DD Series: An effort to differentiate Jalodara (Ascites) due to various causes according to Ayurveda

 

An effort to differentiate Ascites due to various causes according to Ayurveda

Vibhedakatva	Jalodara (Cirrhosis)	Renal (Nephrotic/CKD)	Cardiac Ascites		Kumbhakamla (Hepatic origin)	Malignant Ascites	Pancreatic Ascites
1)Vyadhitva	Well established in Brihatrayi. Charak Udara Roga Chikitsa chapter 13	No direct reference, but Shotha Chikitsa deals with all organ failure pathologies. Udara/Jalodara is also stated as a Shotha (Edema) in Charak sutra 18/31.  Additionally, It has been stated in Udara roga chikitsa that if any serious and chronic disease (Klishta roga apratikara) didn’t get appropriate treatment in time, then it may convert into Udara/Jalodara. Renal, Cardiac, Hepatic, Pancreatic and/ or Malignant Ascites do get manifested through the different kind of pathologies but their mechanism of pathogenesis usually as per hepatic ascites in presence of either as extreme Dhatu kshaya or as a complication of such chronic disease; कफश्चोदकमूर्च्छितः|वर्धयेतां तदेवाम्बु स्वस्थानादुदराय तौ !
2)Pratyatma-Lakshan	शुष्कवक्त्राः कृशैर्गात्रैराध्मातोदरकुक्षयःप्रनष्टाग्निबलाहाराः सर्वचेष्टास्वनीश्वराः|दीनाः प्रतिक्रियाभावाज्जहतोऽसूननाथवत्
3) Nidan Panchak	Well described in Ch.Chi 13	As per specific organic pathology			Pandu roga is nidanarthakara	As per specific organic pathology	It is also fall under big umbrella of Udara roga. Specially Pittodara.
4) Bhedakatva	3 Stages/Types: i)Ajatodaka ii)Anudakam/Apraptam Udaram iii)Udaka Pradurbhava	As these are not described separately as well as precisely like Jalodara, So types or stages should be understood as per the disease stage along with the mechanism of manifestation of Ascites as per Jalodara.
5)Rogamarga	Koshtha and Shakha. Marma involvement in advance condition.	Marma and Shakha. Koshtha involvement in advance condition.		Marma and Koshtha. Shakha involvement in advance condition.	Koshtha and Shakha. Marma involvement in advance condition.	Shakha/Koshtha/ Marma as per the primary or secondary location.	Shakha and Koshtha. Marma involvement in advance condition.
5.A) Signs & Symptoms (Koshthastha-The base of this is Udara Roga symptomatology)	अनन्नकाङ्क्षा छर्दि अरुचि उदरवृद्धि / कुक्षेरतिमात्रवृद्धिः उदकपूर्णदृति-स्पर्श पार्श्वशूल गुदस्राव	अनन्नकाङ्क्षा छर्दि अरुचि उदरवृद्धि / कुक्षेरतिमात्रवृद्धिः उदकपूर्णदृति-स्पर्श पार्श्वशूल		अनन्नकाङ्क्षा छर्दि अरुचि उदरवृद्धि / कुक्षेरतिमात्रवृद्धिः उदकपूर्णदृति-स्पर्श पार्श्वशूल	कृष्णपीत शकृत् मुखच्छर्दि विण्मूत्र विकृति अरुचि आनाह नष्टाग्नि	अनन्नकाङ्क्षा छर्दि अरुचि उदरवृद्धि / कुक्षेरतिमात्रवृद्धिः उदकपूर्णदृति-स्पर्श पार्श्वशूल गुदस्राव	अनन्नकाङ्क्षा छर्दि अरुचि उदरवृद्धि / कुक्षेरतिमात्रवृद्धिः उदकपूर्णदृति-स्पर्श पार्श्वशूल गुदस्राव
5.B) Signs & Symptoms (Shakhagata-The base of this is Udara Roga symptomatology)	नानावर्णराजिसिरा सिरान्तर्धान दौर्बल्य	नानावर्णराजिसिरा सिरान्तर्धान दौर्बल्य		नानावर्णराजिसिरा सिरान्तर्धान दौर्बल्य	भृशं शूनः सरक्ताक्षि दाह तृषा	नानावर्णराजिसिरा सिरान्तर्धान दौर्बल्य	नानावर्णराजिसिरा सिरान्तर्धान दौर्बल्य
5.C) Signs & Symptoms (Marmastha-The base of this is Udara Roga symptomatology)	श्वास कास तमक हिक्का स्वरभेद तृष्णा	मूत्रसङ्ग श्वास कास तृष्णा हिक्का		श्वास तमक कास हिक्का स्वरभेद तृष्णा	ताम्यति तन्द्रा मोह नष्टसञ्ज्ञा क्षिप्रं विपद्यते	श्वास कास तमक हिक्का स्वरभेद तृष्णा	श्वास कास तमक हिक्का स्वरभेद तृष्णा
6)Dosha	Kapha Pradhan Tridosha (Anubandha may be Vata or Pitta as per the initial stage of disease and diseased).				Pitta Pradhan Tridosha (Vata or Kapha anubandha as per stage of disease and diseased).	Tridosha (Vata, Pitta, Kapha anubandh as per stage or location of disease dominant)	Pitta Pradhan Tridosha (Vata or Kapha anubandha as per stage of disease and diseased).
