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Open Access Full Text Article  Review Article

A Critical Review of Qabd (Constipation) in Unani Medicine

Syed Farhanda Farooq ¹*, Zaffar Hussain ², Mehwish Ayoub ¹, Sumeena ¹

¹ PG Scholar Department of Moalajat, Regional Research Institute of Unani Medicine, University of Kashmir, Habbak Srinagar, J&K 190006 India

² Professor, Department of Moalajat, Regional Research Institute of Unani Medicine, University of Kashmir, Habbak Srinagar, J&K 190006 India

 

 

INTRODUCTION

Constipation refers to difficult, infrequent, or seemingly incomplete defecation. Because of the wide range of normal bowel habits, constipation is difficult to define precisely. Most persons have at least three bowel movements per week; however, low stool frequency alone is not the sole criterion for the diagnosis of constipation. Many constipated patients have a normal frequency of defecation but complain of excessive straining, hard stools, lower abdominal fullness, or a sense of incomplete evacuation. The individual patient’s symptoms must be analyzed in detail to ascertain what is meant by “constipation” or “difficulty” with defecation^.1Constipation may occur in many gastrointestinal and other medical disorders^.2Due to the high prevalence of constipation and an increasing tendency to use herbal remedies, and side effects of long-term use of laxative drugs, we have decided to perform review on constipation and laxative herbs in the context of traditional unani medicine. Pathophysiologically, chronic constipation generally results from inadequate fiber or fluid intake or from disordered colonic transit or anorectal function. These result from neuropsychiatric disorders such as Parkinsonism, multiple sclerosis, spinal cord injury, Depression, eating disorders, certain drugs like; Ca+ channel blockers, antidepressants, iron preparations, advancing age, or in association with a large number of systemic diseases that affect the Gastro Intestinal tract like; Irritable Bowel Syndrome Constipation-predominant, hypercalcemia, hypothyroidism etc. Constipation of recent onset may be a symptom of significant organic disease such as tumor, anorectal irritation, or stricture. In idiopathic constipation, a subset of patients exhibits delayed emptying of the ascending and transverse colon with prolongation of transit (often in the proximal colon) and a reduced frequency of propulsive High Amplitude Propagated Contractions. Outlet obstruction to defecation (also called evacuation disorders) accounts for about a quarter of cases presenting with constipation in tertiary care and may cause delayed colonic transit, which is usually corrected by biofeedback retraining of the disordered defecation. Constipation of any cause may be exacerbated by hospitalization or chronic illnesses that lead to physical or mental impairment and result in inactivity or physical immobility.¹

 

 

Materials and Methods

In the context of Unani medicine, a comprehensive literature review was undertaken by searching all accessible classical textbooks using key terms Qabḍ, I‘tiqālal-Baṭn, Ḥuṣr, Iḥtibāsal-Baṭn, Iḥtibāsal-Ṭabī‘a, I‘tiqālal-Ṭabī‘a, Imsākal-Baṭn, and A’tiqaal. Additionally, electronic databases such as Google Scholar, ResearchGate, and PubMed were searched for term such as constipation. The search covered both ancient Unani terminology and botanical nomenclature. Data gathering and subsequent analysis involved thorough consideration of review articles and experimental investigations. This rigorous method sought to gather essential material from both traditional Unani sources and contemporary scientific research, resulting in a comprehensive analysis of constipation’s therapeutic applications and qualities in the context of unani medicine.

 

 

Etiology ¹

Types of constipation and causes	Example
Recent Onset
Colonic obstruction	Neoplasm; stricture: ischemic, diverticuli, inflammatory
Anal sphincter spasm	Anal fissure, painful haemorrhoids
Medications	Analgesics, Iron supplements and SSRI’s
Chronic
Irritable bowel syndrome	Constipation-predominant
Medications	Ca2+ channel blockers, antidepressants
Colonic pseudo obstruction	Slow-transit constipation, megacolon (rare Hirschsprung’s, Chagas’ diseases)
Disorders of rectal evacuation	Pelvic floor dysfunction; anismus; descending perineum syndrome; rectal mucosal prolapse; rectocele
Endocrinopathies	Hypothyroidism, hypercalcemia, pregnancy
Psychiatric disorders	Depression, eating disorders, drugs
Neurologic disease	Parkinsonism, multiple sclerosis, spinal cord injury
Generalized muscle disease	Progressive systemic sclerosis, paralytic ileus

