Acid Indigestion | Amlapitta
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Amlapitta, known as acid indigestion or dyspepsia, is a common and widespread condition of painful or difficult digestion, often accompanied by symptoms such as nausea, heartburn, bloating, belching and stomach discomfort. Madhava describes amlapitta as, "The disease in which the patient has indigestion, exhaustion without any exertion, nausea, belching with bitter or sour taste, feeling of heaviness in the body, burning sensation in the chest and throat and loss of appetite.” (1).
Classically, the causes of Amlapitta are said to include consuming incorrect food combinations, eating stale food and consuming sour and excessively hot food. (2) It is now known that there is also an infective component in amlapitta: the colonization of the stomach by Helicobacter Pylori, an infection usually acquired in childhood, although its effects are most often felt after the age of forty.
Where tikshnagni is present and large amounts of stomach acid are produced, H. pylori colonizes the antrum of the stomach to avoid the acid-secreting parietal cells located in the main part of the stomach. The inflammatory response to the bacteria induces gastrin secretion, stimulating the parietal cells in the corpus to secrete even more acid. In turn the chronically increased gastrin levels lead to an increased number of acid producing cells, adding to a positive feedback loop that ultimately results in duodenal ulceration. On the other hand, where mandagni is present and gastric acid secretion is low, H. pylori colonizes the main body of the stomach, causing atrophy of the gastric mucosa with the result that gastric acid production drops even lower. This mandagni condition can lead to gastric ulcer and ultimately to stomach cancer.
In connection to stomach cancer it is important to note that due to the capacious nature of the stomach there is room for a large carcinoma to grow while creating minimal symptoms. Mild dyspepsia in an elderly male may be the signal of stomach cancer, particularly if there is a history of weigh loss and general malaise. By the same token, dysphagia or difficulty swallowing may be simply an indicator of reflux, but in an elderly person it could be the first symptom of oesophageal cancer. Hence it is important that all patients with dysphagia are worked up by a gastro-enterologist as well as an Ayurvedic practitioner.
Another modern cause of dyspepsia is the widespread use of aspirin and non-steroidal anti-inflammatory drugs (NSAIDs), which can in the long term lead to peptic ulcers. (3) Rheumatology patients are particularly at risk due to long term NSAID use. Smoking may be another important risk factor in dyspepsia and peptic ulceration. One study found that, "Current smokers had a 2.3-fold increased risk (P=0.02) and former smokers a 2.7 increased risk for dyspepsia compared to never smokers.” (4).
As Madhava points out, diet is a crucial factor in dyspepsia. One recent study begins with a profoundly Ayurvedic quotation from Lucretius, Ut quod ali cibus est aliis fuat acre venenum "What is food to one man is bitter poison to others" Lucretius, 99 – 55 BC. (5). It is also extremely important for the Ayurvedic practitioner to note the dramatically increased prevalence of dyspepsia in patients with celiac disease. "The present results indicate that the prevalence of CD in patients with dyspepsia is twice that of the general population. Thus, serological screening for CD should be considered in the early workup of these patients to allow diagnosis and treatment of an eminently treatable disease.” (6) In the author’s experience, many although not all cases of dyspepsia that have association with CD will clear up after one to three months of gluten free diet.
In terms of understanding samprapti of amlapitta, Madhava makes the important distinction between adhoga (downward gati), which can lead to duodenal ulcer, diarrhoea dominant IBS, and intestinal haemorrhage, versus urdvaga (upward gati) amlapitta with symptoms including gastro-esophageal reflux (GERD), nausea and vomiting, haematemesis, sour mouthfuls and waterbrash, belching, heartburn, laryngitis and headache. (7)
A fifty eight year old kapha woman smoking up to a pack a day complained of acid reflux and burping after meals. She consumed a large amount of crackers, toast and cookies. She was advised to wean off smoking slowly with use of a herbal smoking mix and to adopt a gluten free diet. Her predilection for wheat-based food might indicate an addictive allergy, and from an Ayurvedic standpoint, gluten allergies are more likely to occur in Kapha individuals, since gluten, like kapha, is heavy, dull, cloudy and sticky. (For material on working with smokers see this article).
