E-ISSN:2456-3110

Review Article

causes and triggers

Journal of Ayurveda and Integrated Medical Sciences

2024 Volume 9 Number 6 JUNE
Publisherwww.maharshicharaka.in

A systematic review on causes and triggers contributing to Amlapitta in contemporary era

Shrushti N1*, Gujjarwar V2, Akanksha S3
DOI:10.21760/jaims.9.6.19

1* Shrushti Nimje, Post Graduate Scholar, Pg Department of Shalakya Tantra, Government Ayurveda College, Nagpur, Maharashtra, India.

2 Vidula Gujjarwar, HOD, Department of Rog Nidana Evum Vikriti Vigyana, Chaudhary Brahmaprakash Ayurvedic Charak Sansthan, New Delhi, India.

3 Sharma Akanksha, Post Graduate Scholar, PG Department of Rog Nidana Evum Vikriti Vigyana, Chaudhary Brahmaprakash Ayurvedic Charak Sansthan, New Delhi, India.

In Ayurveda Ahara is considered as the best preventive medicine and solely responsible for health and illness, sorrow and happiness. Unlike many infectious diseases, lifestyle disorders are mostly preventable through modifications in lifestyle behaviors. Amlapitta, is often considered a lifestyle disorder were lifestyle choices play a significant role in its development and exacerbation. Amlapitta is the commonest Vyadhi of Annavaha Strotas, caused by vitiated Agni where Amlaguna of Pachak Pitta increases due to Samata manifesting symptoms such as Avipaka (indigestion), Amlotkalesh or Tikta Amlodgara (sour or bitter belching), Hridkantha Daha heart throat burning sensation) and Aruchi (anorexia) affecting more people in India. Main causes for the disease are improper diet, habits, stress, not following Ahara Vidhi Visheshayatana, Viruddhahara, Asatmya Ahara, stale food, spicy irritant food, oily foods, bakery products, some fast foods, excess consumption of tea and coffee, excess food intake, drinking excess water after meals, freeze products, wine, cigarette smoking during meal etc., Amlapitta can be correlated with Acid Peptic Disorders which comprises of Gastroesophageal Reflux Disease, Gastritis, Functional Dyspepsia described in modern science. By promoting healthier lifestyles, individuals can reduce the incidence and severity of Amlapitta symptoms, improving their overall quality of life and well-being. Hence it is important to understand the causes and triggers of Amlapitta. This article’s focus will be on comprehending the factors responsible for development and exacerbation of Amlapitta in the contemporary period.

Keywords: Amlapitta, Agni, Pachak Pitta, Viruddha Ahara, Annavaha Strotas. Hyperacidity

Corresponding Author How to Cite this Article To Browse
Shrushti Nimje, Post Graduate Scholar, Pg Department of Shalakya Tantra, Government Ayurveda College, Nagpur, Maharashtra, India.
Email: 		Shrushti N, Gujjarwar V, Akanksha S, A systematic review on causes and triggers contributing to Amlapitta in contemporary era. J Ayu Int Med Sci. 2024;9(6):131-137.
Available From
https://jaims.in/jaims/article/view/3484

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2024-04-14 2024-04-24 2024-05-03 2024-05-10 2024-05-21
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
Authors state no conflict of interest. Non Funded. The conducted research is not related to either human or animals use. 13.14 All authors have accepted responsibility for the entire content of this manuscript and approved its submission.

© 2024by Shrushti N, Gujjarwar V, Akanksha Sand 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].

J Ayu Int Med Sci 2024;9(6)131
Shrushti Nimje et al. A systematic review on causes and triggers contributing to Amlapitta

Introduction

Ayurveda is only medical science which has insisted more importance on prevention of diseases & maintenance of health rather than treating any disease. In the 21st century, the era of competition life it is full of stress having more speed and accuracy are the prime demands. The needs of the human being are infinite, but the availability is less to fulfil the growing needs which have no end.

Nowadays, the people are attracted toward the junk food; they are changing their diet pattern, lifestyle, and behavioural pattern working with stress and strain. Hence, the people are becoming more stressful with worry, tension, and anxiety causing, so many psychological disorders which hamper the digestion and are causing hyperacidity, gastritis, dyspepsia, peptic ulcer disorders, and anorexia. All these pathological disorders covered under the broad umbrella of “Amlapitta” in Ayurveda.

India being a country of spices and spicy food and faulty sleeping patterns is the major cause for this disease. But in this modern age of advance Technologies, communication, electronic gadgets the level of facilities available for our convenience has increased but it leads to an increased in our problems related to psychosomatic and spiritual health.

