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Open Access Full Text Article   Case Report 

Effect of a Compound Unani Formulation in Constipation (Qabḍ): A Case Report

Sumeena *¹, Shameem Ahmed Rather ², Mehwish Ayoub Khan¹, Syed Farhanda Farooq¹, Farhat Rashid ¹, Umat Jan 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 is a common complaint in clinical practice and usually refers to persistent, 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 defecation¹. According to recent data, 14.4% of people worldwide suffer from constipation, as determined by the Rome IV criteria².Constipation may occur in many gastrointestinal and other medical disorders³.Due to the high prevalence of constipation, an increasing people tendency to use herbal remedies, and side effects of long-term use of laxative drugs, we have decided to investigate constipation and laxative herbs in the context of traditional Greek medicine. Pathophysio-logically, 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+ blockers, anti-depressants, advancing age, or in association with a large number of systemic diseases that affect the GI tract like; IBS-Constipation-predominant, hyper-calcemia, 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 HAPCs. 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

 

 

 

Figure 1: Demonstration of defecation reflex

 

In unani Qabḍ / I‘tiqāl al-Baṭn, Ḥuṣr, Iḥtibās al-Baṭn,  Iḥtibās al-Ṭabī‘a, I‘tiqāl al-Ṭabī‘a, Imsāk al-Baṭn and A’tiqaal. The term "Qabḍ" means "to hold on" or "to grasp," which is translated as "amsak" in Arabic, meaning "Bakheil" or "miser" in English. It is called " Qabḍ" because the intestines hold stool just as a miser holds onto wealth and spends it with great reluctance. Even if forced to spend, a miser releases the smallest amount of money, similar to how the intestines release stool with difficulty. A'tiqaal means to arrest or to stop. In Unani Qabḍ is defined as decrease in function of large intestine. Three forms of Qabḍ are hereby:

1. Delaying the defecation at the time of urge
2. Decrease in quantity of stools
3. Straining during defecation 

As per unani cause include taking dry foods dysfunction in liver, obstruction of intestine, stress, gastritis, gastric ulcer, delaying the defecation urge.⁴

CASE HISTORY:                 

A 29 year old female normotensive, non-diabetic and euthyroid presented to General Medicine OPD of RRIUM Srinagar with complaint of constipation. The patient presented with chief complaint of difficulty in passing stools. She has been facing this illness from early childhood and has progressively worsened over time. Stools are often hard, dry, and difficult to pass, requiring straining (Constipation scoring system⁶ =15, constipation severity index⁸=54 and as per Bristol stool chart⁷ was lumpy, sausage-shaped stool). The duration and severity of constipation have significantly impacted the patient's quality of life, causing discomfort and affecting daily activities. The patient has 4 bowel movements per week. The patient experiences abdominal discomfort, bloating, and occasional abdominal pain. There have been episodes of rectal bleeding during bowel movements, indicating possible complications such as haemorrhoids or anal fissures. The patient occasionally experiences nausea particularly during prolonged periods without bowel movements. Despite efforts to pass stools, the patient often feels as though the bowel movement is incomplete, leading to a sensation of fullness or discomfort in the rectum. The patient has previously sought medical consultations for this issue on multiple occasions, experiencing only temporary relief. At times, the patient has self-administered laxatives such as Cremaffin Plus, Syrup Looz, and Evacuol granules. There is a surgical history of anal dilatation and excision of a sentinel pile. The patient also reported an exacerbation of symptoms on consumption of non-vegetarian foods, pulses. Additionally, symptoms tend to worsen during times of stress. There is a family history of metabolic disorders such as diabetes, hypertension as well as colon and lung cancer. The patient is a student, belongs to a high socioeconomic class and had no history of, smoking, alcohol or other drug intake, weight loss, depression, cold intolerance. The patient had no known drug or food allergies.

Physical examination reveals a well-appearing adult having Damvi temperament (8.50) assessed via Mizaj assessment scale with a temperature of 36.7°C (98.1°F), heart rate of 72 beats/min, respiratory rate of 16 breaths/min, and blood pressure of 110/80 mmHg. Her breast revealed no tenderness or palpable lump, the bilateral chest was clear, and normal vesicular breathing sound & S1 & S2 were audible with no murmur and per abdomen was soft and non-tender. CNS examination revealed normal sensory and motor system. On digital rectal examination anal sphincter tone was normal and rectum appeared non tender. Perineal skin appeared normal with fissure at 6 o’clock. Investigation recommended were CBC, LFT, KFT, RBS, HbA1c, Thyroid profile, Electrolyte balance, Lipid profile, Cortisol level.

Therapeutic Intervention⁵:

The patient was prescribed a Unani formulation Safuf-i-Anardana, containing:

- Anardana                             (Punica granatum)          4gm

- Sana maki                            (Cassia augustifolia)       4gm

- Shoonth                                (Zingiber officinale)        2gm

- Namaksiyah                       (Black salt)                          2gm

- Turbud safeed                    (Operculina turpethum)  2gm

- Badiyan                               (Foeniculum vulgare)       2gm

                                                      

Dose, Route and Duration of drug administration: Safuf prepared from above individual drugs was advisedto be taken 9g after breakfast and 7g after dinner at bed time with 100ml lukewarm water orally for seven days.

Diagnosis & Investigations:

Investigations included CBC, thyroid function tests, random blood sugar, KFT, LFT, lipid profile, and cortisol levels to rule out metabolic or endocrine conditions. The Constipation Severity Index, Constipation Scoring System⁶ and Bristol stool chart were used to measure the severity of symptoms.