 

 

Epidemiology

Recent evidence indicates that the global prevalence of constipation is 14.4% when diagnosed using the Rome IV criteria. The prevalence of functional constipation among children in Asia ranged from 0.7% to 29.6%, falling within the global range of constipation prevalence.³The pooled prevalence of constipation was 12.0%.⁴Children with constipation had significantly higher prevalence of celiac disease (5.65% vs 0.87%) compared to children without constipation.⁵

Risk Factors⁶

Risk factors for constipation include female gender, older age, inactivity, low caloric intake, low-fiber diet, taking a large number of medications, low income, and low educational level. The incidence of constipation is three times higher in women, and women are twice as likely as men to schedule physician visits for constipation. Studies have shown that bowel transit time in women tends to be slower than in men, and many women experience constipation during their menstrual period. Constipation is 1.3 times more likely to occur in non-whites than in whites, and is considerably more common in families of low socioeconomic status. Medicare beneficiary data suggest that in addition to low socioeconomic status, environmental risk factors for constipation may include living in rural areas and in colder temperatures. The medications most strongly associated with constipation include aluminium-containing antacids, diuretics, opioids, antidepressants, antispasmodics, and anticonvulsants.

 

 

 

 

 

 

 

Classification⁷

Cause	Example
Organic	Colorectal cancer, extra-intestinal mass, post-inflammatory, ischemic or  surgical stenosis
Endocrine or metabolic	Diabetes mellitus, hypothyroidism, hypercalcemia, porphyria, chronic renal insufficiency, panhypopituitarism, pregnancy
Neurological	Spinal cord injury, Parkinson’s disease, paraplegia, multiple-sclerosis, autonomic neuropathy, Hirschsprung’s disease, chronic intestinal pseudo-obstruction
Myogenic	Myotonic dystrophy, dermatomyositis, scleroderma, amyloidosis, chronic intestinal pseudo-obstruction
Anorectal	Anal fissure, anal strictures, inflammatory bowel disease, proctitis
Drugs	Opiates, antihypertensive agents, tricyclic antidepressants, iron preparations, anti-epileptic drugs, anti-Parkinsonian agents (anticholinergic or dopaminergic)
Diet or lifestyle	Low fiber diet, dehydration, inactive lifestyle

 

 

Pathogenesis 

Two mechanisms explain the pathophysiology of constipation. Colonic motility dysfunction, or dysmotility, is failure of coordinated motor activity to move stool through the colon. It is sometimes associated with: dietary factors, medications that can alter motility; or systemic disease (e.g. neurologic, metabolic, or endocrine disorders).

Abnormalities of the enteric nerves, such as decreased volume of interstitial cells of Cajal (ICC) and other neural elements. The second mechanism involves pelvic floor dysfunction, or disorders of the anorectum and pelvic floor, which result in outlet dysfunction and an inability to adequately evacuate rectal contents. Functional constipation may occur as a result of disordered movement through the sigmoid colon and/or anorectum. Both mechanisms coexist in some patients, making it difficult to determine the exact underlying mechanisms for constipation.⁸

Symptoms 

Rectal bleeding • Abdominal pain • Vomiting • Loss of appetite • Unexplained weight loss • Family history of gastrointestinal malignancy • Inability to pass gas • Abdominal mass • Sensation of incomplete evacuation • Digital extraction • Straining • Tenesmus • Retention of enemas.⁹

 

 

