In the current era, the diseases allied to Anna vahaand Purīṣavahasrota (~gastrointestinal tract) are commonly found in clinical practice. Among of them Grahaṇīrogais one of the most important disorders. This disease occurs due to the distorted function of Agni (~digestive fire). Various scholars have opined that function of Agni (~digestive fire) can be evaluated through the analysis of gastric juice and different enzymes at Gastro intestinal level. All of them are accountable for the physiological function of digestion, absorption and metabolism. Altered function of the enzymes secreted from Gastro intestinal tract is responsible for foundation of Gastro intestinal disorders. Agni (~digestive fire) is seated at the spectacle of Grahaṇī (the organ hold down the descending progress of the undigested food particles until it is exclusively digested.) which is situated above the umbilical region. The system Grahaṇīis supported and nurtured by the potency of Agni. Improper function of Agni put across the pathological condition like Vidāha (~The condition where a part of food particle become digested, whereas the other part remain in undigested condition which ultimately budges upwards and downwards in gastro-intestinal tract and produce burning sensation). The Pakva (~digested) and Apakva (~undigested) food particles moves downwards and ultimately manifests Grahaṇīroga. In other words, Agnicooks any material located over it i.e. in Āmāśaya or stomach. Till the food is digested, the organ Grahaṇī helps in its withholding in the upper part (stomach), and after digestion, the food is released to the intestinal tract through the sides of Grahaṇī. This liberate of processed foodstuff takes place from the left side of the Grahaṇī because both the Grahaṇī and Guda (~rectum including anus) are located in the left side of the stomach. Both Āma (~unprocessed) and Pakva (~digested) food products come out with the fecal material. When it is vitiated due to weakness of Agni, only Apakva (~undigested) food is perpetually voided and therefore formed several sign and symptoms of Grahaṇīroga. To mitigate the pathogenesis of Grahaṇīroga, fruit powder of Pippalī was administered in this study. The drug Pippalī , botanically identified as Piper longum Linn. is a well known drug in Āyurveda mentioned by ancient classics and frequently practiced for the condition of Agnimāndya (~poor digestive power). Hence the present study aimed to clinically evaluate the efficacy of Pippalī to improve the symptoms of Grahaṇīroga.
MATERIALS AND METHODS
Selection of the patients
Forty patients were selected from OPD and IPD of Institute of Post Graduate Ayurvedic Education and Research at Shyamadas Vaidya Shastra Pith strictly based on the fixed inclusion and exclusion criteria of the study.
Patient belonged to the age group of 16 years and above up to below 70 years.
Patients primarily diagnosed as classical Grahaṇīrogawith no other history of medications.
Patients presenting with cardinal symptoms Muhurvaddhaṃ Muhurdravammalam (frequently loose motion and constipation) and macroscopically presenting undigested vegetable particles in stool.
Patients satisfied the maximum classical subjective criteria for Grahaṇīroga.
Patients those who were not willing to include themselves in the study.
Patients were suffering from any other major systemic disorders like Hepatic Failure, Renal Failure, Cardiac Disorder, Diabetes Mellitus, Malignancy and Thyroid Disorders etc.
Patients presenting the Asādhyalakṣaṇa (~symptoms indicating the poor prognosis).
Patients were receiving any other supplementary therapy.
Subjective parameters of Grahaṇīroga
Patients those who were presenting cardinal symptoms of Grahaṇīroga associated with maximum numbers of the following subjective parameters were included in the study.