A particular lifestyle of a person is changed therefore Modern world is facing a pandemic of various Lifestyle disorder. Sushrut in Sutrasthana mention that quality of Pitta is normally Katu and becomes Amla when it gets Vidagdha.[1]

The aggravated Pitta thus causing Amlapitta produce excessive acidity in the stomach acid eructation, burning sensation and colic pain when associated with Vata. Acharya Kashyapa was the first to describe Amlapitta as disease and analyse it on Dosha basis, whereas Madhavakar further classified it according to Gati i.e., Urdhvag Amlapitta and Adhog Amlapitta and on Dosha basis.[2]

According to Acharya Kashyapa, the Nidana Sevana causes vitiation of Dosha especially Pitta Dosha. This eventually creates Mandagni due to which ingested food become Vidagdha and attains Shuktibhava. This Vidagdha and Shuktibhava of food creates Amlata in Amashaya. This condition is called Amlapitta. Acharya Kashyapa

has given an example for explaining the Samprapati of Amlapitta. The vessels containing some curd or uncleaned vessel which containing Amlarasa, if someone adds milk in it, immediately milk gets converted into curd same procedure occurs in Amashaya - due to vitiated Dosha, the Ahara becomes Vidagdha & Shuktibhava.[3] The Rasa Dhatu is also vitiated. It creates more Mandagni. So, a person who intake more Vidhahi Ahara generate more Shuktibhava of food, which is responsible for the development of Amlapitta.

Materials and Methods

Literature has been studied from various Samhitas, modern books and previous published articles. Causes and triggers of Amlapitta as per Ayurveda Samhitas.

One who consume foods which are incompatible, rotten, sour; food substances which increases burning sensation inside; other factors which aggravates Pitta; eating before digestion of previous meal; indigestion; manifestation of Ama; Ama develops at tissue levels; use of ground cereals (Masa); improperly processed wines & drinks; eating of heavy & moisture producing foods; suppression of natural urges; excessive use of hot, dry, sour & liquid articles, consumptions of Molasses; Kulattha & sugarcane preparations; parched cereals; wildly growing rice and Prthuka (flattened rice obtained from boiled paddy); repeatedly sleeping in day time after eating again and again; over bathing; tub bath; drinking water in between food eating and consumption of stale food.[3]

Causes and Triggers of Amplapitta in Contemporary Era

1. Excess Tea consumption: Tea is the most frequently consumed beverage worldwide, besides water. Heartburn is caused by a bad food habit, an inactive lifestyle, and a high Green Tea consumption. Scientists found that these factors can increase the risk of heart burn and other gastroesophageal diseases. Theophylline in Green Tea can cause acid reflux. The asymptomatic erosive esophagitis can also cause by excessive Green Tea intake. The utilization of high dosages of Green Tea (more than five Liters per day) can cause, stomach ache, dyspepsia, flatulence and diarrhoea, nausea, vomiting, and loss of appetite.[4]


J Ayu Int Med Sci 2024;9(6)132
Shrushti Nimje et al. A systematic review on causes and triggers contributing to Amlapitta

Other study also found that consumption of more than 400 mg/day of caffeine including that present in GT can cause nausea and vomiting. Histopathologic study of excess Lipton tea users shows ulceration of the lumen of the stomach counted as ulcer points.

There were marked histologic changes as evidenced in the degeneration of gastric glands and cells due to loss of mucus. Also, the gastric pits were grossly dilated. Some of the dilated pits were filled with mucus. The oxyntic or parietal cells showed pale cytoplasm in contrast to eosinophilic staining. Thus, concluding that Lipton tea has the tendency of inducing gastric ulcer, achlorhydria and pernicious anaemia.

2. Eating Late at Night: It is estimated that meal stimulation of acid secretion ceases approximately seven hours after eating. "This is confirmed by our observation that approximately four to eight hours after a meal intragastric pH starts to rise from low values. The higher nocturnal pH values after an early dinner could simply signify that postprandial stimulation of gastric secretion ceases just in time as not to interfere with the nocturnal rise of pH, while a late dinner would produce such an interference and prevent the nocturnal rise.

In addition, gastric emptying after late dinner might be slower than after early dinner this could contribute to the more prolonged meal stimulated acid secretion during the night. As early dinner raises intragastric pH during the night and as nocturnal pH is a main determinant of ulcer healing. When the aim of treatment is to obtain a high intragastric pH, the patients might profit from taking early dinner.

