E-ISSN:2456-3110

Case Report

Arishtaka Enema

Journal of Ayurveda and Integrated Medical Sciences

2023 Volume 8 Number 11 November
Publisherwww.maharshicharaka.in

A clinical study to evaluate the efficacy of Arishtaka enema in Pre-Operative Bowel Preparation - A Case Series

Anvekar S1*, Sweta KM2
DOI:10.21760/jaims.8.11.31

1* Suraj Ravi Anvekar, Post Graduate Scholar, Department Of Shalya Tantra, Sri Sri College Of Ayurvedic Science And Research, Bengaluru, Karnataka, India.

2 Sweta KM, Professor HOD, Department of Shalya Tantra, Sri Sri College of Ayurvedic Science and Research, Bengaluru, Karnataka, India.

Bowel preparation before surgery refers to the removal of bowel contents via mechanical cleansing with oral or rectal measures. The proposed benefits are reduced rate of surgical site infections and easier manipulation of the bowel during surgery. An ideal bowel-cleansing agent should be well tolerated by subjects, easily administered, inexpensive and produce adequate clearance. The most extensively used enema agent is soap but due to its chemical constituents it is known to cause various side effects like nausea, gastric irritation, pain, etc. In Ayurveda, Acharya Sushrutha suggests patients are to be Nivrutta Vega i.e., free from natural urges prior to the surgery. Also, the drug Arishtaka seems to have the Rechaka, natural cleansing, non-allergic and surfactant properties. Considering these qualities, a preliminary attempt was made to study the effect of Arishtaka in bowel preparation. In the current study it has shown effective results and adequate quality of bowel preparation.

Keywords: Arishtaka, Soap water, Enema, Bowel preparation

Corresponding Author How to Cite this Article To Browse
Suraj Ravi Anvekar, Post Graduate Scholar, Department Of Shalya Tantra, Sri Sri College Of Ayurvedic Science And Research, Bengaluru, Karnataka, India.
Email: 		Anvekar S, Sweta KM, A clinical study to evaluate the efficacy of Arishtaka enema in Pre-Operative Bowel Preparation - A Case Series. J Ayu Int Med Sci. 2023;8(11):193-198.
Available From
https://jaims.in/jaims/article/view/2890

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2023-09-13 2023-09-18 2023-09-23 2023-09-28 2023-10-21
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
None declared Nil Yes 18.45%

© 2023by Anvekar S, Sweta KMand Published by Maharshi Charaka Ayurveda Organization. This is an Open Access article licensed under a Creative Commons Attribution 4.0 International License https://creativecommons.org/licenses/by/4.0/ unported [CC BY 4.0].

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Suraj Ravi Anvekar et al. Efficacy of Arishtaka enema in Pre-Operative Bowel Preparation

Introduction

Bowel preparation before surgery traditionally refers to the removal of bowel contents via mechanical cleansing with oral or rectal mechanical measures. The proposed benefits from the use of bowel preparation include reduced rates of surgical site infections and easier manipulation of the bowel during surgery.[1]

The ideal bowel-cleansing agent should be well tolerated by subjects, easily administered, inexpensive and produce adequate clearance without allowing explosive gases to form.[2] The most common enema solutions are sodium-phosphate, tap water and soap suds.[3] In soap suds enema the mixture of a mild soap and warm water is injected into the colon in order to stimulate a bowel movement. It is normally given to relieve constipation or for bowel cleansing before a medical examination or procedure.[4]

Even though the conventional soap suds enema is extensively in practice for preoperative bowel preparation, the chemical constituents present in the soap causes various side effects like nausea, gastric irritation, pain, etc.[5] and major concerns are colonic mucosal irritation and colitis[6] hence the quest for a new innovative modality arises.

In Ayurveda, our Acharyas have not directly specified regarding bowel preparation but in Charaka Samhita, Basti Siddhi Adhyaya[7] few enemas for Pakwashaya Shodhana have been explained. In Sushrutha Samhita, Agropaharaniya Adhyaya[8] while explaining Poorvakarma Vidhi, he suggests the patients are to be “Nivrutta Vega” prior to surgeries, hence the bowel preparation becomes essential.

Based upon the above concepts, a modified method of enema using Arishtaka Phala which is having Rechaka [9] property is been taken for the study. Even many articles and studies have highlighted the natural cleansing, non-allergic & surfactant properties of Arishtaka, which is free from harmful chemicals, and available in abundance.[10]

Aim and Objective

To evaluate the efficacy of Arishtaka enema for preoperative bowel preparation.


