Scientific Basis for Ayurvedic Therapies -21

Scientific Basis for

Ayurvedic Therapies 

edited by

Brahmasree Lakshmi Chandra Mishra

Indigestion (Ajirna)

Shankar K. Mitra and Paramesh R. Rangesh

17.1 Introduction

Gastrointestinal (GI) symptoms are among the most common and widespread of health

complaints among the general populace. An alternative term is dyspepsia. Dyspepsia is

often used to refer to upper abdominal pain or discomfort but may also encompass

symptoms of early satiety, postprandial abdominal bloating or distension, nausea, and

vomiting. Dyspepsia can be episodic or persistent and is often exacerbated by eating.

Indigestion is a general term used to describe discomfort or pain in the upper abdomen

or chest, usually after meals.

Ayurvedic treatment is focused on the correction of gastrointestinal pathology for most

of the endogenous disorders ranging from indigestion to arthritis. Ayurvedic texts describe

the anatomy and physiology of the digestive system at great lengths. Here is a brief insight

into the concepts of digestion and indigestion.

17.2 Ayurvedic Concept

17.2.1 The Stomach and Digestion

The stomach is one of the vital organs of the body (

marma

). The other important organs

are the heart, lungs, kidneys, and the brain. The stomach not only stores food during the

process of digestion, but also makes it more permeable through the juices it produces.

The stomach has minute glands from which gastric juice (

pachaka pitta

) is produced. The

gastric juice helps break down food into smaller molecules. The moment food enters the

stomach, the wall of the organ starts a

churning action to mix the food with the gastric

juice so that it becomes absorbable. Foods that are easy to digest (

laghu ahara

), such as fatfree

or low-fat milk and fat-free cereals or fruits, take far less time to digest than heavier

foods (

guru ahara

), such as fried substances, which are rich in fat.

The partially digested food from the stomach enters the intestine and is then exposed

to the action of bile, pancreatic and intestinal juices, and bacteria. The food is broken down

into various easily absorbable substances, which are vital for growth and development,

because these form the building blocks of the body. It is only when food has been eliminated

from the intestine that the process of digestion is complete and the process of

absorption starts.

17.2.2

Agni

and Disease

Ayurvedic literature has recognized 13 types of enzymes (

agni

); the most important is the

digestive enzyme (

jatharagni

), the primary factor of digestion

.

The others are the seven

intracellular enzymes (

dhatu agni

) and the five organic catalysts (

bhuta agni

). The

digestive

enzyme (also called

koshthagni

) contained in the gastric juice

is the source of all the enzymes

of the body. In addition to the digestive enzyme,

there are six other factors that help

digestion process. They are gastric juice

,

gut motility factor (

samana

vata

), moisture and

water, mucin (

kledaka kapha

), time, and a proper combination of the first five. The gut

motility factor propels the food into the stomach, bringing it into contact with gastric juice

,

and supports the

enzymes; moisture breaks down the compactness of the food and mucin

softens the food. Time is required for completing the process of digestion, and a proper

combination of all factors is vital for completion of the process. The food is digested with

the help of the digestive enzyme. This process results in the separation of the nutrient

factors from the food, which circulate in the body and help in tissue building through the

help of intracellular enzymes.

As long as this enzyme is in homoeostasis, it results in a state of health. Disease is the

result of a deviation from this state. The imbalance of the digestive enzyme (including the

enzymes of the stomach and intestine)

gives rise to most disorders of the stomach, particularly

anorexia and dyspepsia. This enzyme occurs in four states: balanced (s

amagni

),

abnormal (

vishamagni

), increased (

tikshnagni

), and decreased (

mandagni

). Except the balanced

state, others are pathological states. These pathological states of enzymes are due

to the influence of three

dosas

:

vata

,

pitta,

and

kapha,

respectively.

Physiologically, food undergoes three stages of conversion in the GI tract. The first is a

mucilaginous neutral stage (

madhurabhava

) under the influence of

kapha

. The second stage,

due to the interference of

pitta

, is an acidic stage (

amlabhava

), and the final stage is a dry,

pungent stage (

katubhava

) under the effect of

vata

. Due to etiological factors such as

abnormal food habits, emotional disturbances, etc., a pathological state of enzyme results

called

agnimandya

.