7)Dushya	Prana, Apan, Twak, Mansa, Rakta, Meda,Ambu, Shukra,Oja,Anna, Sweda,Purisha	Rasa,Rakta, Mansa, Meda, Asthi, Majja, Shukra, Mutra, Udaka.		Rasa, Rakta, Mansa, Prana, Anna, Apana, Mutra, Purisha	Rasa, Rakta, Mansa, Meda, Majja, Shukra, Oja, Anna, Mutra, Purisha	Prana, Udaka, Anna, Sapta Dhatu,Trimala, Oja	As per Jalodara
	The consideration of dushya in the samprapti of any disease in ayurveda is a unique and very much complex phenomenon, because dushyas have not always a fix pattern in the involvement of disease. Initially Jwara starts only with Rasa dushti but it may also start with Rasa - Rakta dushti as per the Naidanika dominancy, but may involve onwards dhatus up to the level of shukra. This progressive pattern of the disease is called as “Dhatugatava or Dhatugamitva” in ayurveda. So it must be remembered that involvement of the dushya may vary according to the stage or progress of the disease. The same principle is always applicable in the ascites of any origin as compiled in this post. Efforts have been made above to identify and describes the dushyas of ascites of various origin. It is advised that consideration of dushyas must be understood as per the dosha,dushya ,srotas,dhatu,agni and related sign and symptoms concerned and condition of the patient.
8)Srotas	Udakavaha, Swedavaha, Rasavaha, Raktavaha upto Sukravaha Srotas	Udakvaha, Mutravaha, Medavah Rasavaha, Raktavaha upto Sukravaha Srotas		Rasa, Rakta, Mansavaha, Medavaha, Prana & Udakavaha	Rasavaha, Raktavaha upto Sukravaha Srotas	Rasavaha, Raktavaha upto Sukravaha Srotas & as per site	Udakavaha,Swedavaha , Rasavaha, Raktavaha upto Sukravaha Srotas
	Srotas involvement is the starting point of ‘Dhatugatatva/Dhatugamitva’ where progressive involvement of tissue does take place. Clinical concept of said ‘Gatatva’ is usually quiet different from literary concise description because of general condition of patient depending upon Desha, Kala, Prakriti, Sara, Sattva etc and chronicity, multisystem/ Marma involvement. Shukra dhatu has always a great role in regeneration of any kind of tissues in the body. When body looses regeneration power locally (organ based) or generalised in the condition of destruction of any functional unit either it may be hepatocytes, nephrons, alveoli, neurons etc or general cellular regeneration that is hampered in various malignancies. So it can be concluded that where there is regeneration failure in any tissue, organs ,then affection of shukra dhatu is considered primarily and regeneration depend upon the generalised dhatu poshan while Dhatu Poshan depends on Ahara rasa and Ahara rasa is dependent on quality food (Pathya) and Agni (Digestive capacity).