Ṥuktapāka (~sour eructation), Kharāṅgatā (~roughness), Āsyaśoṣa (~dryness of mouth), Kaṅṭhaśoṣa (~dryness of throat), Kṣudhā (~loss of appetite), Tṛṣṇā (~feeling of thirst), Timira(~loss of vision), Karṇayoḥsvanaḥ (~persisting sounds on ear), Pārśvaūruvaṅkṣaṇagrīvāruka (~pain in flank, chest, groin and neck region), Visūcikā (~loose motion and vomiting with sever pricking pain), Hṛdpidā (~cardiac pain), Gṛddhiḥsarvarasānāṃ (~desire for all tastes), Mana Sadana (~depression), Jīrṇe- jīryati ca ādhmānaṃ Bhuktesvāsthyamupaiti (~after ingestion of food patient feel well but after digestion and during digestion urges of flatulence), Cirādduḥkhaṃdravaṃśuṣkaṃtanuāmaśabdaphenavatvarca (~sometimes hard and sometimes frothy stool with minimum quantity), Kāsa (~cough with sound like broken bronze pot.), Ajīrṇa (~indigestion), Nīla-Pītābhaṃpītābhaḥsāryatedravam (~altered color of stool), Pūtiamlaudgāra (~foul smelling belching), Bhinnaāmaśleṣmasaṃsṛṣṭa guru varcapravartanam (~ill formed stool with mucus), Akṛśasyāpidaurbalya (~despite lack of emaciation feels weak in sedentary work).
Objective parameters of Grahaṇīroga
Several studies has concluded that function of Agni (~digestive fire) can be evaluated through the analysis of gastric juice and different enzymes at Gastro intestinal level because physiologically Agni is responsible factor for digestion, absorption and metabolism. Based on this, following laboratorial parameters were observed.
Examination of Stool for Routine Examination and Microscopic Examination (occult blood)
Administration of drug
The patients were treated with two gms fruit powder of Pippalī with plain water in two divided doses per day, provided in between two meals, for a period of one month. All the patients were examined to evaluate the subjective and objective parameters after 7days, 15 days and 30 days of administration of test drug. The efficacy of the stipulated drug on Grahaṇīroga was evaluated based on statistical analysis.
Assessment of subjective parameters for Grahaṇīroga
Subjective parameters mentioned in the classical Ayurveda texts were evaluated by the preliminary approach of arbitrary grading system. Appropriate literary meanings of each particular symptom were encompassed after methodical discussion with subjective experts to make the arbitrary grading (Table 2). An assessment scale was framed to assess the rate of improvement. At the end of management, the consequence in analysis of percentage of relief was classified under the subsequent headings (Table 1).
Effect test drug was evaluated by Statistical method ‘Paired t-test’.
RESULTS AND DISCUSSION
Effect of drug on subjective parameters: Effect of drug on subjective parameters were analyzed (Graph 1).
Effect of drug on objective parameters: Before and after administration of drug the biochemical parameters and examination of stool were performed. In analysis of objective parameters like serum bilirubin, SGPT, SGOT, alkaline phosphatase, prothrombin time, gamma glutamyl transpeptidase, serum amylase, serum lipase; data were found to be statistically insignificant (P>0.05) and significant changes (P<0.001 and P<0.01) were observed in the parameters of serum proteins, serum albumin, serum globulin, albumin globulin ratio. Significant changes were also noticed in physical, microscopical and chemical parameters of stool. After completion of one month, undigested food materials were completely absent.
Assessment of progress: The assessment of progress was first noted at the end of 7th day, 15th day and 30th day i.e. after the course of treatment. An assessment scale was framed to assess the rate of improvement. Result obtained from the study is discussed (Table 1 and Graph 1).