Agnimandya

is the principal cause for all metabolic disorders commencing

with indigestion

(

ajirna

).

17.2.3 Indigestion

Indigestion, a deviation in any of the steps described above, also known as upset stomach,

dyspepsia, or gastric indigestion, is discomfort or a burning feeling in the upper abdomen.

It is often accompanied by nausea, abdominal bloating, belching, and sometimes vomiting.

1

Dyspepsia, which means bad (dys) digestion (pepsia), is a term often used by doctors

to describe a set of symptoms believed to have their cause somewhere in the upper part

of the GI tract.

Ayurvedic physicians diagnose the disease with clinical interrogation about the state of

digestive enzymes and digestion with certain clinical features such as absence of hunger,

abdominal discomfort, and belching of undigested food. The physicians also examine the

abdomen by palpation and percussion for the presence of flatulence.

To diagnose indigestion, the doctor of conventional medicine might perform tests for

problems like ulcers. In the process of diagnosis, a person may have x-rays of the stomach

and small intestine or undergo an endoscopy, in which the doctor uses an instrument to

look at the inside of the upper GI tract.

17.3 Definition

According to classic Ayurveda, the word

ajirna

in Sanskrit means bad (a) digestion (

jirna

).

It is defined as a pathological condition in which food is not digested easily and is the

root cause for many internal diseases (metabolic). In conventional medicine, the term

dyspepsiais,

derived from the Greek words

dys

(bad) and

pepsis

(digestion), refers to symptoms

thought to originate in the upper GI tract.

17.4 Clinical Description

Indigestion, lassitude, heaviness in the body, the retention of flatus and constipation, or

loose motion are the common signs and symptoms of

ajirna

, as described in classic texts.

In conventional medicine, dyspepsia is characterized by upper abdominal pain or discomfort.

It may also encompass symptoms of early satiety, postprandial abdominal bloating

or distension, nausea, and vomiting.

17.5 History and Epidemiology

Dyspepsia is common; surveys in Western societies have recorded a prevalence of between

23 and 41%. For many people, dyspeptic symptoms are an acceptable part of living. Why

some sufferers (about 25% of the population) seek help from doctors is not clear, but

concern about symptoms seems to be as important as the symptoms themselves. The

minority of sufferers (5% of the population) who do consult doctors are the major consumers

of resources. In the U.K., in 1994, more than 400 million pounds was spent on

ulcer-healing drug prescriptions issued by general practitioners. About 4% of general

practice consultations are for dyspepsia and 2% of the entire populations receive either

an endoscopy or barium swallow (upper GI) each year. Time lost from work and interference

with quality of life is more difficult to measure but are likely to be considerable.

2

Only 10% of patients attending their general practitioner with dyspepsia will be referred

for hospital consultation or investigation.

The prevalence of dyspepsia ranges from 26% in the U.S. to 41% in the U.K. Although

only 20 to 25% of persons with dyspepsia seek medical care; the problem is responsible

for 2 to 5% of visits to primary care physicians. Nonulcer dyspepsia results in substantial

health-care costs.

2

17.6 Etiology

According to Ayurveda, the chief causes that affect digestion are the following:

1. Drinking too much liquid or water

2. Irregular eating habits, which include erratic schedules and quantities (i.e., eating

at abnormal intervals [between meals, middle of the night, etc.] or too large or

too small a serving)

3. Food allergies

4. Iatrogenic indigestion due to improper application of

panchakarma

(the detoxification

procedures)

5. Suppression of nature’s call or urges like hunger, defecation, etc.

6. Sleep disturbances

7. Emotional disturbances (e.g., envy, phobia, fury, depression, vengeance)

© 2004 by CRC Press LLC

Indigestion (Ajirna)

311

8. Seasonal changes

9. Debilitating chronic illnesses

In general, food selection, frequency of intake, seasonal changes, and emotional disturbances

affect digestion.