Drug Review[11]

Arishtaka

Botanical Name - Sapindus trifoliatus L
Synonyms - Sapindus laurifolia VAHL

Other varieties

  • Sapindus mukorossi GAERTN.
  • Sapindus emarginatus VAHL.

Family - Sapindaceae

Vernacular Names

English nameSoap Nut, Soapberry
Sanskrit nameArishtaka, Arishta, Phenila, Arthasadhana, Guchhaphala, Krishnavarna, Kumbhabijaka, Mangalya, Garbhapatana, Prakirya, Raktabija, Rishta, Somavalkala, Pita Phena.
Kannada nameAntuvaalada Kaayi, Kugatemara, Burugukayi
Hindi nameRitha, Aritha

Properties[12-14]

RasaTikta, Katu
GunaLaghu, Tikshna
ViryaUshna
VipakaKatu
PrabhavaVamaka
DoshaghnataTridoshaghna
RogaghnataShotha, Vedana, Visphota, Kushtha, Gandamala, Kandu, Shirahshoola, Ardhavabhedaka, Murchha, Apatantraka, Kasa, Shwasa, Sandhivata, Amavata, Pakshaghata, Daha, Udaravikara, Krimiroga, Raktavikara, Rajorodha, Kastaprasava, Sarpavisha, Vrishcheekavisha, Visha, Grahabadha.
KarmaVamaka, Shothahara, Vedanasthapana, Lekhana, Vishaghna, Kushthaghna, Maadaka, Krimighna, Raktashodhaka, Kaphanissaraka, Garbhashayasankochaka, Rechana, Garbhapatana, Kandughna.

Materials and Methods

Materials required

  • Arishtaka Phala Churna - 3g
  • Water - 750ml
  • Vessel - 1
  • Enema Can - 1
  • Lignocaine gel 2% - 1

Intervention

Preparation of Arishtaka Churna and Enema

  • The Aristaka Phala was collected and authenticated by the Department of Dravyaguna, Sri Sri College of Ayurvedic Science and Research, Bengaluru.
  • It was dried, deseeded and made into a coarse powder using Khalva Yantra and stored in an air tight container.

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Suraj Ravi Anvekar et al. Efficacy of Arishtaka enema in Pre-Operative Bowel Preparation
  • Aristaka enema was prepared with all aseptic measures where 3g of Arishtaka Churna was added to 750ml of lukewarm water then stirred well till it turns frothy and filtered using kora cloth.

Figure 1: Arrangement of materials for enema
Jaims_2890_1.jpg

Procedure

The solution was administered using a sterile enema can, with the temperature carefully maintained within the range of 98°F to 105°F (37-40.5°C).[15] To ensure the absence of air bubbles in the tube, fluid was allowed to run through it before clamping. Subjects were positioned in the left lateral posture, and the nozzle tip was appropriately lubricated with 2% lidocaine gel. The tube was gently inserted into the anal canal, not exceeding a depth of 4 inches. Subsequently, the tube clamp was released, and the enema can was elevated to facilitate the unimpeded flow of the solution until it was emptied. Following this, subjects were repositioned in the supine posture and instructed to defecate upon feeling the urge. The evaluation encompassed both subjective and objective parameters to assess the effectiveness of the procedure.

Figure 2: Arishtaka Phala
Jaims_2890_2.jpg


Figure 3: Arishtaka Churna
Jaims_2890_3.jpg

Figure 4: Enema Can
Jaims_2890_4.jpg

Figure 5: Administration of enema
Jaims_2890_5.jpg

Subjective Parameter

1. Pain (Assessment through VAS scale[16]

No pain - 0
Mild pain - 1-3
Moderate pain - 4-6
Severe pain - 7-10

2. Nature of Evacuation[17]

ParametersScore
Easy evacuation0
With mild stress1
Require straining2

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Suraj Ravi Anvekar et al. Efficacy of Arishtaka enema in Pre-Operative Bowel Preparation

3. Feeling after Defecation[18]

ParametersScore
Satisfied0
Partially Satisfied1
Dissatisfied2

Objective Criteria

a)  Aronchik Scale[19]

To assess the quality of bowel preparation

ScoreRating/description 
1Excellent: Small volume of liquid; > 95% of mucosa seenTotal score range: Minimum 1 (excellent) to maximum 5 (inadequate)Scoring performed after evacuation of bowels.
2Good: Clear liquid covering 5%-25% of mucosa, but > 90% of mucosa seen
3Fair: Semisolid stool could not be suctioned or washed away, but > 90% of mucosa seen
4Poor: Semisolid stool could not be suctioned or washed away and < 90% of mucosa seen
5Inadequate: Repeat preparation/screening needed

5 subjects aged between 21-60 years, with no systemic illness who were diagnosed with Arshas (Internal Hemorrhoids) and posted for Kshara Karma under Local/Spinal anesthesia were taken up for the study.