 

 

Figure 2: Bristol stool chart

 

Table 1: Showing ingredients of Safuf-i-Anardana:

S.N.	Ingredients	Botanical Name	Mizaj	Mechanism	Ref
1	Anardana	(Punica granatum)	Cold and dry temperament 1st degree	Inhibit intestinal motility	9
2	Sana maki	(Cassia augustifolia)	Cold and dry temperament 1stdegree	Influence on the motility of the large intestine Influence on secretion processes	9
3	Shoonth	(Zingiber officinale)	Hot and dry temperament in 3rd degree	Intestinal motility in intravenous preparations and facilitated gastrointestinal motility in oral preparations	9, 14
4	Namaksiyah	(Black salt)	Hot 2 degree and dry 2 degree	promotes water absorption into the intestine, which helps bulk up the feces and facilitates evacuation	10
5	Turbud safeed	(Operculina turpethum)	Hot 3rddegree and dry 2nd degree	Enhanced intestinal motility, discharge of watery faeces and increase in intestinal fluid content.	11, 12, 14
6	Badiyan	(Foeniculum vulgare)	Hot and dry in 2 degree	Regulation of intestinal muscle movement	13

 

 

RESULTS AND DISCUSSION: 

Constipation is a common gastrointestinal disorder that affects individuals of all ages. It is characterized by infrequent bowel movements, difficulty passing stool, or a sensation of incomplete evacuation. Despite its prevalence, constipation is often poorly defined and can vary widely among individuals. Normal bowel function varies, with most people having bowel movements between three times a day and once every three days. Infrequent bowel movements beyond this range can often be attributed to a poor diet and may respond well to bulk laxatives. When conventional investigations do not reveal any abnormalities, constipation is considered functional. In such cases, it is essential to apply functional tests to assess anal and anorectal function for further evaluation. Psychological illnesses like anxiety and depression are commonly evaluated among patients seeking medical treatment. Additionally, conditions such as diabetes mellitus (DM), hypothyroidism, uraemia, and certain autoimmune diseases can be underlying causes of unexplained constipation. Sedentary lifestyles and poor bowel evacuation habits can further contribute to the problem. The decision on treatment depends on prognostic factors such as the frequency of bowel movements, completeness of evacuation, duration of symptoms, and the difficulty experienced during defecation. In this particular case, there was concern regarding the patient's excessive use of laxatives, highlighting the need for a comprehensive treatment plan.

Barg e Sana having temperament cold dry 1^stdegree⁹ holds primary place in purgatives and helps in purgation of safra, sauda and balgham. It increases peristalsis in large intestine. In low doses acts as laxative and in higher doses acts as purgative. Senna is an anthranoid type stimulating laxative. The laxative effect is due to the action of sennosides and their active metabolite, rhein-anthrone, in the colon. There are two different mechanisms of action:

1. An influence on the motility of the large intestine: The laxative effect is realized by the inhibition of water and electrolyte absorption from the large intestine, which increases the volume and pressure of the intestinal contents. This will stimulate colon motility resulting in propulsive contractions.

2. An influence on secretion processes: Stimulation of active chloride secretion increases water and electrolyte content of the intestine. These changes in active electrolyte transport are dependent on calcium in serosal surface.

The laxative action of Senna is partially via stimulation of colonic fluid and electrolyte secretion, and this secretion is mediated by stimulation of endogenous prostaglandin E2formation. Ginger having hot and dry temperament in 3^rd degree⁹ contains 6-shogaol, generally more potent than 6-gingerol, has inhibited intestinal motility in intravenous preparations and facilitated gastrointestinal motility in oral preparations. Turbud having hot 3^rd dry 2^nd degree temperament having mushil bil jazib property¹¹. Anardana having cold dry temperament 1^st degree⁹ used in compound formulations of laxatives and purgatives for corrective purposes. Namak siyah in the abdomen promotes water absorption into the intestine, which helps bulk up the feces and facilitates evacuation. This is why namak siyah is commonly included in compound formulations of Unani medicine for treating constipation.¹⁰ 

Laxative drugs excrete humors only from the stomach and intestine, whereas purgative drugs are much stronger than laxative drugs and excrete humors from all other organs. On the other hand, laxative drugs are weaker and therefore safer to use than purgative drugs. The prognosis for chronic constipation depends on the underlying cause, severity of symptoms, and response to treatment. With appropriate management, including dietary and lifestyle modifications, medications, and behavioral therapies, many patients experience significant improvement in their symptoms and quality of life.

There was significant improvement in constipation, as the Constipation Severity Index decreased from 54 before treatment to 18 after treatment.

According to the constipation scoring system, which ranges from 0 to 30, the patient had a score of 15 before treatment and a score of 6 after treatment.

CONCLUSION: 

The present case report provides the evidence that compound unani formulations are effective in patients with chronic constipation. Further research is required to evaluate and establish these unani formulations as reliable therapeutic unexplained constipation.

Acknowledgements: I am thankful to my co-authors for their patience and support and also to the participant who extended her willingness to be part of the study and supportive staff of the hospital in providing necessary infrastructure.

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

Funding: Nil 

Authors Contributions: All the authors have contributed equally.

Source of Support: Nil

Informed Consent Statement: Informed consent was obtained from the subject involved in the study

Data Availability Statement: The data presented in this study are available on request from the corresponding author. 

Ethics approval: N/A

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