Featured Case

MODERN DIAGNOSIS: Renal calculi

ABOUT THE DISEASE:

Renal calculi are also called as Kidney stones, nephrolithiasis or urolithiasis. They are hard deposits made of minerals and salts that form inside your kidneys. Kidney stones can affect any part of your urinary tract — from your kidneys to your bladder. Often, stones form when the urine becomes concentrated, allowing minerals to crystallise and stick together. There are different types of Kidney stones- calcium, struvite, uric acid, and cystine, that differ from each other in cause and presentation. The risk factors are Family or personal history, dehydration, certain diet, obesity, diseases of the digestive tract and surgery, certain medical conditions, supplements and medications.  

Causes: Diet, excess body weight, some medical conditions, and certain supplements and medications are among the many causes of kidney stones. Passing kidney stones can be quite painful, but the stones usually cause no permanent damage if they're recognised in a timely fashion. 

Symptoms: A kidney stone usually will not cause symptoms until it moves around within the kidney or passes into one of the ureters. The ureters are the tubes that connect the kidneys and bladder. If a kidney stone becomes lodged in the ureters, it may block the flow of urine and cause the kidney to swell and the ureter to spasm, which can be very painful. At that point, you may experience these symptoms: 

• Severe, sharp pain in the side and back, below the ribs
• Pain that radiates to the lower abdomen and groin
• Pain that comes in waves and fluctuates in intensity
• Pain or burning sensation while urinating 
• Other signs and symptoms may include: 
• Pink, red or brown urine
• Cloudy or foul-smelling urine
• A persistent need to urinate, urinating more often than usual or urinating in small amounts
• Nausea and vomiting
• Fever and chills if an infection is present
• Pain caused by a kidney stone may change — for instance, shifting to a different location or increasing in intensity — as the stone moves through your urinary tract.

Diagnosis: Medical history and clinical examination are the basic diagnostic tools. Blood tests, Urine tests, Imaging, and analysis of the passed out stones are some of the tools that may also be incorporated as a part of diagnosis. The doctor decides the type of test required depending upon the clinical presentation. 

In this case report, the patient is a 43-year-old female patient presented with lower abdomen pain and burning micturition since 15 days. The associated symptoms were frequent mouth ulcer since 2 years and irregular periods since 1 year. There were no prior consultations or treatments. Based on the clinical findings and USG report, the biomedical diagnosis was Multiple left renal calculi with mild hydronephrosis and the Ayurvedic diagnosis was Udavarta janya ashmari.

Image 1. USG Abdomen at baseline dated 16.6.2023

Treatment: In most of the cases, medications would suffice to get relief from the symptoms or the condition itself. But if the stones become lodged in the urinary tract, are associated with a urinary infection or cause complications — surgery may be needed.

Small stones Small stones with minimal symptoms. 

Most small kidney stones won't require invasive treatment. You may be able to pass a small stone by: 

Drinking water. Drinking as much as 2 to 3 quarts (1.8 to 3.6 liters) a day will keep your urine dilute and may prevent stones from forming. Unless your doctor tells you otherwise, drink enough fluid — ideally mostly water — to produce clear or nearly clear urine.

Pain relievers. Passing a small stone can cause some discomfort. To relieve mild pain, your doctor may recommend pain relievers such as ibuprofen (Advil, Motrin IB, others) or naproxen sodium (Aleve).

Medical therapy. Your doctor may give you a medication to help pass your kidney stone. This type of medication, known as an alpha blocker, relaxes the muscles in your ureter, helping to pass the stones. 

In the case of large kidney stones, they cannot pass on their own, and may cause bleeding. There is also a possibility of kidney damage and ongoing urinary tract infections that may require more-extensive treatment. Procedures may include: 

Using sound waves to break up stones. 

Surgery to remove very large stones in the kidney. 

Using a scope to remove stones. 

Parathyroid gland surgery.

Lifestyle changes and diet habits will help prevent the condition to a great extent. 

Prognosis: Depends upon the size of the stone and the location of the stone. Small stones are completely curable, with lifestyle changes and supportive medicines. Larger stones may need medical intervention. 

Reference

1. https://www.mayoclinic.org/diseases-conditions/kidney-stones/diagnosis-treatment/drc-20355759

AYURVEDA DIAGNOSIS: Udavarta janya ashmari

ABOUT THE DISEASE:

About Udavarta: This means the upward or backward or reverse movement of Vata Dosha. Usually obstruction to the normal pathway of Vata results in reverse movement. Most commonly, this condition occurs due to the suppression or obstruction to the natural urges or natural functioning of vata. Rarely it occurs as a secondary to organic obstruction.

Acharya Sushruta explains that complete obstruction of Vata in its pathway by any suppression of the urges, constipation, dryness of the minute channels etc, lead to upward /backward course of Vata and hence Udavarta is caused. So, he emphasizes to treat all such conditions by Vata pacifying measures. The adharaniya vegas are Flatus, Faces, Urine, Hunger, Thirst, Yawning, Tears, Regurgitation, Sneezing, Vomiting, Semen, Respiration and Sleep. The symptoms produced are different in each type of Udavarta. 