3. Relying on Processed Foods: They are heavily modified foods, resulting in enhanced amounts of salt, added sugar, and fat as well as the use of additives to make this food category highly palatable.

It further argues that controlling food processing, rather than examining nutrients, should be foremost in shaping nutrition policy. Certain characteristics (tastes, properties, etc.) engineered into these types of products through food science and other technologies can skew mechanisms in the digestive system and brain that signal satiety and control appetite, and cause overconsumptions.

Processes such as mixing, extrusion, or heating can destroy a food’s natural cell wall structures and, in many cases, processing produces softly textured foods that are eaten quickly and promote energy intake Regularly consuming processed and fast foods, which are often high in unhealthy fats, sugars, and salt, can lead to higher risk of health problems like irritable bowel syndrome and functional dyspepsia.

4. Consuming Too Much Sugar: Our body would cease to function properly if there is no sugar intake, but it has some negative effects on human beings, especially its excess consumption which overweighs its positive effects on our health. It is sucrase enzyme that metabolises sucrose in the body; and when it is not produced in small intestine in sufficient quantities, sucrose intolerance occurs. latter could be visualised by abdominal cramps and bloating, diarrhoea and constipation, vomiting, dyspepsia, hypoglycaemia and headache, poor growth, viral infection in the upper respiratory tract, anxiety, etc. The people of Alaska are more prone to sucrose intolerance.

5. Mindless Eating: Eating while distracted, such as watching TV or working, can lead to overeating and poor food choices because you are not fully aware of how much or what you are eating. the current meal is increased when distracted by watching televisiondistract an individual making it easier to overeat and harder to monitor how much is being consumeddistraction may influence food intake the emphasis to date has been on distraction as a trigger to the onset of eating behaviour and food choice rather than eating as an ongoing behaviour. At its simplest, eating behaviour is a classic example of a negative feedback system as it is driven by factors such as hunger and a desire to eat which are in turn modified and reduced once food has been consumed causing a sense of fullness or satiety. From this perspective, it is therefore hypothesised that not only does distraction trigger the onset of eating it distracts from the consequences of this eating, thus making changes in hunger and/or fullness harder to detect. Thus, give rise to symptoms of

6. Emotional Eating: According to the psychosomatic theory emotional eaters overeat in response to negative affect because they have learned that it alleviates them from aversive mood states.


J Ayu Int Med Sci 2024;9(6)133
Shrushti Nimje et al. A systematic review on causes and triggers contributing to Amlapitta

Consistent with these theories, several studies found that an increase of manipulated negative affect was associated with an increase of eating in normal-weight and obese emotional eaters Using food to cope with emotions such as stress, boredom, or sadness can lead to unhealthy eating patterns and weight gain. Which eventually leads to indigestion and hyperacidity.

7. Frequent Consumption of Energy Drinks: The trend of energy drink got its popularity with the incorporation of red bull energy drink in 1997. Energy drinks contain different ingredients including higher doses of stimulant such as caffeine (ranging from 50 mg to 505 mg per can or bottle), taurine, guarana, sweetener such as sucrose, vitamin B, sodium and other minerals, and plant or herbal extract. Based on its dose, caffeine has been shown to exert positive as well as negative health effects. The intake of caffeine up to 400 mg/day is not associated with adverse health effects. The polish adolescent consuming energy drink reported common side effects including stomach ache (about 50%), overexcitement, heart palpitations or vomiting and dyspepsia. Awareness about energy drink did not correlate well with knowledge among young adults. Unexpectedly, the positive awareness about energy drink among students prompted them towards more consumption.

8. Yo-Yo Dieting: Anorexia nervosa and bulimia nervosa are two serious eating disorders often associated with dieting behaviours. Lead to an unhealthy preoccupation with food and body weight. Increase the risk of binge eating due to extreme hunger and deprivation. Serve as a trigger for the onset of disorders like Malnutrition, Electrolyte imbalances, Heart problems, such as bradycardia and hypotension, Osteoporosis, Amenorrhea and increased gastric secretion especially in individuals with a genetic or psychological predisposition.

9. Inconsistent Eating Schedule: Inconsistent eating schedules can have a significant impact on your overall health and well-being. Circadian rhythms are essential in coordinating biological processes to environmental routines such as sleep-active and eating cycles. Nearly every cell in the body possesses a molecular clock, which is wired to the central clock in the brain that is regulated by light-dark cycles. However, the clock in our digestive tract could be directly controlled by food signalling.