A thirty four year old pitta woman working a high stress academic setting complained of jaw clenching, tight muscles, anxiety and heartburn. She was currently taking over the counter antacids. She said, "Either I don’t eat or I eat but don’t enjoy it.” Stress played a major role in this patient’s symptom picture. As a variety of studies illustrate, depression and stress are significant in amlapitta. "Patients with functional dyspepsia experienced significantly more life events than patients with duodenal ulcer and healthy controls. The difference in life events between the groups was due to the difference in stressful life events. The patients with functional dyspepsia had higher levels of state-trait anxiety, general psychopathology, and depression than patients with duodenal ulcer and healthy controls.” (8)
Herbal strategies for working with amlapitta should include anti-inflammatory herbs, herbs high in tannins (astringent taste) and demulcent mucilaginous herbs. In addition, it will be valuable to give herbal agents that are active against H. pylori and of course herbs that are Agni dipan or enhance digestion. As well as herbal measures, it will of course be important to give a pitta soothing diet as well as pitta pacifying yoga practices such as Chandra namaskar, shitali and sarvangasana.
Herbs with established activity against H. pylori include neem, an extremely valuable gastroprotective herb in amlapitta. Not only is neem proven to inhibit H. pylori, (9) it also has an anti-ulcer effect similar to omeprazole, the most popular drug for dyspepsia and hyperacidity.(10) Another herb famous for its benefits for amlapitta is licorice, which has also been found to contain anti-helicobacter flavonoids. (11) Again, licorice too has an additional gastro-protective action since it additionally regulates gastro-intestinal motility through its flavonoid component Isoliquiritigenin. (12). In working with both licorice and neem it is important to be aware that these are strong herbs with potential side effects. Neem can lower libido and licorice can raise blood pressure, both effects that could be significant in the elderly population that most frequently suffers from dyspepsia. It is important to use these herbs in smaller parts within the formula to avoid untoward effects. They synergize well and will to a great extent offset each other’s side effects since neem is bitter, light and dry/ruksha and licorice is sweet, heavy and snighdha.
Anti-inflammatory herbs have a key role to play in reducing gastric and duodenal inflammation. At the same time, they have rheumatological benefits that may help reduce the quantity of pitta-provoking NSAIDs a rheumatology patient has to take. Turmeric, a star ingredient in the Ayurvedic diet as well as in the pharmacy, has an anti-inflammatory and gastro-protective effect via its curcumin components. Guggulu has an anti-inflammatory effect that is both anti-ulcer and cytoprotective in preventing the development of stomach cancer. (14) if Kaishore Guggulu is used as the best anti-pitta Guggulu, the additional gastro-protective effects of Guduchi will be felt. (15)
As well as the bitter taste (neem) and sweet taste (licorice), the astringent taste is of course important in pacifying pitta. Astringent herbs are high in tannins. Here amalaki is a great example of a classic pitta soothing herb rich in gastro-protective tannins. (16). Bhumyamlaki is likewise a rich source of antoxidant tannins. (17). One or other of these herbs should typically be included in the regime of a client complaining of amlapitta.
When selecting a dosha pratyanika herb for a client with amlapitta, a demulcent, mucilaginous herb can be chosen. Shatavari, a celebrated herb for pitta and amlapitta, is demulcent and also improves gastric emptying time. (18). Vidari is especially beneficial where both vata and pitta are involved. As a starchy root, Vidari has mucilaginous and demulcent properties. (19)
As agni deepan (kindling to digestion) ginger can be used, with an established benefit for gastric emptying time as well as a world-wide reputation for benefit in dyspepsia. (20). Fennel, another important agni deepan herb for pitta, has been shown to be effective against H. pylori. (21,22).
Thus by combining strong vyadhi pratyanika herbs such as neem and licorice with anti-inflammatory herbs, antoxidant-rich teas and bacteriostatic spices to kindle agni, the causes as well as the symptoms of amlapitta can be effectively addressed.
1. Madhava Nidan, Ch 51 v 2 tr. Srikantha Murthy, Chaukhambha Oreintalia, Varansi.
2. ibid v1
3. BMJ, doi: 10.1136/bmj.38232.680567.EB, (Published 8 October 2004), The effectiveness of five strategies for the prevention of gastrointestinal toxicity induced by non-steroidal anti-inflammatory drugs: systematic review Lee Hooper 1, Tamara J Brown
4. Functional bowel symptoms in a general Dutch population and associations with common stimulants. P J Boekema, E F van Dam van Isselt, M L Bots, A J Smout Neth J Med 2001; 59(1):23-30
5. The American Journal of Gastroenterology (2003) 99, 170–181; doi:10.1111/j.1572-0241.2004.04003.x Diet, Food Intake, and Disturbed Physiology in the Pathogenesis of Symptoms in Functional Dyspepsia Christine Feinle-Bisset1, Rosalie Vozzo1
6. Increased Prevalence of Celiac Disease in Patients With Dyspepsia Maria Teresa Bardella, MD; et al, Arch Intern Med. 2000;160:1489-1491
7. Madhava op cit v 3-6.
8. Life events and stress in patients with functional dyspepsia compared with patients with duodenal ulcer TT Haug, I Wilhelmsen, A Berstad, H Ursin - Scandinavian Journal of Gastroenterology, 1995 Jun;30(6):524-30.
