24 year old male patient with diffused agonising abdominal pain…

July 9, 2019

Yesterday we encountered a 24 year old male patient who gave history of  diffused agonising abdominal pain. According to him he was asymptomatic before 3 years and he developed the condition suddenly while sleeping. He felt this urge of defecation and then passed 3-4 loose motions. He was relieved after defecating, hence ignored the need of visiting the physician. But, his condition got worse with time and he started losing weight with simultaneously increasing defecation frequency(8-10 times a day). He has lost 13 kg weight since the first episode. Since then he has switched to many  doctors and was relieved only during the course of medication. He visited a renowned ayurveda physician and got to know about the importance of Pathya- apathya. This well behaved young man often get irritated by the fact that no doctor ever told him about Pathya-Apathya palan, and how he lost his crucial time in visiting clinics.
Can you help him?

Now, you may have jumped to a diagnosis right after reading the introduction. We suggest you not to.
Lets rule out every possible condition.

First of all detailed history is very important . As patients words, symptoms and signs are the gateway to his body. Once you enter their, you could do wonders for his system. Samaprapti vighatan is all you need to do, so make sure you do your job sincerely and religiously.

1. Pain (This small word should open lot of pop ups in your mind)

Q. Whether diffused or localised?

Use SOCRATES to gain details of the pain:

  • Site – Q. Where is the pain?
  • Onset – Q. Did it come on suddenly or gradually?
  • Character – Q. What kind of pain is this? (sharp / aching / burning)
    Q. Is it continuous or intermittent?
  • Radiation – Q. Does the pain move anywhere else?
  • Associated symptoms – Q.  Are there any other symptoms that seem associated? (e.g. weakness / numbness / saddle anaesthesia / urinary or faecal incontinence? / weight loss? / fevers? / sweats?)
  • Timing – Q. When exactly did it start?
  • Exacerbating / relieving factors – Q. Does anything make it better or worse?
    Q. Is it worse when you walk, sit down or lay flat?
  • Severity – Q. On a scale of 1-10 how bad is the pain? Has it gotten better or worse?

2. What other questions you should ask to complete your history taking?

Past medical history:
Other medical problems?
Rule out allergies?
Malignancy – any previous or current malignancy?
Drug history:
Regular medication?
Over the counter drugs?
Recreational drugs?
Social history:
Living situation
Economic statusWho lives with you?
Level of functional independence.
Current occupation.
Surgical history:  Significant at times.
Should be noted when patient complains of pin point pain…….
Addiction history :– Smoking status- get detailed information about quantity and duration of smoking. The type is also significant at times, whether bidi, cigarette, hukkah, cigar etc.
– Consuming tobacco or not?
– Whether Alcoholic or not. Amount and duration are again significant.
– Tea, cold drinks and coffee addictions should also be noted.
Travel history: Recent travel?
Systemic inquiry: Any other symptoms in other body systems? For example-  weight loss, weakness, headache, thirst etc.
Dietary history – Regular or irregular? What exactly are his food habits? The amount of different rasa’s present in his meals. Quantity and quality are the point which should be focused on.
Immunisation history- 

Patient’s response-  I was quite well before 3 years then suddenly developed this diffused agonising pain in abdomen only  which persists throughout the day. I got relief after defecation but felt weakness and just after taking tea the urge to defecate increases. I never ever went to doctor, and was doing great before the onset of this condition. I used to take healthy homemade food (with adequate spices) regularly and never engaged in any sort of addictions. I even ignored the condition initially as i was a boy with stout built and went to doctors only because my pain persists even on rest.

Samprapti Sangathan

  • विकार प्रकृति
    दोष – वात पित्त 

    अग्न्यधिष्ठानमन्नस्य ग्रहणाद्ग्रहणी मता|
    नाभेरुपर्यह्यग्निबलेनोपष्टब्धोप बृंहिता ||५६||
    अपक्वं धारत्यन्नं पक्वं सृजति पार्श्वतः|
    दुर्बलाग्निबला दुष्टा त्वाममेव विमुञ्चति||५७||
    आम – साम पुरीष 
  • विकार अधिष्ठान
    स्रोतस –

    1.पुरीषवह स्त्रोतस-  स्थूल पुरीष,  अति द्रव पुरीष,
    2. मज्जा वह स्त्रोतस – भ्रम
    3. मनोवह स्त्रोतस –  मनोविभ्रंश
    4. अन्नवह स्त्रोतस – अरुचि, अविपाक,
    5. रसवाह स्त्रोतस – मुख वैरस्यता, हृल्लास ,अंगमर्द, अग्निमांध 
    आमाशय / पक्वाशय  
  • विकार समुथान

पूर्वरूपं तु तस्येदं तृष्णाऽऽलस्यं बलक्षयः|
विदाहोऽन्नस्य पाकश्च चिरात् कायस्य गौरवम्||५५|कटु तिक्त कषायातिरूक्ष शीतल भोजनैः|
प्रमितानशनात्यध्व वेग निग्रह मैथुनैः||५९||
करोति कुपितो मन्दमग्निं सञ्छाद्य मारुतः |
तस्यान्नं पच्यते दुःखं शुक्त पाकं खराङ्गता||६०||
कण्ठास्य शोषः क्षुत्तृष्णा तिमिरं कर्णयोः स्वनः|
पार्श्वोरुवङ्क्षण ग्रीवारुजोऽभीक्ष्णं विसूचिका||६१||
हृत्पीडा कार्श्य दौर्बल्यं वैरस्यं परिकर्तिका|
गृद्धिः सर्व रसानां च मनसः सदनं तथा||६२||
जीर्णे जीर्यति चाध्मानं भुक्ते स्वास्थ्यमुपैति च|
स वातगुल्म हृद्रोग प्लीहा शङ्की च मानवः||६३||
चिरादुःखं द्रवं शुष्कं तन्वामं शब्दफेनवत्|
पुनः पुनः सृजेद्वर्चः कास श्वासार्दितोऽनिलात्||६४||