According to conventional medicine, the main causes of dyspepsia are overeating, eating

wrong food combinations, eating too rapidly, and neglecting proper mastication and

salivation of food. Causes also include overeating and making the stomach, liver, kidneys,

and bowels harder. When the food putrefies, its poisons are absorbed into the blood and

consequently the whole system is poisoned. Certain foods, if not properly cooked, can

cause dyspepsia. Other causes are intake of fried, rich, and spicy foods; excessive smoking;

intake of alcohol; constipation; insomnia; lack of exercise; and emotions such as jealousy,

fear, and anger.

17.7 Pathogenesis and Pathology

Ayurvedic texts state that diminished digestive enzymes lead to a state in which the patient

is unable to digest even wholesome (

satmya

) and easily digestible food taken in an orderly

time frame. This condition is known as

ajirna

.

Etiological factors disturb the homoeostasis of the

dosas

, which in turn influence the

digestive enzyme and result in three states dependent on the three

dosas

. They are the

vata

-dependent abnormal state (

vishamagni

),

pitta

-dependent increased state (

tikshnagni

)

and

kapha

-dependent decreased state (

mandagni

). These three pathological states of enzyme

bring about

dosa

-specific indigestion. They are static indigestion (

vishtabdha ajirna

), acid

indigestion (

vidagdha ajirna

), and endotoxic indigestion (

ama ajirna

), which are caused by

vata

,

pitta,

and

kapha

dosas

, respectively. Section 17.9 details the types indigestion as

described in Ayurvedic texts.

17.8 Clinical Diagnosis

The following clinical features as described in classic Ayurveda help to diagnose the three

pathological states of enzyme:

1. Abnormal state of enzyme (

vishamagni

) — In this state, the enzyme is antagonistic

due to involvement of vitiated

vata

. Symptoms include a very unpredictable

digestive capacity. Sometimes the food is digested well, whereas at other times

even light food in small quantities cannot be tolerated. Gaseous distension is

common.

2. Increased state of enzyme (

tikshnagni

) — In this circumstance, the appetite is good,

but the food that is eaten is not assimilated in the body. At such times, eating

more food does not help at all. In fact, the enzyme will become more disturbed

and so will the digestion process. A typical feature of this condition is that whatever

the food that is eaten (and digested) seems to disappear down a slightly

overburdened gut.

3. Decreased state of enzyme (

mandagni

) — In this condition, simple meals are

difficult to digest and there is an uneasy feeling of indigestion. Other symptoms

are malaise and vomiting.

17.9 Classification of Indigestion

Ayurvedic literatures describe a total of six types of indigestion, of which three are

pathological types. They are static indigestion (

vishtabdha ajirna

), acid indigestion

(

vidagdha ajirna

), and endotoxic indigestion (

ama ajirna

). The other three are transient

indigestion (

rasasesha ajirna

), diurnal indigestion (

dinapaki ajirna

),

and successive indigestion

(

prativasara ajirna

). Although the latter three are not pathological types, they are

transitional and occur physiologically in between any two meals every day. Dislike for

food intake until the earlier food is digested is known as transient indigestion. The

feeling of abdominal heaviness and lethargy soon after food ingestion is a natural process

called diurnal indigestion and

successive indigestion. The three pathological types are

described below.

1. Endotoxic indigestion (

ama

ajirna

) — The clinical features, such as abdominal

heaviness, hypersalivation, puffiness of face, and belching out undigested food

particles help diagnose this type of indigestion.

2. Acid indigestion (

vidagdha

ajirna

) — This condition is presented with clinical

features such as giddiness, intense thirst, daze, acid reflux, increased sweating,

and a burning sensation all over the body.

3. Static indigestion (

vishtabdha

ajirna

) — Clinical features, such as pain in the abdomen,

abdominal distension, obstruction to bowel and flatus movements, bewilderment,

and myalgia, are presented in this type of indigestion.

In conventional medicine, the clinical diagnosis is based on several signs and symptoms.