To assess the state of Grahaṇīroga initial move towards arbitrary grading system were utilized. Where Grade 4 was considered as maximum severe condition and Grade 0 was considered as the minimum grave condition (table-2). After one month administration of drug marked and moderate improvement was observed. Study showed that the drug is significantly helpful in subjective parameters of Grahaṇīroga (Graph 1). Maximum subjective parameters were to be found statistically significant (P<0.05) except Kharāṅgatā (~roughness), Tṛṣṇā (~feeling of thirst), Timira (~loss of vision), Visūcikā (~loose motion and vomiting with sever pricking pain) where observed ‘p’ value was statistically insignificant (P>0.05). Significant changes of objective parameters were observed on examination of stool. Other parameters were found to be statistically insignificant. At the end of management, the result in view of percentage of relief was classified. Here in no such parameter 100% improvement was observed. Less than 100% to 75% i.e. marked improvement of subjective parameters were observed on the parameters of Śuktapāka (~sour eructation), Visūcikā (~loose motion and vomiting with sever pricking pain), Hṛdpidā (~cardiac pain), Jīrṇe- jīryati ca ādhmānaṃbhuktesvāsthyamupaiti (~after the ingestion of food patient feels well but after digestion and during digestion urge of flatulence). Moderate improvement (≥ 50% - < 75%) was observed on the parameters of Kaṇṭhaśoṣa (~dryness of throat), Āsyaśoṣa (~dryness of mouth), Kṣhudhā(~loss of Appetite), Karṇayoḥsvanaḥ (~persisting sounds on ear), Pārśvaūruvaṇkṣaṇagrīvāruka (~pain in flank chest groin and neck region), Gṛddhiḥsarvarasānāṃ (~desire for all tastes), Mana sadana (~depression), Cirādduḥkhaṃdravaṃśuṣkaṃtanuāmaśabdaphenavatvarca (~sometimes hard and sometimes frothy stool with leastquantity), Kāsa (~cough with sound like broken bronze pot), Ajīrṇa (~indigestion), Nīla-pītābhaṃpītābhaḥsāryatedravam (~altered colour of stool), Pūtiamlaudgāra (~foul smelling belching), Bhinnaāmaśleṣmasaṃsṛṣṭa guru varcapravartanam (~ill formed stool with mucus), Akṛśasyāpidaurbalya (~despite lack of emaciation feels weak in sedentary work) likewise mild improvement (≥25% - <50%) was observed on the parameter of Kharāṇgatā (~roughness), Tṛṣṇā (~feeling of thirst).
The drug Pippalī is a renowned drug in Āyurveda due to its multidimensional exploit. The drug may acts through its Kaṭu rasa (~pungent taste), Laghu (~light), Snigdha (~unctuous), Tīkṣṇaguṇa (~raggedness property), Madhuravipāka (~sweet metabolic transformation) and Anuṣṇavīrya (~medium temperate active potency).  All the Dravya (~substances) are constituted by five Mahābhūta (~five basic elements). So, after scrutiny the Pāñcabhautika composition of Pippalī, it was observed that Pippalī have significant ability to alleviate the symptoms of Grahaṇīroga by its Dīpana (~stimulation of digestion), Pācana (~digestion andmetabolism), Rocana (~craving), Lekhana (~scrap), Vṛṁhana (~nourishing) and Śodhana (~purification) Karma (~action). In Āmāvasthā (~unprocessed ingested food materials) the Dīpana (~stimulation of digestive process), Pācana (~absolute digestion), etc. karma and in Pacyamānāvasthā (~during the processing of ingested food materials) Śodhana karma (~action of purification) are meticulous (Fig. 1 and 2).
By virtue of these properties the drug was markedly effective in the symptoms like Śuktapāka (~sour eructation), Visūcikā (~loose motion and vomiting with sever pricking pain), Hṛdpidā (~cardiac pain), Jīrṇe- jīryati ca ādhmānaṃ bhukte svāsthyamupaiti (~after the ingestion of food patient feel well but after digestion and during digestion urge of flatulence) etc.
The present study ascertains that succeeding one-month administration of fruit powder of Pippalī (Piper longum Linn.) was significantly effective in improvement of subjective parameters of Grahaṇīroga. Ultimately, marked to moderate intensification was observed in the participants but no marked changes were found in most of the objective parameters of Grahaṇīroga, except in the parameters of Serum Proteins, Serum Albumin, Serum Globulin, Albumin Globulin ratio and physical, microscopical and chemical parameters of stool. Explanation behinds this may be the constraint of study like small sample size, short duration of study and few objective criteria were not found in every selected patient. Further study can undertake with special consideration of these limitations.