Diagnosis ¹⁰

Rome II Criteria for Constipation Adults Two or more of the following for at least 12 weeks (not necessarily consecutive) in the preceding 12 months: Straining during >25% of bowel movements  Lumpy or hard stools for >25% of bowel movements  Sensation of incomplete evacuation for >25% of bowel movements  Sensation of anorectal blockage for >25% of bowel movements  Manual maneuvers to facilitate >25% of bowel movements (e.g., digital evacuation or support of the pelvic floor)  <3 Bowel movements per week  Loose stools not present, and insufficient criteria for irritable bowel syndrome met  Infants and children Pebble-like, hard stools for a majority of bowel movements for at least 2 weeks  Firm stools ≤2 times per week for at least 2 weeks No evidence of structural, endocrine, or metabolic disease

 

 

 

 

Complication ¹¹

(1) Hemorrhoids: Prolonged straining and increase of intra-abdominal pressure raises the venous pressure in the plexus and arteriovenous anastomoses of the anorectal junction. 

(2) Anal fissure: Trauma and sudden tear of the anal mucosa during evacuation of hard stool is usually an initiating event, but spasm of the internal anal sphincter leading to relative ischemia is thought to be the perpetuating factor.

(3) Organ prolapse: Chronic constipation is a known risk for prolapse of pelvic organs such as the uterus, rectum, urinary bladder, and vagina.

(4) Fecal impaction and bowel obstruction: Prolonged stasis of fecal matter leads to impaction and giant fecolith obstructing the large bowel, necessitating surgery.

(5) Bowel perforation and stercoral peritonitis: Extremely impacted feces (fecaloma) can compress the colonic wall, causing an ischemic ulcer and subsequent perforation, culminating in stercoral peritonitis and sometimes death. 

(6) Fecal incontinence: Overflow incontinence caused by fresh fecal matter bypassing the inssipated obstructing bolus may confuse the diagnosis of chronic constipation unless a rectal examination is performed.

Unani Concept

INTRODUCTION

In Unani medicine, "Qabḍ" (also known as I‘tiqālal-Baṭn, Ḥuṣr, Iḥtibāsal-Baṭn, Iḥtibāsal-Ṭabī‘a, I‘tiqālal-Ṭabī‘a, Imsākal-Baṭn, and A’tiqaal) refers to the condition of constipation. The term "Qabḍ" originates from the Arabic word meaning "to hold on" or "to grasp," similar to the word "amsak," which translates to "miser" in English. This comparison is drawn because just as a miser hoards wealth and is reluctant to spend it, the intestines hold onto stool and release it with difficulty. Even when forced, the miser spends only a minimal amount, similar to how the intestines may release stool only with great effort.¹²

In Unani medicine, "Qabḍ" is specifically defined as a decrease in the function of the large intestine. There are three recognized forms of Qabḍ:

1. Delaying defecation when the urge arises
2. Reduction in the quantity of stool passed
3. Straining during defecation

According to Buqrat, both the softening and hardening of stool are unfavorable.¹²

In children, an increase in moisture (Rutūbat) can lead to a decrease in vital functions, and reduced bile secretion into the intestines which can also lead to constipation.¹³ In developed countries, millions of people suffer from this condition, children, women, and the elderly being more affected.¹⁸

Some physicians believe that chronic constipation is caused by an excess of black bile (Sawdā) in the body. Therefore, treating constipation by addressing the excess Sawdāis considered important.¹⁹

Females are more predisposed to constipation than males especially during pregnancy.²²

CAUSES^12,14

Constipation, according to Unani medicine, can arise from various factors, depending on the strength of the intestines, the proper movement of food, and the power of excretion. A primary cause of constipation is weakness in the intestines.

Causes of Intestinal Weakness:

1. Congenital or Hereditary Factors: 
   1. Some individuals may be born with or inherit a predisposition to weak intestines, leading to constipation.
2. Age-Related Factors:
   1. With advancing age, the intestines may weaken, resulting in constipation.

Temporary Causes:

1. Fevers and Acute Conditions:
   1. Temporary illnesses can weaken the intestines and lead to constipation.
2. Anemia:
   1. A deficiency of red blood cells can cause general weakness, including in the intestines.
3. Melancholia:
   1. A state of deep sadness or depression can negatively impact digestion and lead to constipation.
4. Neurological Conditions:
   1. Weakness in the nerves, paralysis, palsy, or flaccidity can disrupt bowel movements, causing constipation such as multiple sclerosis.