As dyspepsia is a group of symptoms, it alerts doctors to suspect diseases of the upper

GI tract. It includes symptoms of upper abdominal discomfort, retrosternal pain, anorexia,

nausea, vomiting, bloating, fullness, early satiety, and heartburn, among others. A firm

clinical diagnosis can be difficult based on these symptoms, as few symptoms are discriminatory.

Many diseases cause dyspepsia; these include peptic ulcers, esophagitis, cancer

of the stomach or pancreas, and gallstones. In a large proportion of cases, no clear pathological

cause for a patient’s symptoms can be determined. Other symptoms include a foul

taste in the mouth, coated tongue, and foul breath. At times, a sensation of tightness in

the throat is experienced. In most cases of indigestion, the patients suffer from constipation.

An organic cause is found in 40% of patients with dyspeptic symptoms. The most

common organic disorders causing dyspepsia are gastroduodenal ulcer, gastroesophageal

reflux disease, and gastric cancer. In 50% of patients, no cause is apparent and the dyspepsia

is considered idiopathic, meaning the diagnosis is essential, functional, or nonulcer

dyspepsia.

2

The history and physical examination do not reliably differentiate organic

from nonulcer dyspepsia.

Many people do not require invasive investigation. However, as persistent indigestion

may suggest a more serious underlying complaint, the doctor of conventional medicine

may decide to arrange the following:

1. An endoscopy to enable the doctor to look into the stomach

2. A barium swallow test to enable the outline of the stomach to show up on an x-ray

3. An ultrasound to scans the abdominal organs

4. A blood test to detect anemia or any other abnormality

Ayurvedic physicians currently also use these diagnostic procedures.

17.10 Clinical Course and Prognosis

Indigestion not treated in time may lead to the development of sequelae such as stupor

(

murcha

), incoherent talk (

pralapa

), vomiting (

vamathu

), hypersalivation (

praseka

), severe

myalgia (

sadana), vertigo (bhrama), and even death (marana).3 The GI disturbances that

may be followed by metabolic imbalances, either due to toxic states (especially metabolic

histotoxic anoxia) or malnutritional states (which are acute to begin with) may tend to

become chronic.

The acute conditions are among others that are caused by the impairment of enzymes

(agni) and the formation of endotoxin (ama). Among the subacute and chronic conditions,

both GI and metabolic, that may occur in a kind of chain sequence, the following may be

mentioned here: functional impairment of colon, liver damage, and hepatic diseases. In

fact, according to Ayurveda, most of the diseases included under internal medicine may,

from this point of view, be stated to be the outcome of this endotoxin and dosa combined

with this, called sama.

There is increasing evidence that individuals with autoimmune diseases, like rheumatoid

arthritis, have intestines that are more permeable to certain antigens, allowing these

antigens to invade the body and stimulate the symptoms. These antigens may be akin

with the Ayurvedic concept of ama.4

17.11 Management

17.11.1 Ayurvedic Therapy and Management of Indigestion

The management of indigestion begins with treating enzyme disturbance because it is

considered the basic cause of this condition. Agnimandya is treated as follows5:

1. The abnormal state of enzyme is treated with food and drinks that have sour and

salty tastes, along with some quantity of fat.

2. The increased state of enzyme is brought to equilibrium with dairy products such

as curds, milk, and milk gruel (payasam).

3. The decreased state of enzyme is treated with food and drinks that have pungent,

bitter, and astringent tastes, which stimulate enzymes.

Indigestion is generally treated with drugs that have digestive and carminative activities:

1. In endotoxic indigestion, digestive drugs have to be used. If there is excess kapha,

then vamana (emesis) is done under a physician’s supervision followed by digestive

drugs such as panchakola curna, agnitudi vati, and rasonadi vati (Table 17.1).

2. Acid indigestion is treated with light and easily digestible food. If there is excess

pitta, virecana (purgation) is followed by using antacids, such as sankha vati (Table

17.1).

3. To control vata in static indigestion, virecana with castor oil or Terminalia chebula

is used followed by basti (enema) treatment done under medical supervision. To

relieve constipation and indigestion, compound herbal powders such as bhaskaralavana

curna and hingvastaka curna are used (Table 17.1).