9)Srotodushti	Sanga+ Vimargami Atipravrutti	Sanga+ Vimargami Atipravrutti		Sanga, Vimargami Atipravrutti	Sanga, Vimargami Atipravrutti	Sanga + Granthi Vimargami Atipravrutti	Sanga Vimargami Atipravrutti
10)Udbhav Sthana	Amashaya	Amapakwashaya		Amashaya	Amashaya	Ama/Pakwashaya	Amashaya
11)Vyakt Sthan	Udara	Sarvang-Udara		Lower limbs- Udara	Udara	Udara & Involved site	Udara
12)Samprapti	अत्यम्बुपानान्नष्टेऽग्नौ मारुतः क्लोम्नि संस्थितः४५ स्रोतःसु रुद्धमार्गेषु कफश्चोदकमूर्च्छितः| वर्धयेतां तदेवाम्बु स्वस्थानादुदराय तौ४६   बाह्याः सिराः प्राप्य यदा कफासृक्पित्तानि सन्दूषयतीह वायुः| तैर्बद्धमार्गः स तदा विसर्पन्नुत्सेधलिङ्गं श्वयथुं करोति८ Chakrapani Tika: बाह्याः सिरा इत्यादिसम्प्राप्तिकथनम्| बाह्या इति अगम्भीराः| सिराशब्देन स्रोतसां सामान्येन ग्रहणम्| बद्धमार्ग इति आवृतमार्गः| उत्सेधेनाव्यभिचारिणा लिङ्ग्यत इति उत्सेधलिङ्गः८     Agnimandya → Yakrit Dushti → Portal obstruction → Udakavaha Srotodushti → Jalodara	अत्यम्बुपानान्नष्टेऽग्नौ मारुतः क्लोम्नि संस्थितः४५ स्रोतःसु रुद्धमार्गेषु कफश्चोदकमूर्च्छितः| वर्धयेतां तदेवाम्बु स्वस्थानादुदराय तौ४६   बाह्याः सिरा इत्यादिसम्प्राप्तिकथनम्| बाह्या इति अगम्भीराः| सिराशब्देन स्रोतसां सामान्येन ग्रहणम्| बद्धमार्ग इति आवृतमार्गः| उत्सेधेनाव्यभिचारिणा लिङ्ग्यत इति उत्सेधलिङ्गः८   In chronic kidney disease (CKD), Ayurvedic pathogenesis of Shotha may later manifest as ascites in advanced disease.   Agnimandya → Vrikka Dushti → Protein loss/Fluid retention → Jalodara   The vitiated Vata carries and aggravates Kapha, Rakta, and Pitta within the bahya siras (superficial channels/srotas). Due to srotorodha (obstruction of body channels), the normal movement and drainage of body fluids are impaired. As a result, fluid escapes from the vascular channels and accumulates in the interstitial tissues, producing Shotha (edema).   In advanced CKD, persistent renal dysfunction leads to sodium and water retention, hypoalbuminemia, and increased capillary permeability, further promoting fluid accumulation. When this excess fluid collects in the peritoneal cavity, it manifests clinically as ascites (Jalodara).   Thus, the concept of "baddha marga" (obstructed channels or Srotorodha) and Shotha described in Ayurveda closely correlates with the pathophysiology of fluid overload and ascites seen in advanced CKD.		अत्यम्बुपानान्नष्टेऽग्नौ मारुतः क्लोम्नि संस्थितः४५ स्रोतःसु रुद्धमार्गेषु कफश्चोदकमूर्च्छितः| वर्धयेतां तदेवाम्बु स्वस्थानादुदराय तौ४६   बाह्याः सिरा इत्यादिसम्प्राप्तिकथनम्| बाह्या इति अगम्भीराः| सिराशब्देन स्रोतसां सामान्येन ग्रहणम्| बद्धमार्ग इति आवृतमार्गः| उत्सेधेनाव्यभिचारिणा लिङ्ग्यत इति उत्सेधलिङ्गः८   In cardiac ascites, impaired cardiac function leads to systemic venous congestion, which can be understood in Ayurveda as Srotorodha (obstruction of the channels). The term Sira in this context represents all fluid-conducting channels (Srotas), including the venous and lymphatic pathways. Due to obstruction (Baddhamarga/Avarita Marga), Kapha and Udaka (body fluids) become stagnant (Murchhita), preventing their normal circulation. As described in the shloka, स्रोतःसु रुद्धमार्गेषु कफश्चोदकमूर्च्छितः| वर्धयेतां तदेवाम्बु स्वस्थानादुदराय तौ४६, the obstructed channels cause the accumulated fluid to increase and shift from its normal location into the abdominal cavity, resulting in Udara (ascites).   Hridya Daurbalya → Venous congestion → Udakavaha Dushti →Jalodara     From a modern perspective, right-sided heart failure elevates central and hepatic venous pressures, leading to increased hydrostatic pressure, transudation of fluid into the peritoneal cavity, and ultimately the development of cardiac ascites.   Thus, the Ayurvedic concepts of Srotorodha, Kapha-Udaka accumulation, and abnormal fluid redistribution closely parallel the modern pathophysiology of cardiac ascites.	