वेगान्न धारयेद्वातविण्मूत्रक्षवतृट्क्षुधाम्।

निद्राकासश्रमश्वासजृम्भाश्रुच्चर्दिरेतसाम्॥१॥ (AH.Su.4)

In this case report, the patient is a 43-year-old female patient presented with lower abdomen pain and burning micturition since 15 days. The associated symptoms were frequent mouth ulcer since 2 years and irregular periods since 1 year. There were no prior consultations or treatments. Based on the clinical findings and USG report, the biomedical diagnosis was Multiple left renal calculi with mild hydronephrosis and the Ayurvedic diagnosis was Udavarta janya ashmari.

Here the condition is diagnosed as Ashmari caused by Udavarta. The symptoms of Udavarta janya ashmari can be connected to the suppression of mutra vega. 

अङ्गभङ्गाश्मरीबस्तिमेढ्रवंक्षणवेदनाः॥४॥

मूत्रस्य रोधात्पूर्वे च प्रायो रोगाः—————॥५॥(AH.Su.4)

The Lakshana of mutrarodha are severe pain, calculi, pain in the urinary bladder and the genitalia. This tallies with the symptoms of the biomedical diagnosis Renal calculi and also of the ayurvedic correlation of Ashmari. 

Line of treatment mentioned is 

----------------------------------तदौषधम्।

वर्त्यभ्यङ्गावगाहाश्च स्वेदनं बस्तिकर्म च॥५॥ (AH.Su.4)

The treatments given are varti, abhyanga, avagaha, svedana and vasti karma. 

About Ashmari: 

सामान्यलिङ्गं रुङ् नाभि सीवनिवस्तिमूर्धसु । विशीर्णधारं मूत्रं स्यात्तया मार्गे निरोधिते ॥

तद्व्यापायात्सुखं मेहेदच्छं गोमेदकोपमं । तड् सङ्क्षोभात् क्षते सास्रमायाच्चातिरुग्भवेत् ॥ (Va.Ni.A.9)

The General signs and symptoms of asmari (calculi) include – pain in the region of the  umbilicus, perineum and dome of the bladder. In this condition, since the urinary passage is interrupted or blocked by the stone, the flow of urine comes out in many streams. When the stone gets dislodged, the person easily voids urine which is clear, having the colour of gomedaka gem (yellowish red in colour), of blood coloured or mixed with blood (due to bleeding in the urinary tract). If the interior of the urinary bladder (and urinary passages) get injured due to the friction by stone, bleeding also occurs along with urine. When the person tries to void the urine forcibly in spite of the stone being present in the urinary passage, the pressure causes severe pain. 

In this case report, the type of ashmari is not mentioned. Just that the ashmari is caused by Udavarta. 

The line of treatment mentioned  by Sushruta for Ashmari is as follows:

Apakarshana –Shasta karma (Surgical intervention)

Prakrutivighatana – Shodhana and Shamana 

Nidana parivarjana – Avoidance of causative factors

Shamanoushadhis: which are selected in Ashmari should have the following properties- Kaphahara , Mutra virechana and Apana vayu anulomana.

Rationale for treatment as mentioned by the physician:

Sukumara kashayam- Give strength to uterus and ovaries (apana vayu drushti nashaka and balance pitta and kapha), avrodha nashaka, regulation of menstrual cycle.
Drakshadi kashayam- Pitta and vata shamana, amlapitta nashaka,useful in burning sensation and hair fall, pittaja grahani nashaka, mukhapaka nashaka.
Shringa bhasma- Pitta shamaka, useful in gastritis.

Sukumara Lehyam- Pitta and vata shamana. (Relief from Cramp and pain of abdomen in period) It mainly gives strength to uterus and pakvashaya region. 

Virataradi kashayam - Mutrashamari nashaka
Brihatyadi kashayam - Useful  in all urinary disorder.
Varanadi kashayam - Kapha and meda nashaka, useful in fatty liver 

Chandraprabha vati- Tridosha shamaka, rasayana properties, gives strength to basti region 

Gokshura curna- Klednashaka,brimhana (strengthens basti region), mutrala 

Prognosis: Asmari is life threatening if it is associated with severe swelling in the scrotum (testes) and umbilicus, total obstruction of urine, severe pain and presence of gravel in it (because such asmari is incurable).

प्रशूननाभिवृषणं बद्धमूत्रं रुजातुरं। अश्मरी क्षपत्याशु सिकता शर्करान्विता॥१७॥ (MN. Chapter 32)

In this case report, the patient is a 43-year-old female patient presented with lower abdomen pain and burning micturition since 15 days. The associated symptoms were frequent mouth ulcer since 2 years and irregular periods since 1 year. There were no prior consultations or treatments. Based on the clinical findings and USG report, the biomedical diagnosis was Multiple left renal calculi with mild hydronephrosis and the Ayurvedic diagnosis was Udavarta janya ashmari.

Assessment: Subjective and objective parameters were assessed to analyse the outcome of the treatment.

Subjective parameters: In 1 week after starting ayurvedic medicines, there is no pain or burning sensation. In 1 month, complete relief from pain and burning micturition. The mouth ulcer completely healed.   

Objective parameters: A repeat USG was done after 1 month of treatment. 

Image 1. USG at endpoint dated 15.7.2023

Table 1. Findings of the USG at baseline and endpoint tabulated