4. In any stage of indigestion, ginger (Zingiber officinale), cumin (Cuminum cyminum),

asafetida (Ferula foetida), and rock salt are used as digestives and carminatives.6

Therapy for functional gastrointestinal disorders comes under phytotherapeutic treatment.

From ancient times, phytotherapeutics played a very important role in patients with

dyspeptic symptoms. Bitter herbal drugs stimulate at even very small concentrations,

sensorially, the secretions of the stomach as well as the digestive glands, and also

strengthen the smooth musculature of the digestive tract (via the gustatory system, vagus,

and the enteric nervous system). At higher dosages, herbs and food articles with bitter

tastes probably directly affect the mucous membranes of the stomach and the bowels as

stimulants. Bitters often are combined with essential oils (some volatile oils such as

aromatic bitters, drug combinations of a volatile oil with a bitter taste). Essential oils act

primarily as spasmolytic, carminative, and local anesthetic. In the past few years, several

controlled studies were carried out with phytotherapeutic combinations (e.g., with Iberis

amara, caraway oil, peppermint oil, curcuma, and ginger extracts) in which the herbal

drugs proved to be superior compared with placebo and were as effective as prokinetics

(studies according to evidence-based medicine).7

17.11.2 Clinical Experiences

1. In case of abdominal pain, shankha vati is used at 250 to 500 mg twice daily with

warm water.

TABLE 17.1

Compound Formulas for Indigestion, Poor Digestion, and Dyspepsia

Name of Formulation Activity Dose Adjuvant Ref

Bhaskaralavana curna Digestive, appetizer 1–3 g twice/day

before meals

Warm water and

lemon juice

10

Hingvastaka curna Carminative,

antiflatulent

1–2 g twice/day

before or with

meals

Warm water,

buttermilk, and

ghee

5

Panchakola curna Digestive,

carminative

1–2 g twice/day

before or with

meals

Warm water 10

Agnitudi vat Carminative,

antispasmodic

240–480 mg twice/

day before meals

Warm water 10

Rasonadi vati Digestive,

antiflatulent

240–480 mg twice/

day before meal

Warm water 10

Sankha vati Digestive,

antiflatulent

240–480 mg twice/

day before meals

Lime water 6

2. To control and relieve borborygmi, 1 to 3 g of hingvashtaka curna is used with 1/2

tsp of cow’s ghee along with the first morsel of cooked rice twice daily.

3. If there is constipation with indigestion, 1 to 3 g bhaskaralavana curna is used with

warm water twice daily.

17.11.3 Lifestyle Changes

A person with an abnormal enzyme and indigestion should avoid stale, cold, and oily

foodstuffs, cold drinks, and cold water. Onions, potatoes, sweet potatoes, eggplant,

yogurts, bananas, pickles fried, hot and spicy foods, dairy products, liquor, and desserts

should be avoided.

Items like ginger, garlic, cumin, coriander, coriander leaves, curry leaves, and lemon

should be added to the diet. Vegetables such as radishes, yams, drumsticks, snake gourd,

bitter gourd, and pumpkin or fruits (e.g., pomegranates) can be eaten freely. Whole wheat

bread, whole cereals, and rice (harvested and stored for a long time) are also helpful.

To avoid indigestion, adhere to the following guidelines:

1. Eat meals at regular times.

2. Do not rush meals.

3. Enjoy eating and drinking, but do so in moderation.

4. Avoid those foods that are associated with symptoms.

5. Avoid nonsteroidal anti-inflammatory drugs (NSAIDs). If possible, consult a doctor

before doing so.

6. Avoid stressful situations that cause emotional upset.

7. Stop smoking.8

17.11.4 Review of Ayurvedic Therapies

The provision of dosage information in this section does not constitute a recommendation

or endorsement but rather indicates the range of doses commonly used in Ayurvedic

practice. Doses are given for single herb use and must be adjusted when using herbs in

combinations. Doses may also vary according to the type and severity of the condition

treated and individual patient conditions.