For bowel preparation, the subjects were provided with Arishtaka enema 2 hours prior to the surgery and assessment were done on the basis of subjective and objective parameters.

There was no pain noticed during or after the intervention. The subjects experienced easy evacuation and a feeling of complete satisfaction after defecation.

The Aronchik score showed highest grade i.e., Excellent bowel preparation where >95% of the inner mucosa was visible with no signs of congestion or excess secretion.

Figure 6-8: Assessment of Inner Mucosa of Rectum & Anal canal using Proctoscope
Jaims_2890_6.jpg

Jaims_2890_8.jpg

Discussion

An ideal bowel-cleansing agent should be well tolerated by subjects, easily administered, inexpensive and produce adequate clearance.

The Arishtaka possessing Vatanulomana action and it’s Rechaka Prabhava aids in the easy evacuation of bowel also the Tikta Rasa acts locally and does the Shoshana, thereby reduces the secretions, which helps in better visualization of the inner mucosa.

Arishtaka contains Saponins, which are natural, secondary plant metabolites with surfactant properties. The detergent properties of it results from their amphiphilic structure, thereby reduces the surface tension of water and manifest foam-forming properties. The analytical study has shown that the Arishtaka enema has a neutral pH 7.2, where soap water is highly alkaline in nature. This suggest that Arishtaka is less likely to irritate the inner mucosa of the rectum and anal canal. In the current study Arishtaka has shown promising results in effective evacuation and proper bowel preparation with no adverse effects.



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Conclusion

The benefits from the use of bowel preparation include reduced rates of surgical site infections, adequate visualization and easier manipulation of the bowel during surgery. The ideal bowel-cleansing agent should be well tolerated by subjects, easily administered, inexpensive and produce adequate clearance, the Arishtaka enema was ahead to match with the foresaid qualities. It has showed enhanced cleansing without any known complications. This is attributed to its Tikta Katu Rasa, Laghu Teekshna Guna, Ushna Veerya, Katu Vipaka, Tridoshahara, Rechaka, Vedanasthapaka, Kapha Nissaraka, Krimighna properties along with anti-inflammatory, analgesics, anti-oxidant, anti-microbial, anthelmintic activity. Hence, Arishtaka could be considered as a better choice of enema in the bowel preparation.

References

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2. Hung, SY., Chen, HC. & Chen, W.TL. A Randomized Trial Comparing the Bowel Cleansing Efficacy of Sodium Picosulfate/Magnesium Citrate and Polyethylene Glycol/Bisacodyl (The Bowklean Study). Sci Rep 10, 5604 (2020). https://doi.org/10.1038/s41598-020-62120-w

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4. Soapsuds enema [Internet]. Biology Articles, Tutorials & Dictionary Online. 2019 [cited 2023 Aug 20]. Available from: https://www.biologyonline.com/dictionary/soapsuds-enema

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7. Acharya Jadavaji Trikamji (Ed.) Agnivesha’s Charaka samhita of Acharya Charaka, Dridhabala Krit, Siddhi Sthana. Ch.10. Varanasi: Chaukhambha Orientalia; 2015. p.835.

8. Acharya Jadavaji Trikamji (Ed.) Sushruta Samhita, Sutrasasthana: Agropaharaneeya adhyayam ; Varanasi: Chaukhamba Surbharati Prakashan; 2014. p.18-23

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10. Bhatta, S., Joshi, L.R., Khakurel, D., Bussmann, R.W. (2021). Sapindus mukorossi Gaertn. SAPINDACEAE. In: Kunwar, R.M., Sher, H., Bussmann, R.W. (eds) Ethnobotany of the Himalayas. Ethnobotany of Mountain Regions. Springer, Cham. https://doi.org/10.1007/978-3-030-45597-2_214-1

11. Sapindus trifoliatus L. | Species [Internet]. India Biodiversity Portal. 2016 [cited 2023 Aug 24]. Available from: https://indiabiodiversity.org/species/show/231088

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Pana in Vibandha (MD dissertation). Bengaluru: Rajiv Gandhi University of Health Sciences; 2009.

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