretics, paracentesis, insertion of peritoneo-venous shunt and TIPS (Transjugular intrahepatic portosystemic shunt). [18] If ascites does not respond to treatment then liver transplant may be recommended. [ [22]  Definition of Virechana (Purgation therapy): The process of expelling out Doshas through downward tract (anus) is called Virechana. [23]  Definition of Nitya virechana: It can be defined as a type of Virechana karma which is done to eliminate the excessively aggravated Doshas (Bahu dosha) in small quantity (Stoka stoka dosha nirharana) in Alpa bala rogi on daily basis by administering Mridu virechaka aushadha. [24]

Application of Nitya virechana in Jalodara
In Jalodara, there are Dosha atimatra upachayat (excessive accumulation of Doshas) and Srotomarga nirodhanat (obstruction to the opening of srota). That's why, the patient of Jalodara should be given purgation therapy everyday (Nityameva virechayet). [25] For this purpose following medicines are administered [26] .
i. Eranda taila (castor oil) mixed with cow's urine or cow's milk should be given daily for one or two month(s). ii. Mahisha mutra (buffalo's urine) mixed with milk for seven days. iii. Gomutra haritaki prayoga.
When body is cleansed by the help of Virechana then Samsarjana karma should be followed. Thereafter, the patient should be given to drink milk for the promotion of his strength. Drinking of milk should be stopped when Utklesha (nausea) has started to develop. That means when patient has regained his strength then milk should be stopped. [27]

DISCUSSION
In Jalodara, there is distension of abdomen due to accumulation of fluid. So, such type of treatment should be adopted which removes the accumulated fluid from the body and prevent further accumulation of fluid in the abdomen. Ayurveda has described the management of Jalodara in details. In this article all these treatment principles have been discussed. These include Nidan parivarjana, Nitya virechana, therapies which remove the defects of liquid elements (Apam doshaharanam), Dipana and Shastra karma (abdominal tapping). Among all these treatment principles, Nitya virechana has been discussed in details. Nitya virechana is a type of Virechana karma which can be used on regular basis. It helps to remove the accumulated Doshas from the body of Jalodara rogi. On the other hand it also removes the Srota avarodha which is one of the important causes for the accumulation of fluid. Thus all the above mentioned treatment principles help to remove the accumulated fluid from the body. Somehow, also prevent the further accumulation of fluid in the abdomen.
Proper Pathya-apathya should also be followed along with above mentioned treatment. Takra (butter milk) and Kshira (milk) are very beneficial for Jalodara rogi. In Jalodara, takra mixed with Trikatu curna should be given. [15] After the body is cleansed of impurities and it has become emaciated then cow's milk, goat's milk, and buffalo's milk are very useful. [28] All the eight types of Mutra (urine) should be used for Seka (sprinkling over the abdomen) and Pana (drinking) in Udara roga. [29] Salt and water restricted diet should be given to the patient of Jalodara. CONCLUSION Jalodara is one among the eight types of Udara roga. It is mainly manifested by distension of abdomen due to accumulation of fluid. It can be managed by proper treatment in its initial stage. But in Jatodaka avastha, it becomes incurable. The main lines of treatment for Jalodara are Nidana parivarjana (avoidance of etiological factors), Shodhana chikitsa (Purificatory therapy), Shamana chikitsa (Palliative therapy) and Shastra karma (Surgical measure). Niranna, Nirjala and Nirlavana chikitsa are proved to be very beneficial for this disease. Nitya virechana is one of the most effective Shodhana therapies for Jalodara. It helps to remove the accumulated Doshas from the body and also helps in Srota shodhana. Hence, Nitya virechana is very significant in the management of Jalodara (Ascites).