17.11.4.1 Imbalanced States of Digestive Enzymes

1. 2 g of dried ginger (Zingiber officinale) powder taken, twice daily, with warm water

stimulates enzymes and relieves indigestion.

2. 5 g of fresh ginger taken with salt or jaggery twice daily before meals.

3. 3 g of chebulic myrobalan (Terminalia chebula) powder taken twice daily before

meals with salt or jaggery.

4. 7 to 14 ml of lemon juice taken three times daily after meals.

5. Heat 1 g each of long pepper (Piper longum) powder and salt on a half lemon fruit

over blue flame. The juice of this cooked lemon is to be sucked two or three times

daily with meals.

6. 1 g each of the powdered fruit of long pepper and salt to be taken with lemon

juice twice daily with meals.

7. Take equal parts of fruit rind of chebulic myrobalan, dried ginger, and rock salt

in powder form, and add to it jaggery (approximately one third of the total

weight). This is to be taken in 1 to 3 g doses with warm water once daily before

the first meal.9

8. Fennel is one of the ingredients in a compound pill called rasonadi vati. It is useful

in low enzyme states.10

9. Distillate of peppermint leaves relieves nausea, stimulates enzyme secretion, and

improves appetite and taste.11

17.11.4.2 Indigestion

Various Ayurvedic formulas commonly used for indigestion are commercially available

listed below.

1. Dried ginger tea should be taken several times a day.

2. Take 1 to 3 g of the powdered fruit rind of black chebulic myrobalan (Terminalia

chebula) with an equal quantity of raw unrefined sugar twice daily before meals.

3. 1 to 3 g powdered dried ginger taken three times daily with jaggery.

4. 3 to 6 g of a paste prepared from equal parts of chebulic myrobalan fruit rind,

raw unrefined sugar, and raisins is to be taken with honey twice daily before meals.

5. 1 g of the powder of equal parts of rock salt, fruit rind of chebulic myrobalan,

fruit of long pepper, and root of leadwort (Plumbago zeylanica) should be taken

with warm water twice daily after meals.

6. 14 to 28 ml of a decoction prepared from equal parts of clove (Syzygium aromaticum),

fruit rind of chebulic myrobalan, and rock salt should be taken twice daily

before meals.

7. 14 to 28 ml of decoction of equal parts of fruit of coriander (Coriandrum sativum)

and dried ginger should be taken twice daily before meals.9

8. The powder of the turmeric rhizome (3 g) is useful in distaste and indigestion.11

17.11.4.3 External Applications

1. A hot poultice prepared from equal parts of asafetida (Ferula foetida), rock salt,

and hot water may be applied on the abdomen when it is warm to relieve abdominal

discomfort.

2. A warm poultice prepared from equal parts of asafetida powder, black pepper

(Piper nigrum), rock salt, and hot water may be applied on the abdomen to relieve

abdominal discomfort.9

According to conventional medicine, the treatment of indigestion includes avoidance

of the foods and situations that seem to cause indigestion; in some cases this is the most

successful way to treat indgestion. Excess stomach acid does not usually cause or result

from indigestion, so antacids are not an appropriate long-term treatment, although some

people report that they do help. Smokers can help relieve their indigestion by quitting

(Table 17.1). Other simple home remedies consisting of single herbs or multiple herbs are

smoking, or at least not smoking right before eating. Exercising with a full stomach may

cause indigestion, so scheduling exercise before a meal or at least an hour after might help.

To treat indigestion caused by a functional problem in the digestive tract, the doctor

may prescribe medicine that affects stomach motility. Because indigestion can be a sign

of or mimic a more serious disease, patients should see a doctor if they have vomiting;

weight or appetite loss; black tarry stools or blood in the vomit; severe pain in the upper

right abdomen; discomfort unrelated to eating; and indigestion accompanied by shortness

of breath, sweating, or pain radiating to the jaw, neck, or arm.