As such, abnormal food timing with respect to the host activity phase could cause central-peripheral desynchrony, leading to circadian rhythm disruption We found that individuals with inconsistent eating patterns had higher incidence of GIT related diseases than those with consistent eating time.

10. Regular Consumption of Alcohol: Regardless of the type and dose of beverage involved, alcohol facilitates the development of gastroesophageal reflux disease by reducing the pressure of the lower oesophageal sphincter and oesophageal motility.[5]

Ayurveda has also mentioned consumption of Madya leads to Pitta and Rakta Dushti which eventually leads to [6] Fermented and no distilled alcoholic beverages increase gastrin levels and acid secretion. Succinic and maleic acid contained in certain alcoholic drinks also stimulate acid secretion. Low alcohol doses accelerate gastric emptying, whereas high doses delay emptying and slow bowel motility. Alcohol facilitates the development of superficial gastritis and chronic atrophic gastritis - though it has not been shown to cause peptic ulcer.

Alcoholic beverages, fundamentally wine, have important bactericidal effects uponHelicobacter pyloriand enteropathogenic bacteria. The main alcohol-related intestinal alterations are diarrhoea and malabsorption, with recovery after restoring a normal diet. Alcohol facilitates the development of oropharyngeal, oesophageal, gastric, and colon cancer.

11. Smoking: After smoking a single cigarette there is a significant nicotine and carboxyhaemoglobin boost which reaches its peak within 10 minutes. The half-life of nicotine and carboxyhaemoglobin" is thought to be approximately two hours.

These chronological events relate well with the acute changes in gastric secretion seen after smoking a single cigarette. Chronic nicotine administration equivalent to a daily consumption of 10-15 cigarettes a day produced a significant increase in basal gastric secretion.

12. Sedentary Lifestyle: A sedentary lifestyle affects the human body through various mechanisms. Sedentary behaviours reduce lipoprotein lipase activity, muscle glucose, protein transporter activities, impair lipid metabolism, and diminish carbohydrate metabolism.


J Ayu Int Med Sci 2024;9(6)134
Shrushti Nimje et al. A systematic review on causes and triggers contributing to Amlapitta

The regular, moderate exercise can exert a beneficial effect on GI-tract disorders such as reflux esophagitis, peptic ulcers, cholelithiasis, constipation and Inflammatory Bowel Disease (IBD) leading to the attenuation of the symptoms. Gastric emptying during exercise is subject to several factors including calorie count, meal osmolality, and meal, temperature, and exercise conditions. It seems that moderate exercise would have little effects on gastrointestinal tract motility, but when exercise becomes more severe, there may be some inhibiting effects, especially at the level of gastric emptying. Gastric acid secretion probably changes little with exercise although it has been postulated that ulcer patients may increase secretion with exercise.

13. Stress: Stress is widely believed to play a major role in developing functional gastrointestinal disorders. Sushrut Acharya also mention Bhaya, Shok and Krodh as causative factor for Pitta Vriddhi which results in[7] Patients with serious stress frequently complain of gastrointestinal symptoms. Common upper gastrointestinal symptoms include fullness and bloating after small meals, abdominal distention, nausea, and loss of appetite. It is well known that acute stress inhibits solid gastric emptying in humans, dogs, and rats. Acute stress delays gastric emptying via central CRF and peripheral sympathetic pathways.

14. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): Are frequently used to treat inflammatory pain. A major limitation to their use, however, is the adverse reaction they cause to the gastrointestinal (GI) tract, including the formation of gastric lesions, the potentiation of ulcerogenic responses to stress, and the impairment of gastric ulcer healing.[8] Concerning the mechanism of NSAID-induced gastric damage, prostaglandin (PG) deficiency is of prime importance to the gastric ulcerogenic response to NSAIDs, yet it has proven to be more complicated than expected and involves multiple, closely interacting elements, including hypermotility, neutrophils, free radicals, and so on. The PG deficiency caused by NSAIDs is due to the inhibition of cyclooxygenase (COX). COX exists in two isozymes, COX-1 and COX-2; the former is constitutively expressed in various tissues, including the stomach, while the latter appears to be expressed in most tissues in response to growth factors and cytokines].

This tissue specificity of the COX isozymes has led to the idea that COX-1 is critical for housekeeping actions in the GI mucosa, whereas COX-2 functions under pathological conditions such as inflammation.