9. S. Arivazhagan, B. Velmurugan, V. Bhuvaneswari, S. Nagini. Journal of Medicinal Food. Fall 2004, 7(3): 334-339. doi:10.1089/jmf.2004.7.334 Effects of Aqueous Extracts of Garlic (Allium sativum) and Neem (Azadirachta indica) Leaf on Hepatic and Blood Oxidant-Antioxidant Status During Experimental Gastric Carcinogenesis
10. Uday Bandyopadhyay, Kausik Biswas et al. Gastroprotective effect of Neem (Azadirachta indica) bark extract: Possible involvement of H+-K+-ATPase inhibition and scavenging of hydroxyl radical, Life Sciences Volume 71, Issue 24, 1 November 2002, Pages 2845-2865
11. Toshio Fukaia, Ai Marumo et al Anti-Helicobacter pylori flavonoids from licorice extract, Life Sciences
Volume 71, Issue 12, 9 August 2002, Pages 1449-1463
12. Gang Chen *, Lingxin Zhu et al Isoliquiritigenin, a flavonoid from licorice, plays a dual role in regulating gastrointestinal motility in vitro and in vivo Phytotherapy Research Volume 23 Issue 4 Pages 498 – 506 Published Online: 9 Dec 2008
13. RAFATULLAH, M TARIQ, MA AL-YAHYA, JS MOSSA, AM
Journal of Ethnopharmacology, 29 (1990) 25 — 34 25 EVALUATION OP TURMERIC (CURCUMA LONGA) FOR GASTRIC AND DUODENAL ANTIULCER ACTIVITY IN RATS,
14. M. M. Al-Harbi , , S. Qureshi Gastric antiulcer and cytoprotective effect of Commiphora molmol in rats, Journal of Ethnopharmacology Volume 55, Issue 2, January 1997, Pages 141-150 Evaluation of Cytotoxic Effects of Dichloromethane Extract of Guduchi (Tinospora cordifolia Miers ex Hook F & THOMS) on Cultured HeLa Cells
15. Ganesh Chandra Jagetia and Shaival Kamalaksha Rao Evid Based Complement Alternat Med. 2006 June; 3(2): 267–272. Published online 2006 April 24. doi: 10.1093/ecam/nel011
16. Chawla YK, Dubey P Indian J Med Res. 1982 Dec;76 Suppl:95-8 Treatment of dyspepsia with Amalaki (Emblika Officinalis Linn) an Ayurvedic Drug Gastroprotective effects of `Amla? on test models in rats. Phytomedicine, Volume 9, Issue 6, Pages 515-522
17. Indian medicinal herbs as sources of antioxidants Shahin Sharif Ali Naresh Kasoju Food Research International Volume 41, Issue 1, 2008, Pages 1-15
18. Dalvi SS, Nadkarni PM, Gupta KC. Effect of Asparagus racemosus (Shatavari) on gastric emptying time in normal healthy volunteers. J Postgrad Med 1990;36:91
19. Pharmaceutical Biology 1967, Vol. 7, No. 3, Pages 1051-1058 , DOI 10.3109/13880206709083329. Botanical Studies of Some Ayurvedic and Yunani Drugs "Bidhara” J. G. Srivastava
20. European Journal of Gastroenterology & Hepatology: May 2008 - Volume 20 - Issue 5 - pp 436-440 doi: 10.1097/MEG.0b013e3282f4b224. Effects of ginger on gastric emptying and motility in healthy humans Wu, Keng-Liang; Rayner, Christopher K.;
21. Bacteriostatic effect of dill, fennel, caraway and cinnamon extracts against Helicobacter pylori. Siavash Sadeghian; Tirang R. Neyestani; Mohammad Hassan Shirazi; Parvaneh Ranjbarian. Journal of Nutritional & Environmental Medicine, 1364-6907, Volume 15, Issue 2, 2005, Pages 47 – 5
22. In Vitro susceptibility of Helicobacter pylori to botanical extracts used traditionally for the treatment of gastrointestinal disorders. Gail B. Mahady 1 2 *, Susan L. Pendland
Alakananda Ma M.B., B.S. (Lond.) is an Ayurvedic Doctor (NAMA) and graduate of a top London medical school. She is co-founder of Alandi Ayurveda Clinic and Alandi Ayurveda Gurukula in Boulder Colorado, as well as a spiritual mother, teacher, flower essence maker and storyteller. Alakananda is a well known and highly respected practitioner in the Ayurveda community both nationally and internationally.
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