Critical Review of Raktatisara vis-a-vis Ulcerative Colitis

Many studies have been conducted for the role of Ahara (~dietary habits), Vihara (~abnormal Physical activity) and Manas (~Psychological factors) and their association with pathogenesis of Ulcerative colitis, which is a subtype of inflammatory bowel disease, which pursue a protracted relapsing and remitting course, usually extending over years. The causes of relapsing of ulcerative colitis are not known. Dietary factors have been associated in the pathogenesis of ulcerative colitis as well as associated with an increased risk of relapse of ulcerative colitis. Here, we have reviewed the probable mechanisms of the role of diet and its association with pathogenesis of Ulcerative colitis (UC). In Ayurveda, on the basis of signs and symptoms ulcerative colitis can be best compared with Raktatisara. This article is an attempt to do critical review and put a light on the role of diet, faulty lifestyle and Psychological factors in occurrence and progression of Ulcerative colitis (UC), and try to explain Etiopathogenesis of Raktatisara in relation to ulcerative colitis by going through Ayurvedic texts, Google Scholar, PubMed journals etc.

A Many studies have been conducted for the role of Ahara (~dietary habits), Vihara (~abnormal Physical activity) and Manas (~Psychological factors) and their association with pathogenesis of Ulcerative colitis, which is a subtype of in lammatory bowel disease, which pursue a protracted relapsing and remitting course, usually extending over years. The causes of relapsing of ulcerative colitis are not known. Dietary factors have been associated in the pathogenesis of ulcerative colitis as well as associated with an increased risk of relapse of ulcerative colitis. Here, we have reviewed the probable mechanisms of the role of diet and its association with pathogenesis of Ulcerative colitis (UC). In Ayurveda, on the basis of signs and symptoms ulcerative colitis can be best compared with Raktatisara. This article is an attempt to do critical review and put a light on the role of diet, faulty lifestyle and Psychological factors in occurrence and progression of Ulcerative colitis (UC), and try to explain Etiopathogenesis of Raktatisara in relation to ulcerative colitis by going through Ayurvedic texts, Google Scholar, PubMed journals etc.

INTRODUCTION
Ulcerative colitis is a subtype of in lammatory bowel disease with unknown etiology in lammatory disease that affects the colon and is best characterized by relapse and remission mucosal in lammation (Ungaro et al., 2017) Ulcerative Colitis (UC) is an in lammatory bowel disease, which can persist for years. Incidences of ulcerative colitis are increasing at an alarming rate due to erroneous dietary habits and faulty lifestyle (Jowett, 2004). Studies reported that prevalence rate of ulcerative colitis is 44.3 per 100000 inhabitants in Punjab and in other parts of North India, which is not much less than that reported from Europe and North America (Sood, 2003). UC causes rectal bleeding and mucus discharge, sometimes accompanied by tenesmus. In severe cases; anorexia, malaise, weight loss and abdominal pain occur, and the patient becomes toxic with fever, tachycardia and signs of peritoneal in lammation (Nicolas, 2006). The prevalence of age of onset of UC is mainly between 15 and 30 years and second peak prevalence occurs between the age of 60 and 80 years. The male to female ratio for ulcerative colitis is 1:1.4 The prevalence of UC is increasing at an alarming rate and allopathic line of treatment including administration of steroids in the form of oral high dose of prednisolone and enemas etc. is not proved to be effective in the management and puts a huge burden on the health of the patient (Lennard-Jones et al., 1965). It possesses a big challenge for medical health professionals due to its high morbidity and mortality. Ayurveda described Raktatisara (~haemorrhagic diarrhoea), which has symptoms similar to ulcerative colitis i.e. Shula (~pain in abdomen), Gudapaaka (~burning sensation in rectum) and Trishna (~excessive thirst) (Shukla and Tripathi, 2002a).

Etiopathogenesis of Ulcerative Colitis
Ulcerative colitis is a disease with several origin. Involvement of environmental and genetic factors are being considered as causative factors but exact cause is not known of Ulcerative colitis. Several Genes, environmental factors as well as microbiota dysbiosis resulted into dysregulated or abnormal immune response is the probable and closest pathophysiology of the Ulcerative Colitis (Satsangi et al., 1997). The term "dysbiosis" indicating both reduced diversity as well as an imbalance within intestinal microbiota but at present lacks strict de inition. Ulcerative colitis is more common in nonsmokers and ex-smokers and HLA-DR103 associated with severe ulcerative colitis (Nicolas et al., 2006a). Linkage of chromosomes 1 and 4 (Rutgeerts and Geboes, 2001), CDH1, ECM 1, HNF 4α and Laminin B1genes which participate and responsible for intestinal mucosal barrier function (Thompson and Lees, 2011), low iber diet are dietary factors that are responsible for occurrence of Ulcerative colitis. The most suitable etiology of Ulcerative colitis is depicted in Figure 1. In Ancient System of Indian medicine etiological factors elaborated in Charaka Samhita for the pathogenesis of Raktatisara is having much resemblance with those depicted in Figure 1. Like Environmental factors may be understand as Ahara (~foods) and Vihara (~Physical Activity) as described in Figure 2 (Shukla and Tripathi, 2002b,a). Purishashaya (~colon) is mentioned as the place where Raktatisara (~bleeding diarrhoea) occurs and same in Ulcerative colitis where changes in function of intestinal Microbiotata resulted into occurrence of Ulcerative colitis. (Sartor, 2006)