15. Screen Time: Dependency on digital devices resulting in an ever-increasing daily screen time has subsequently also been the cause of several adverse effects on physical and mental or psychological health. Constant exposure to devices like smartphones, personal computers, and television can severely affect mental health- increase stress and anxiety. Teenagers that use the internet more frequently have lesser durations of sleep, delayed bedtimes and wakeup times, and more daytime fatigue.[9] Those accessing social networking sites at night are more likely to sleep poorly, particularly if there is emotional involvement in the same. Additionally, engaging in an exciting task while staring at a luminous cell phone screen may enhance psychophysiological arousal, disturbing sleep. All this factors directly and indirectly affect gastric secretion and causes

16. Sleeping Late at Night: Insufficient sleep duration has been linked to physical health problems and to unhealthy behaviours such as altered food preferences, particularly for high sugar and high fat food, use of stimulants, and physical inactivity, which may also conversely affect sleep times. The chronic mismatch between biological and societal schedules disrupts the circadian rhythm and dysregulates physiological pathways such as metabolism, blood pressure, immune functions, and pain.

Sleeping late at night provides fewer opportunities for engaging in healthy behaviours because the biologically optimal times for activities, such as eating and physical exercise, are misaligned relative to their social times. For example, youths with a late chronotype are more likely to skip breakfast or eat at the wrong time for their biology, affecting their digestion and nutrition. Thus, leading to lifestyle disorders like Amlapitta.

17. Chocolates: Excessive consumption of chocolate can have several effects on gastric secretion and overall digestive health Chocolate is believed to cause heartburn because of one of its constituents - theobromine, which relaxes the oesophageal sphincter muscle - hence permitting stomach acidic contents to enter the oesophagus.


J Ayu Int Med Sci 2024;9(6)135
Shrushti Nimje et al. A systematic review on causes and triggers contributing to Amlapitta

The methylxanthines in chocolate can relax lower oesophageal sphincter, muscle that separates oesophagus from stomach. This relaxation can allow stomach acid to reflux into oesophagus, causing gastroesophageal reflux disease (GERD) symptoms. Excessive consumption of chocolate can irritate stomach lining, especially in people with preexisting conditions such as gastritis or peptic ulcers. The increased acid production can exacerbate these conditions, leading to discomfort and potential damage to stomach lining.[10]

18. Inconsistent Sleeping Schedule: Sleep disorders affect many individuals worldwide and their prevalence is increasing. It has been estimated that up to 70 million people in US and 45 million in Europe suffer from a chronic sleep disorder that adversely affects health and quality of life. There is strong evidence for a bidirectional relationship between GERD and sleep disturbances, since GERD symptoms cause difficulty falling asleep, sleep fragmentation, and early morning awakenings, while in turn sleep deprivation appears to induce oesophageal hyperalgesia. Thus, GERD patients with sleep disturbances report more severe symptoms and a worse than those without sleep disturbances.[11]

19. Fermented Food (Amla Padartha): Highly fermented foods undergo extensive fermentation processes, leading to significant changes in their chemical composition. Some common examples include: idli dosa, cheese, curd, dhokla etc Lactic Acid in Fermented foods, particularly those involving lactic acid bacteria (LAB), contain high levels of lactic acid. This acid can stimulate production of gastric acid in stomach, potentially increasing acidity. Other organic acids produced during fermentation (e.g., acetic acid in kombucha) can also stimulate gastric acid secretion, contributing to higher acidity levels.[12]

Too much Spicy Food Vidagdha Aahara): ( Capsaicin primary compound in spicy foods (especially in chili peppers) that gives them their heat. Capsaicin can stimulate secretion of gastric acid. This is thought to occur because capsaicin activates sensory neurons in stomach lining, leading to an increase in gastric acid production. High consumption of spicy foods is associated with (chronic uninvest gated dyspepsia) CUD, frequent postprandial fullness and epigastric pain.[13]

Discussion

Amlapitta disorders are a common health concern affecting a significant portion of the population worldwide. Ayurveda, the ancient Indian system of medicine, offers a unique perspective on understanding and managing Amplapitta through its holistic approach to health and wellness. Understanding causes and tiggers of Amlapitta disease is important for effectively managing Amplapitta and promoting overall health through Ayurvedic principles. This causes and triggers are of two types Aaharaj and Viharaj. Aaharaj causes includes excess tea consumption, eating late at night, regular consumption processed food, excess sugar intake, mindless eating, emotional eating, excess energy drink intake, dieting, inconsistent eating schedule, alcohols, smoking, NSAIDs, chocolates, fermented foods, spicy food were as Viharaj causes include Sedentary lifestyle, stress, sleeping late at night, inconsistent sleeping schedule. Knowing this cause helps healthcare professionals tailor treatment plans that address the specific triggers and contributing factors. This can involve lifestyle changes, dietary modifications, and the appropriate use of medications, leading to better management of symptoms and prevention of complications. Amlapitta if left untreated, can lead to serious complications such as esophagitis, Barrett's oesophagus, and oesophageal cancer. Identifying and managing the causes can help prevent these potential complications, thereby reducing long-term health risks.