Local Causes:

1. Flatulence:
   1. The build-up of gas can lead to abdominal distension, making it difficult to pass stools.
2. Inflammation (Ghisha-e-Mukhati Ka Nazla):
   1. Inflammation of the mucosal lining can interfere with normal intestinal function, leads to constipation.

Other Contributing Factors:

1. Stimulants of Excretion:
   1. Food acts as a primary stimulant for excretion. A reduced quantity of food and dry foods, decreases the stimulation needed for proper bowel movements.

 

2. Dietary Factors:
   1. Protein-rich foods, foods high in carbohydrates, low fluid intake, and bulky foods can all reduce the stimulation of excretion.
3. Digestive Efficiency:
   1. Some individuals have an increased power of digestion and absorption, resulting in less waste material and consequently, reduced excretion.
4. Liver and Gall Bladder Diseases:
   1. Diseases that reduce bile production can lead to constipation, as bile acts as a natural stimulant for excretion in Unani medicine.
5. Ignoring the Urge to Defecate:
   1. Continuously avoiding the urge to defecate can diminish the sensation, leading to chronic constipation.
6. Reluctance to Use Unfamiliar Restrooms:
   1. Hesitance or reluctance to use restrooms in unfamiliar places, such as offices or schools, along with the unavailability of facilities, can contribute to constipation.
7. Physical Obstructions:
   1. Narrowing of the intestinal lumen due to healing ulcers, or compression caused by uterine congestion or inflammation, can lead to constipation.
8. Pregnancy and Obesity:
   1. Pregnancy, obesity, and the use of a tight tourniquet on the back are also known causes of constipation.
9. Mental Overexertion:
   1. Intellectual strain can redirect blood flow to the brain, reducing the supply to the digestive system and leading to constipation.
10. Muscle Weakness:
    1. Weakness in the abdominal muscles, respiratory muscles, and perineal muscles can impair the process of defecation, leading to constipation.
11. Safrā and Balgham:
    1. In cases of excessive accumulation of Safrā, waste material may dry up in the intestines, causing hard and dry stools.Additionally, thick and sticky phlegm (Balgham) can coat the mucous membrane of the intestine, obstructing the passage of stool.

CLINICAL FEATURES

• Rectal Heaviness: A sensation of heaviness or fullness in the rectum.
• Pruritus Ani: Persistent itching around the anus.
• Anorectal Varicosities: Engorgement of veins in the anus and rectum, potentially leading to hemorrhoids.
• Thigh and Calf Pain: Pain in the thighs and calf muscles, possibly due to compression of pelvic nerves, which may be related to chronic constipation or impacted stools.
• Gastrointestinal Symptoms: Flatulence and belching, often accompanied by changes in tongue color (whitish or brownish coating).
• General Malaise: Symptoms of low mood, lethargy, and headache, potentially related to underlying gastrointestinal or systemic condition

COMPLICATIONS^12,18,20

• Hepatic Diversion of Toxins: Accumulation of morbid matter leading to increased burden on the liver.
• Bowel Obstruction: Partial or complete obstruction of the intestines.
• Colitis: Inflammation of the colon, which may be due to infection, inflammatory bowel disease, or other causes.
• Ulceration: Presence of ulcers in the gastrointestinal tract, potentially affecting the stomach or intestines.
• Anemia: Reduced red blood cell count or hemoglobin, potentially due to impaired liver function.
• Dyspepsia: Indigestion or discomfort in the upper abdomen, often associated with nausea, bloating, or belching.
• Rectal Prolapse: Protrusion of the rectal wall through the anus.
• Hemorrhoids: Swollen and inflamed veins in the rectum and anus.
• Incomplete Defecation: A feeling of unsatisfactory bowel emptying after defecation.
• Scybalous Stools: Passing of hard, pellet-like stools, often indicative of severe constipation.