17.12 Scientific Basis

17.12.1 Zingiber officinale (Ginger)

17.12.1.1 Antinausea and Antiemetic Effects

17.12.1.1.1 Animal Studies

In mice, ginger’s effect in enhancing intestinal motility was similar to metoclopramide’s.12

In shrews, dogs, and rats, ginger extracts effectively reduced chemotherapy-associated

vomiting.13,14 Ginger also protected frogs against experimentally induced emesis.15 An

herbal combination including ginger and ginkgo was as effective as metoclopramide in

another animal study of experimentally induced nausea.16 Studies in rats and mice suggest

that ginger produces its antiemetic effects by stimulating peripheral anticholinergic and

antihistaminic receptors and by antagonizing 5-hydroxytryptamine (serotonin) receptors

in the gut.17,18

17.12.1.1.2 Clinical Studies

Both during fasting and after a standard test meal, ginger extracts significantly enhanced

gastroduodenal motility in 12 normal volunteers.19 Several randomized controlled trials

support ginger’s use as an antiemetic for nausea secondary to several conditions: morning

sickness, chemotherapy-associated nausea, postoperative nausea, and motion sickness. In

a randomized, double-blind, placebo-controlled crossover trial of 30 women with hyperemesis

gravidarum, ginger (250 mg four times daily) proved significantly more effective

than placebo in preventing and reducing nausea.20 Ginger also proved useful in treating

chemotherapy-induced nausea in a small pilot study of 11 adult patients; their nausea

scores fell from an average of 2 (out of maximum of 4) to 0.7 after taking 1.5 g of powdered

ginger.21 Another case series also supported ginger’s use as an antiemetic in patients

undergoing chemotherapy.22

Data on ginger’s effectiveness in preventing postoperative nausea have been conflicting.

In two randomized, double-blind studies of women undergoing gynecologic surgery,

those treated with ginger had significantly less postoperative nausea and vomiting than

those treated with placebo; ginger was as effective as metoclopramide in preventing

postoperative GI symptoms.23,24 Two other randomized, controlled trials failed to document

any statistically significant benefits of preoperative ginger (500 to 2000 mg) on

postoperative nausea or vomiting.25,26 Several studies have evaluated ginger’s effectiveness

in preventing motion sickness or seasickness and the potential mechanisms for this

effect. In an open study of 1741 tourists traveling by sea, ginger supplements (250 mg

every 2 h) were as effective as both nonprescription and prescription medications in

preventing sea sickness.27

In a randomized, crossover trial of eight healthy volunteers, ginger supplements were

significantly more effective than placebo in alleviating vertigo associated with motion sickness.

28 In a randomized, controlled trial of naval cadets, ginger was significantly more

effective than placebo in preventing seasickness, both vomiting and vertigo.29 In an early

trial involving 36 college students prone to motion sickness, ginger was as effective as a

dimenhydrinate in preventing nausea.30 In a randomized, controlled trial in healthy volunteers,

ginger was an effective antiemetic, but its mechanism of action appeared not to rely

on alterations in gastric emptying.24 In a study evaluating potential mechanisms for ginger’s

ability to reduce motion sickness, ginger had no impact on experimentally induced nystagmus

associated with motion sickness; the investigators concluded that ginger’s primary

effect was on the stomach rather than the central nervous system.31 In one National Aeronautics

and Space Administration (NASA)-sponsored study in healthy volunteers, ginger

(500 to 1000 mg) had no apparent effect on gastric emptying.32 Other studies have reported

enhanced intestinal motility after oral administration of ginger.12

17.12.1.2 Carminative and Antiulcer Effect

17.12.1.2.1 Animal Studies

In mice, zingiberene and gingerol significantly reduced gastric ulceration experimentally

induced by ethanol and hydrochloric acid.33

These results were confirmed in several subsequent studies using several of ginger’s

constituents, including beta-sesquiphellandrene, beta-bisabolene, gingesulfonic acid, curcumene,

and 6-shogaol. The results showed a demonstration of antiulcer effects and

protection of gastric mucosa against alcohol, NSAIDs, and hydrochloric acid.34,35 Rats given

ginger extracts (gingerols) had enhanced bile secretion.36

17.12.1.2.2 Clinical Studies

A Chinese case series reported that an herbal mixture containing ginger was effective in

halting upper gastrointestinal hemorrhage.37 There are no randomized, controlled trials

in humans evaluating ginger’s effect as a carminative or ulcer remedy.