Conclusion

Amlapitta is a chronic illness that impairs quality of life in terms of health. In the ancient textbooks of Ayurveda, it is described that irregular food and lifestyle habits are the main causative factor for the disease. While describing the total management for this disease, it is very much emphasized that treatment will be only successful if the causative factor is corrected and implementation in the proper approach. For that it is crucial to understand this factors which mainly include tea consumption, eating late at night, regular consumption processed food, excess sugar intake, mindless eating, emotional eating, excess energy drink intake, dieting, inconsistent eating schedule, alcohols, smoking,


J Ayu Int Med Sci 2024;9(6)136
Shrushti Nimje et al. A systematic review on causes and triggers contributing to Amlapitta

NSAIDs, chocolates, fermented foods, spicy food, Sedentary lifestyle, stress, sleeping late at night, inconsistent sleeping schedule.

References

1. Sushuruta Samhita, Sutrasthana, Kaviraj Ambicadatt Shastri, Chaukhamba Sanskrit Sansthan Varanasi, Reprint 2017, Vranaprashna Adhyay 21/11, Page 116.

2. Madhav Nidan, Part 2, Dr. Brahmananda Tripathi, Chaukhmba Surbharti Prakashan, Sanskaran 2005, Amlapitta Nidan Adhyay, 51/3-6 Page 226-227.

3. Kashyap Samhita, Khilsthana, Ayurvedalankara Shri Satyapal Bhishagaacharya, Choukhamba Sanskrit Sansthan Varanasi, Reprint 2022, Amlapitta Chikitsa Adhyay, 16/10,11, Page 514.

4. Sarma DN, Barrett ML, Chavez ML, Gardiner P, Ko R, Mahady GB et al. Safety of green extracts: A systematic review by the US pharmacopeia. Drug Saf. 2009; 31:469-484.

5. HARRISON’S Principles of Internal Medicine, Volume 2, 21st Edition, Mc Graw Hill, part 10 Disorders of Gastrointestinal System, Section 1, Chapter 324 Peptic Ulcer Disease, Page 2437

6. Ashtang Hridayam, Sutrasthan, Dr. Brahmananda Tripathi, Chaukhamba Sanskrit Prakashan Delhi, Sanskaran 2017, Dravadravyavidnyaniya Adhyay 5\64, Page 78.

7. Sushuruta Samhita, Sutrasthana, Kaviraj Ambicadatt Shastri, Chaukhamba Sanskrit Sansthan Varanasi, Reprint 2017, Vranaprashna Adhyay 21/21, Page 118.

8. Davidson’s Principle and Practice of Medicine Book, 23rd Edition 2018, Sir Stenley Davidson, Part 3, Chapter 21, Gastroenterology, Gasto-oesophageal Reflux Disease Page 791.

9. Woods HC, Scott H: #Sleepyteens: Social media use in adolescence is associated with poor sleep quality, anxiety, depression and low self-esteem. J Adolesc. 2016, 51:41-9. 10.1016/j.adolescence.2016.05.008.

10. Davidson’s Principle and Practice of Medicine Book, 23rd Edition 2018, Sir stenley Davidson, Part 3, Chapter 21, Gastroenterology, Gastric and Duodenal Ulcer Page 798.

11. HARRISON’S principles of internal medicine, Volume 2, 21st edition, Mc Graw hill, part 10 Disorders of Gastrointestinal System, section 1, chapter 323 Diseases of Oesophagus, Page 2431.

12. Kashyap Samhita, Khilsthana Ayurvedalankara Shri Satyapal Bhishagaacharya, Chaukhamba Sanskrit Sansthan Varanasi, Reprint 2022, Amlapitta chikitsa Adhyay, 16/4 Page 514.

13. Madhav Nidan, Part 2, Dr. Brahmananda Tripathi, Chaukhmba Surbharti Prakashan, Sanskaran 2005, Amlapitta Nidan Adyay 51/1, Page 225.


J Ayu Int Med Sci 2024;9(6)137