3. On Systemic Examination 

Inspection- No scar marks visible
Palpation- Non tender abdomen
Percussion- Tympanic note
Auscultation- peristaltic sound audible

4. Investigations 

CBC, ESR, Hb%, Urine- routine and microscopic, Stool Examination, Endoscopy, RA factor, CRP, Aslo filter HbsAg, HIV, FBS, Lipid profile, LFT

5. Differential diagnosis

1. Abdominal pain can indicate so many conditions, for proper approach we need to rule out all the possibilities. Ask for specific pain site (if any) then rule out the conditions according to site involved.
If diffused we need to rule out other possible condition. Can take hint from the image attached below –

DD for abdominal pain-m ayunext

6. Diagnosis

IBS  – Can confirm the condition after cross checking with the criteria, ROMS 3rd criteria.

Samaprapti Vighatan

  • उपक्रम
    a. अपतर्पण – लंघन रुक्षण स्वेदन
    b. संतर्पण  – बृंहण  स्नेहन  स्तम्भन
  • चिकित्सानुक्रम Ch. Chi. 15
    ज्ञात्वा तु परिपक्वामं मारुत ग्रहणी गदम्|
    दीपनीय युतं सर्पिः पाययेताल्पशो भिषक्||७७||
    किञ्चित्सन्धुक्षिते त्वग्नौ सक्त विण्मूत्र मारुतम्|
    द्व्यहं त्र्यहं वा संस्नेह्य स्विन्नाभ्यक्तं निरूहयेत्||७८||
    तत एरण्ड तैलेन सर्पिषा तैल्वकेन वा|
    स क्षारेणानिले शान्ते स्रस्त दोषं विरेचयेत्||७९||
    शुद्धं रूक्षाशयं बद्धवर्चसं चानुवासयेत्|
    दीपनीयाम्ल वातघ्न सिद्धा तैलेन मात्रया||८०||
    निरूढं च विरिक्तं च सम्यक् चैवानुवासितम्|
    लघ्वन्नं प्रति सम्भुक्तं सर्पिरभ्यासयेत् पुनः||८१||
  • प्रकृति स्थापन
    औषध मात्रा-
    1. संजीवनी वटि 250 mg
    बिल्व चूर्ण 3 gm
    दाड़िमाष्टक चूर्ण 3gm
    _1X 2 with तक्र___
    2. धान्यपंचक क्वाथ 80 ml 1X2 मात्रा
    3. गन्धक वटि 2 bd खाने के बाद
    4. द्राक्षावलेह  2 TSP 1X2 मात्रा
  •  निदान परिवर्जन
    अन्नवर्ग- जीर्णशाल्यान्न, विलेपी, लाजमण्ड, मसूरी-तुवरी-मुद्गयूष ;
    शाकवर्ग- चांगेरी, रम्भापुष्प, कमलकंदशाक ;
    फलवर्ग –रम्भा, जबु, कपित्थ, दाडिम ;
    दुग्धवर्ग- १) अजादुग्ध-दधि-तक्र-घृत २)गोदुग्ध-दधि-तक्र-घृत ३) अजानवनीत-गोनवनीत क्षीरजं- दधिजं वा ;
    तैलवर्ग- तिल तैल
    मांस वर्ग- लाव-शश-हरीण-कपिंजल-मांसरसा, क्षुद्रमत्स्य ;
    विहार-निद्रा (भोजनात् पूर्व) 1. पञ्चकोलक यूषश्च मूलकानां च सोषणः||११५||
    स्निग्धो दाडिम तक्राम्लो जाङ्गलः संस्कृतो रसः|
    क्रव्याद स्वरसः शस्तो भोजनार्थे सदीपनः||११६||
    तक्रारनाल मद्यानि पानायारिष्ट एव च|११७|
    तक्रं तु ग्रहणीदोषे दीपन ग्राहि लाघवात्||११७||
    श्रेष्ठं मधुर पाकित्वान्न च पित्तं प्रकोपयेत्|
    कषायोष्ण विकाशित्वाद्रौक्ष्याच्चैव कफे हितम्||११८||
    वाते स्वाद्वम्ल सान्द्रत्वात् सद्यस्कम विदाहि तत्|
    तस्मात् तक्र प्रयोगा ये जठराणां तथाऽर्शसाम्||११९||
    विहिता ग्रहणीदोषे सर्व शस्तान् प्रयोजयेत्|
    2. तक्रारिष्टः (Ch. Chi. 15)
  • अपथ्य –
    आहार –
    १) गुरु-स्निग्ध-भोजन
    २) अम्बुपान ;
    १) स्नान-अवगाह- अभ्यंग-व्यायाम-अग्निसंताप

7. Management 

providing psychological support and recommending dietary measures. Pharmacologic treatment is adjunctive and should be directed at symptoms, such as modulation of persistent visceral hyperalgesia.

8.Progress of the management – follow up suggestions” 

Ask patient if there any improvement in the condition?
Patients response- Intensity of pain reduced and only going to the loo 3 times a day. Though i still feel lack of energy and appetite too is reduced but, its okay. 

9.Follow up suggestions ( if any)

Weather treatment was a success or a failure? Does the condition demands care?

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