 DIFFERENTIAL DIAGNOSIS ⁹

The detailed list of conditions to consider in the differential diagnosis of constipation includes: • Abdominal hernias 

• Anal fissure

 • Anorectal malformations 

• Anxiety disorders 

• Appendicitis 

• Chagas disease (American trypanosomiasis) 

• Colorectal cancer 

• Colonic obstruction 

• Crohn's disease 

• Depression 

• Diverticulitis 

• Dysfunctional voiding 

• Hirschsprung disease 

• Hypopituitarism (Panhypopituitarism) 

• Hypothyroidism

• Ileus

• Internal anal sphincter hypertonicity or achalasia 

• Intestinal motility disorders 

• Intestinal obstruction 

• Irritable bowel syndrome (IBS)

• Large bowel obstruction 

• Multiple endocrine neoplasia type 2 (MEN 2) 

• Ogilvie syndrome 

• Pelvic floor dyssynergia 

• Pelvic/rectal masses 

• Peritonitis and abdominal sepsis 

• Rectal prolapse • Rectocele 

• Toxic megacolon 

Additionally, consideration should be given to: Psychosocial issues, Medications, Spinal cord anomalies, Cystic fibrosis, Connective tissue disorders, Celiac disease, Cow's milk protein allergy Parkinson's disease 

Management of Constipation in Unani Medicine

Ilājbi’l-Tadbīr (Regimenal therapy)

It is advisable to avoid erratic medication instead try to heal through natural and traditional remedies on the basis of Asbāb Sitta Ḍarūriyya

Water:

It is written in Unani literature that Ma’ulkadr and Ma’ul Namkeen causes constipation. Ma’ul Naushadri is ma’eenshikam. Warm water helps in relieving constipation.¹⁵

Foods:(Ghidhā’)

Diet should be adequate in quantity and should not be dry neither by bi’lFi‘l nor bi’lQuwāRice causes constipation and therefore avoided.¹²As per Sheikh ul Raees Abu Ali Senna, the retention of food in stomach depends upon the quality of food itself like Afis, GhalīḍִwaLazij foods stay for longer time in intestines and can result in constipation.¹³

Avoid fried foods, spicy foods, confectionaries,¹⁷Aample amount of vegetables (spinach, fenugreek, beet root, carrot etc) and fruits (papaya, mango, fig, raisins, grapes, melon etc). Avoid meat and carbohydrate rich foods. Inclusion of wheat in diet is recommended. 

Bodily movement andrepose (Al-Ḥarakawa’lSukūn al-Badanī)

It is essential for the patient to establish consistent schedules for both eating and bowel movements to promote the formation of a regular physiological routine. A sedentary lifestyle is a contributing factor to constipation, as it diminishes intestinal motility. Physical activity enhances peristalsis and gastrointestinal function. Therefore, exercises that involve body movement, such as walking, horseback riding, boxing, swimming, and sports that require physical exertion, including football, hockey, and tennis, are recommended to improve bowel function.¹²

Psychic movement andrepose:(Al-Ḥarakawa’lSukūn al-Nafsānī)

Patient should avoid overexertion of mind because stress is one the cause of constipation.

Sleep and wakefulness:(Al-Nawmwa’lYaqẓa)

Insomnia causes increase in biloushumours which is one of the cause of constipation.Hypersomnia causes increase in phlegmatic humors which is also a cause of constipation. Therefore patient should take adequate amount of sleep. 

Evacuation and Retention:(Al-IḥtibāswaAl-Istifrāgh)

In chronic constipation avoid strong purgatives. Use laxatives and oils like Roghan e Badām, milk, green vegetables, flour etc .In Acute constipation purgatives can be used.

