Analysing Crohn’s Disease Through the Perspective of Ayurveda: A Conceptual Study in Relation to Grahani Roga

Crohn’s disease is a chronic inflammatory bowel disease (IBD) characterised by granulomatous inflammation that is generally transmural, leading to irreversible tissue damage to the gastrointestinal tract. In Asia, the reported incidence ranges from 0.04 to 5.0 per 100,000 population and the prevalence from 0.88 to 67.9 per 100,000¹ which emphasises the importance of environmental factors in disease pathogenesis. The true prevalence across different regions of India remains unknown.

In Ayurveda, the concept of Agni and Grahani Roga plays a crucial role in understanding the pathophysiology of gastrointestinal disorders. Grahani is the organ that holds and regulates the food, and it is the seat of Agni and is so named because it holds the ingested food². It is the sixth Pittadhara Kala³ and is situated between the Pakvashaya and the Amashaya. Agni is the root of life and health. Bala, Arogya, Ayu and Prana are dependent on the state of Agni that burns when fed by the fuel of food and drink or diminishes when deprived of them. When Agni is disturbed, Grahani becomes vitiated by the factors that diminish Agni (Agnisadana Hetu)⁵.

1.2 Methodology

A conceptual review was conducted using material collected from classical texts and contemporary medical literature. The study analyses the pathophysiology of Crohn’s disease through the perspective of Ayurveda and its relevance to Grahani Roga.

2. Literature Review

2.1 Ayurvedic literature on Grahani Roga

Acharya Charaka defines Grahani Roga as a condition in which a person with Durbala Agni (weak Agni) undergoes Vidaha (abnormal, acidic transformation) of the ingested food, which then moves upwards or downwards, or is passed as Ama (undigested) or Pakva (digested) stool.The stool in this condition is described as Atisrishta (loose), Vibaddha (constipated) or Drava (liquid)⁶. The entire food remains in the Vidagdha stage. The Lakshanas described are:

• Trishna (thirst)
• Arochaka (anorexia)
• Vairasya (altered or distasteful taste)
• Praseka (excessive salivation)
• Shoona Pada Kara (swelling of the feet and hands)
• Asthi and Parva Ruk (pain in the bones and joints)
• Chardi (vomiting)
• Jvara (fever)
• Ama Gandhi Udgara and Amla Udgara (foul-smelling and sour eructations)

Grahani Roga is listed among the Mahagadas (major diseases) ⁷, and its treatment is considered Krichrasadhya (difficult to treat) ⁸.

2.2 Modern literature on Crohn’s disease

The tissue inflammation in Crohn’s disease is caused by an uncontrolled immune response against luminal bacterial antigens, the most significant change being hyperactivity of T cells with excessive production of cytokines. In a normal host, microbial or dietary antigen stimulation produces only physiological, limited inflammation of the intestinal mucosa with no tissue injury. In a susceptible host, the same stimulation provokes uncontrolled inflammation with extensive tissue injury.

The disease is frequently diagnosed in its chronic stages. Conventional treatment relies on immunosuppressive drugs (azathioprine, mercaptopurine, methotrexate, infliximab, adalimumab), anti-inflammatory aminosalicylates, and corticosteroids (prednisone, methylprednisolone), the last of which are powerful anti-inflammatory agents that can quickly stop painful flare-ups⁹.

3. Modern and Ayurvedic View

3.1 Ayurvedic view: Nidana

The Nidana of Grahani Roga are divided into Samanya (general) and Vishishta (specific, according to Dosha)⁹.

Samanya Nidana: Abhojana (fasting), Atibhojana (overeating), Ajirna (eating during indigestion), Vishamashana (irregular eating), Guru, Sheeta and Atiruksha Bhojana, Sandushta Bhojana (contaminated or incompatible food) and Vega Dharana (suppression of natural urges).

Vishishta Nidana:

• Vataja- Katu, Tikta, Kashaya, Atiruksha and Sheeta food, Vega Nigraha and Atimaithuna.
• Pittaja -Katu, Vidahi Anna, Amla and Kshara food.
• Kaphaja - Guru, Atisnigdha and Sheeta food.

Vidahi Anna includes substances such as Madya, Amla, Takra, Dadhi, Nishpava, Vrihi, Varicara Mamsa and Kulattha when taken in excess.

The causes of Crohn’s disease are broadly grouped into environmental and genetic factors. Environmental factors include smoking, diet and lifestyle, while genetic susceptibility arises from gene mutations (for example: NOD2) and familial clustering. Recognised risk factors include smoking, antibiotic use and oral contraceptives.

3.2 Modern view of the pathogenesis

Environmental factors (diet, drugs) and risk factors (smoking, sedentary lifestyle) trigger a systemic immune response directed primarily against the gastrointestinal tract, resulting in inflammation of the GI lining and impaired digestion and metabolism. Uncontrolled inflammatory cytokines destroy the mucosal epithelial cells of the GI wall through apoptosis, producing the characteristic patchy “skip lesions”. Atrophy and scarring of the intestinal villi impair absorption of nutrients and lead to weight loss. Sodium reabsorption gradually disappears from the epithelium, so that more sodium is retained in the intestinal lumen, causing diarrhoea.