Etiopathogenesis of Raktatisara in Ayurveda
In Ayurveda, the ancient system of India medicine, is mainly based on the concept of three major constitutional types (Vata, Pitta and Kapha) which is known as Prakriti (Govindaraj et al., 2015). In Charka Samhita erroneous dietary pattern, faulty lifestyle and psychological factors along with suppression of Agni (~Digestive ire) are mentioned as root cause of Pittatisara which in chronic stage manifest as Raktatisara (Shukla and Tripathi, 2002a,b), it is described that if Pittaja Prakriti individuals having habits of taking Ahara (~foods) like Amla (~sour), Lavan (~saline) substances in excess; Vihara (~lifestyles) where human body having constant direct exposure to Suryasantap (~Scroaching sun) and UsanhMaruth (~hot winds) at the same time also having psychological stress with Krodh (~anger) and Irsha (~Jealous) all these etiological factors causes aggravation of Pitta which causes Suppression of Agni (~digestive ire) due to Drava guna (~liquidity) of Pitta and after reaching the colon it causes break up of Purish (stool) because of Usanh (~heat), Drava (~liquidity) and Sara (m obility) and causes Pittaja Atisara as showed in Figure 1 (Shukla and Tripathi, 2002c).
In Charaka Samhita Pittatisara patients passes stool of different colours like green, blue, yellow, black and associated with Rakta and pitta (~stool with blood and mucus) and smelling extremely unpleasant (Shukla and Tripathi, 2002b). If PittajaAtisara Patient not following Kriya muktva (~treatment and precautions) (Shukla and Tripathi, 2002c) and continues to take pitta aggravation Ahara (~foods and drinks) which further aggravates Pitta this resulted into aggravating Rakta dhatu (~blood) which manifested as Raktatisara (~bleeding diarrhoea) (Shukla and Tripathi, 2002a). In Ayurveda the pathogenesis of Raktatisara (~haemorrhagic diarrhoea) may be understand as explained Figure 2.

DISCUSSION
The major symptom of ulcerative colitis is bloody diarrhoea, emotional stress is also play a provoking role in relapse (Nicolas et al., 2006b). In Ancient system of Indian medicine, Raktatisara is also having symptom blood in the stool. Psychological stress with Krodh (~anger) and Irsha (~Jealousy) (Shukla and Tripathi, 2002b) is main cause of Pittatisara which later on turned in Raktatisara (~bleeding diarrhoea). The course of Ulcerative colitis is variable but majority of Ulcerative colitis patients follow a relapsing and remitting course (Langholz et al., 1994). Dietary factors have been implicated in pathogenesis and relapse of Ulcerative Colitis. Multiple studies (Geerling et al., 2000) have been done to examined role of dietary factors in relation to onset of Ulcerative colitis but none have systematic approach to examine the relationship between dietary intake and relapses of Ulcerative colitis.
Ulcerative colitis is known to be associated with major morbidity in Western countries, and its incidence is increasing at an alarming rate in developing countries (Ramos and Papadakis, 2019). In Ayurveda, it has been suggested that dietary habits (Shukla and Tripathi, 2002b) causes suppressing of Digestive ire which resulted in Raktatisara.
Brown et al. also suggested diet-induced changes in microbiota may causes healthy microbiota into disease induced entity that could easily perpetuate in lammation in patients (Brown et al., 2012). Western diet (Persson et al., 1992) can be act as etiology for UC. Many review articles have focused on relationship between Stress and In lammatory bowel disease (Keefer et al., 2008). In Charaka Samhita role of Psychological factors i.e. stress, anger is also explained in Pittatisara which in chronic stage manifested as Raktatisara (Shukla and Tripathi, 2002b,a). In Indian system of medicine manuscripts like Sushruta Samhita described Pittatisara patients as having lakshan (~symptoms) like Trishna (~thirst), Murcha (~Fainting), Jwara (~Fever) Guda paka (~Ulceration in the rectum) (Sharma, 2008).

CONCLUSIONS
Ulcerative colitis is a chronic in lammatory bowel disease, whose aetiology is unknown. The dietary habits of the patient i.e. frequent consumption of spicy, oily, junk food may be a predisposing factor of Ulcerative colitis. Many studies indicate that psychological factors play a role in the Etiopathogenesis of Ulcerative colitis. To establish Etiopathogenesis, signs and symptoms of Raktatisara (~bleeding Diarrhoea) and Contribution of Diet habits, faulty lifestyle and psychological role as predisposing factors requires further study.