Ilājbi’l-Dawā (Pharmacotherapy)

In case cause of constipation is hotness and dryness of intestines then give Mubarridwa Muraṭṭibwamuzliq medicines. Ma’uljuban is beneficial.¹⁹Use nerve and intestinal tonics like kuchla which increases the power of excretion. Asphagol, Rogan e badam, Rogan ebaidanjeer. Addroghaniyāt in diet.²²

Single drug formulations (Mufridāt)

Aspaghol (Plantago ovata)

Anjeer (Ficus Carica)

Mawweez Munaqqa(Vitis vinifera)

Banafsha (Viola odorata Linn)¹⁹

Compound formulations (Murakabaat)

Hab-e-ghariqoon, majun Anjeer, Hab-e-muqil, Hab-e-Mubarak ¹³

Safuf e mullayyin ,Safuf e anardaana.¹⁶

Itrifalzamani, Itrifalmullayyin, Qursmullayyin, Sharbat deenar, Majooninjeer^[18

Gul-e-kand^, Hab e Qabzkusha²⁰

Treatment⁹

The treatment of constipation requires a comprehensive approach that addresses underlying causes and focuses on promoting regular bowel movements and symptom relief:

Dietary and Lifestyle Modifications: Emphasize increased fiber intake from fruits, vegetables, and whole grains, along with adequate hydration to soften stools. Scheduled bathroom time and regular physical activity further promote bowel regularity. 

Physical Therapy: For patients with pelvic floor dysfunction, physical therapy focusing on the pelvic floor can be beneficial.

Biofeedback Therapy: Biofeedback therapy or cognitive behavioural therapy may be beneficial, particularly when stress or anxiety exacerbates symptoms. 

Over-the-Counter Medications: Bulk-forming agents, stool softeners, or osmotic agents may provide short-term relief but should be monitored for extended use. 

Medications: Paraffin, lactulose, Sodium picosulfate, Milk of magnesia, Polyethylene glycol.  

Surgical Interventions: In cases of colonic inertia, total abdominal colectomy with ileorectal anastomosis may be necessary.

Special Considerations: 

Sacral Nerve Stimulation: Used for refractory constipation, sacral nerve stimulation may help modulate inhibitory reflexes in some patients. 

Peripherally Acting Mu-opioid Antagonists: Methylnaltrexone, naldemedine, and naloxegol may be used to treat opioid-induced constipation.

Long-term Safety Concerns: Caution is advised regarding the long-term safety of certain pharmacological agents, and their use should be carefully considered.

Conclusion

Constipation is a prevalent gastrointestinal disorder and often serves as an indicator of underlying issues within the digestive tract. It is characterized by infrequent, difficult, or painful bowel movements, which can result in conditions such as irritable bowel syndrome (IBS). Constipation is typically diagnosed when an individual experiences fewer than three bowel movements per week. During episodes of constipation, the stools become hard, making defecation difficult and requiring significant straining. This can lead to complications such as anal fissures or hemorrhoids. A more concerning issue arises when the passage of stools becomes completely obstructed, which, if persistent, can result in serious health consequences. Constipation can affect individuals of all ages, including children, often due to dietary factors or a lack of physical activity.

Conventional treatments for constipation generally involve the use of laxatives to facilitate stool passage. However, prolonged use of chemical-based laxatives can disrupt the body's metabolic balance and impair normal digestive function. Thus, constipation should not be overlooked, and appropriate treatment is essential. The etiology of constipation can be multifactorial, with contributing factors such as poor diet and medication side effects. The widespread adoption of unhealthy dietary habits and a sedentary lifestyle has exacerbated this condition.

From a physiological standpoint, effective elimination is crucial for maintaining overall health, vitality, and energy. Unani medicine, a holistic approach to health, posits that constipation is primarily due to an imbalance in the body’s humors (Akhlāṭ). Treatment focuses on restoring harmony among these humors, thereby improving digestion and metabolic processes to facilitate normal bowel function. Unani therapeutic strategies for constipation involve the use of herbal formulations, which consist of carefully selected herbs that work synergistically to correct humor imbalances, enhance digestion, and restore normal colonic function. These interventions offer potential benefits in alleviating the symptoms of constipation and promoting regular bowel movements.

Consent and ethical Approval: It is not applicable.

Acknowledgements: The authors are thankful to Deputy Director of RRIUM, Srinagar, for providing essential facilities and the library staff for supplying appropriate literature for this review work.

Competing interests: The authors have stated that no competing interests exist.

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