17.12.1.2.3 Dose

There is disagreement on the optimal form and dose of ginger. A pediatric dose is not

established. Reputable physicians and herbalists recommend a range of doses. A dose of

dried ginger at 250 mg, four times daily taken orally,38 is commonly used. Some German

herbalists recommend up to four times this amount.39 Chinese herbalists may use up to

ten times this amount. The following methods for preparing ginger can be used:

1. Tea — 1 tsp of fresh ginger root boiled in 1 to 2 cups of water for 10 to 20 min.

Cool for 5 minutes and sweeten as desired. May be mixed with peppermint or

chamomile.

2. Ginger tincture — 1.5 to 3.0 ml/dose.38

3. Candied ginger — A 1-in. square piece is presumably equivalent to 500 to 1000

of dried ginger.40,41

Ginger is used worldwide as a cooking spice, condiment, and herbal remedy. Rhizomes

of ginger have long been used in traditional medicine for alleviating symptoms of GI

illness.14 It is used as a carminative to enhance digestion and reduce intestinal gas and

flatulence. In experimental studies, gingerol, an active constituent of ginger, had enhanced

bile secretion.36 Ginger in combination with long pepper and black pepper (the combination

is called trikatu in Ayurvedic literature) promoted the secretion of digestive juices and

an increased appetite; it is also reported useful in patients with gastric disorders accompanied

with clinical symptoms of achlorhydria and hypochlorhydria.42

17.12.2 Foeniculum vulgare (Fennel)

Fennel is a promoter of normal GI motility and is an antispasmodic.43 In experimental

studies, fennel was reported to stimulate bile flow from the liver, which could help in

relieving GI discomfort.44

17.12.3 Curcuma longa (Turmeric)

Experimental study with ethanolic extract of turmeric has proved its ability to inhibit

gastric secretion and to protect gastroduodenal mucosa against the injuries caused by

pyloric ligation; hypothermic-restraint stress; indomethacin; reserpine and cysteamine

administration; and cytodestructive agents, including 80% ethanol, 0.6 M HCl, 0.2 M

NaOH, and 25% NaCl. Turmeric extract has found to increase the gastric wall mucus and

also restored the nonprotein sulfhydryl (NP-SH) content in the glandular stomachs of

rats.45

A number of clinical trials on turmeric have proved it beneficial in the treatment of

peptic ulcer and nonulcer dyspepsia and right upper abdominal pain that may often be

caused by biliary dyskinesia.46–50 Further acute and chronic oral toxicity studies on the

turmeric rhizomes in mice, rats, guinea pigs, and monkeys found it to be safe.51,52

17.12.4 Mentha piperita (Peppermint Oil) and Carum carvi (Caraway Oil)

A combination of peppermint and caraway oils in the treatment of functional dyspepsia

has been extensively studied in experimental models and in clinical conditions of dyspepsia.

53,54

The peppermint and caraway oil combination was found to be a safe preparation that

acted locally to cause GI smooth muscle relaxation.55 The favorable risk-benefit ratio of a

peppermint and caraway oil combination was demonstrated for the treatment of functional

dyspepsia.56 Peppermint oil was known to inhibit enterocyte glucose uptake via a

direct action at the brush border membrane in the intestinal lumen.57

Acknowledgments

The authors acknowledge the data input provided by M.V. Venkatranganna and S. Gopumadhavan,

Pre-Clinical Pharmacology Laboratory, R&D Center, The Himalaya Drug Company,

Makali, Bangalore, India.

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Om Tat Sat

                                                        

(Continued...) 

(My humble salutations to H H Maharshi ji,  Brahmasri Sreeman Lakshmi Chandra Mishra ji and other eminent medical scholars and doctors   for the collection)