The principal clinical features are abdominal pain, diarrhoea, weight loss, constipation, abdominal distension, burning sensation, canker sores, joint pain, vomiting, fever, swelling, anaemia, weakness and loss of appetite.

3.3 Ayurvedic view: Samprapti (pathogenesis)

Nidana sevana (indulgence in the causative factors) vitiates Agni, producing Agnidushti and Agnimandya. The undigested food then forms Ama along with the Tridosha Dushti (sama dosha). The Ushnatva of Agni is compromised, so that food is not digested even when it is light (Na Tat Pachati Laghvapi). Ama possesses the Gunas Drava, Snigdha, Picchila and Guru. With continued Nidana Sevana the food undergoes Shuktatva (sour fermentation), and the Ama becomes Ghora Annavisha i.e. Amavisha – which possesses the Gunas of Visha (Visharupata). Agnimandya leads to Ajirna and then to Grahani Dosha. This presents with Karshya, Dhoomaka, Jvara, Vishtambha, Svayathu of the hands and feet, Asthi-Parva Ruk and Chardana, which parallel the features of Crohn’s disease

Amavisha causes Dhatu Vaishamya and affects the Gunas of Ojas, resulting in Ojo Dushti leading to Ojo Vikruti resulting in dysregulated Vyadhikshamatva. The Tikshna Guna of Pitta leads to the formation of Vrana (ulcers), while the Drava and Ushna Gunas of Pitta, together with Laghu and Ruksha Guna of Vata, give rise to the stool pattern described as Atisrishta Vibaddham Va Dravam (loose stool or constipated).

4. Management in Ayurveda

The chikitsa of Grahani Roga follows the principle of correcting Agni and clearing ama, adapted to the stage of the disease, as given in the Charaka Samhita.

• Nidana parivarjana -avoidance of the causative dietary and behavioural factors.
• Sadyo Vamana -when Amavisha is present with symptoms such as Vishtambha, Praseka, Vidaha, Aruchi and Gaurava, emesis is given at once with Ushna Ambu (warm water) or a Kashaya of Pippali and Madanaphala with Sarshapa.
• Virechana -If Ama moves downward and affetcs Pakvashaya¹⁰.
• Pachana of Ama - Langhana and Pachana with Deepana drugs, depending on whether the Ama is lodged in the Pakvashaya or has spread through the body along with the Rasa ¹¹.
• Niramavastha Chikitsa -once Ama is cleared, Snehapana with Deepaniya Gana drugs, Abhyanga, Svedana, Niruha Basti and Anuvasana Basti are administered¹².
• Takra Prayoga - Buttermilk Is Given as the Pathya in Grahani Roga¹³. It is Laghu, Deepana and Grahi, with Madhura Vipaka, so it does not aggravate Pitta; Its Kashaya Rasa and Ushna Virya pacify Kapha, and its Madhura and Amla Rasa pacify Vata.
• Piccha Basti mentioned in Arshas Chikitsa can be administered here in case of Atisara along with Rakta.
• Shamana Oushadi- Ghrita Prayoga such as Dasahamooladya Ghrita, Chandanadya Ghrita¹⁴ etc. Rasa Parpati such as Panchamrita Parpati, Loha parpati, etc can be given.
• Pathya Ahara and Vihara – the maintenance of Agni through suitable diet and lifestyle, which differs from person to person.

DISCUSSION

Grahani Roga occurs due to diminished function of Agni. When Agni functions normally it provides Bala, Ayu and Prana but when it is disturbed, various diseases arise, of which Grahani Roga is one. The pathophysiology of Crohn’s disease can therefore be understood as Sama Dosha Dushti progressing to Amavisha.

The modern sequence of environmental and behavioural triggers, immune activation, mucosal inflammation and malabsorption corresponds closely with the Ayurvedic sequence of Nidana Sevana, Agnimandya, Ama, Amavisha and Dhatu Vaishamya. The Guna Siddhanta offers a coherent explanation for every symptom, from the Vata-related pain, distension and wasting, to the Pitta-related diarrhoea, burning, fever and ulceration, and the Kapha and Ama related heaviness, anorexia and weakness. The persistent, relapsing course of the disease also fits the classical description of Sannipataja Grahani, in which all three Doshas are involved.

Grahani Roga is mentioned as one of the Mahagadas and Crohn’s disease is often diagnosed in its chronic stages. The condition is Krichrasadhya, but can be managed by Sannipataja Grahani Chikitsa. Whereas conventional therapy relies on immunosuppressants, aminosalicylates and corticosteroids, the Ayurvedic approach aims at removing nidana, clearing Ama and Amavisha, and restoring Agni, with Pathya Ahara and Vihara individualised for each patient.

CONCLUSION

Crohn’s disease can be understood through the framework of Grahani Roga, in which diminished Agni leads to Sama Dosha Dushti, progresses to Amavisha and ultimately disturbs Ojas. The Guna Siddhanta provides a practical means of interpreting each clinical feature and of selecting treatment. The management principles of Nidana Parivarjana, Sadyo Vamana in Amavisha, Ama Pachana, Snehana, Svedana, Basti and Takra Prayoga, together with individualised Pathya, form a rational basis for managing Crohn’s disease. Although the disease is Krichrasadhya, timely Sannipataja Grahani Chikitsa offers a useful approach. Clinical studies are needed to validate these concepts.

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