अत्यम्बुपानान्नष्टेऽग्नौ मारुतः क्लोम्नि संस्थितः४५ स्रोतःसु रुद्धमार्गेषु कफश्चोदकमूर्च्छितः| वर्धयेतां तदेवाम्बु स्वस्थानादुदराय तौ४६   कालान्तरात् खरीभूता कृच्छ्रा स्यात् कुम्भकामला| कृष्णपीतशकृन्मूत्रो [१] भृशं शूनश्च मानवः३७ सरक्ताक्षिमुखच्छर्दिविण्मूत्रो यश्च ताम्यति| दाहारुचितृषानाहतन्द्रामोहसमन्वितः३८ नष्टाग्निसञ्ज्ञः क्षिप्रं हि कामलावान् विपद्यते|३९ खरीभूतेति कठोरतामुपगता| कुम्भकामलेति अवस्थाभेदेन कोष्ठगतकामलायाः सञ्ज्ञा;  कुम्भः कोष्ठः, तदाश्रया कामला कुम्भकामला| अस्यां च शोथोऽपि लक्षणं भवति| उक्तं हि सुश्रुते- “भेदस्तु तस्याः खलु कुम्भसाह्वः शोथो महांस्तत्र च पर्वभेदः” (सु. उ. अ. ४४) इति३४-३८- Kumbha Kamala is considered the advanced and chronic stage of Kamala (jaundice) in Ayurveda and closely resembles severe chronic liver disease, particularly decompensated liver cirrhosis in modern medicine.   As the disease progresses, persistent vitiation of Pitta, Rakta, Kapha, and Vata leads to structural and functional damage of the liver, causing srotorodha (obstruction of channels) and impaired fluid metabolism.   Acharya Chakrapani’s commentary specifically mentions "अस्यां च शोथोऽपि लक्षणम्", indicating that edema is an important feature of Kumbha Kamala.   In advanced liver disease, portal hypertension, hypoalbuminemia, and renal sodium-water retention result in the accumulation of fluid within the peritoneal cavity, producing ascites.   Thus, although the Charak Samhita describe Shotha (edema) rather than using the term ascites, the pathophysiology strongly supports the development of ascites (Jalodara) in patients with Kumbha Kamala, making it comparable to decompensated cirrhosis with ascites in modern medicine. बाह्याः सिरा इत्यादिसम्प्राप्तिकथनम्| बाह्या इति अगम्भीराः| सिराशब्देन स्रोतसां सामान्येन ग्रहणम्| बद्धमार्ग इति आवृतमार्गः| उत्सेधेनाव्यभिचारिणा लिङ्ग्यत इति उत्सेधलिङ्गः८     .	अत्यम्बुपानान्नष्टेऽग्नौ मारुतः क्लोम्नि संस्थितः४५ स्रोतःसु रुद्धमार्गेषु कफश्चोदकमूर्च्छितः| वर्धयेतां तदेवाम्बु स्वस्थानादुदराय तौ४६   बाह्याः सिरा इत्यादिसम्प्राप्तिकथनम्| बाह्या इति अगम्भीराः| सिराशब्देन स्रोतसां सामान्येन ग्रहणम्| बद्धमार्ग इति आवृतमार्गः| उत्सेधेनाव्यभिचारिणा लिङ्ग्यत इति उत्सेधलिङ्गः८   Malignant ascites can be interpreted through the Ayurvedic concepts of Srotorodha (obstruction of channels), Kapha, Udaka, and deranged fluid dynamics. The term Sira refers to all fluid-conducting channels (Srotas), including the venous, lymphatic, and serosal pathways.   Arbuda → Srotorodha → Peritoneal spread → Jalodara   In malignancy, tumor infiltration of the peritoneum, lymphatic obstruction, and compression of vascular channels produce Baddhamarga (obstructed pathways). Consequently, Kapha and Udaka become stagnant (Murchhita) within the obstructed Srotas. As described in the shloka, स्रोतःसु रुद्धमार्गेषु कफश्चोदकमूर्च्छितः| वर्धयेतां तदेवाम्बु स्वस्थानादुदराय तौ४६ the accumulated fluid progressively increases and shifts from its normal physiological location into the abdominal cavity, resulting in Udara (ascites). From a modern perspective, malignant ascites develops due to peritoneal carcinomatosis, increased vascular permeability mediated by tumor-derived factors such as VEGF( VEGF is a signaling protein (growth factor) that stimulates the formation of new blood vessels (angiogenesis) and also increases vascular permeability), allowing fluid to leak out of blood vessels.), lymphatic obstruction, and impaired peritoneal fluid absorption, leading to excessive fluid accumulation within the peritoneal cavity.   Thus, the Ayurvedic concepts of Srotorodha, Kapha-Udaka stagnation, and abnormal fluid redistribution provide a conceptual parallel to the modern pathophysiology of malignant ascites.	अत्यम्बुपानान्नष्टेऽग्नौ मारुतः क्लोम्नि संस्थितः४५ स्रोतःसु रुद्धमार्गेषु कफश्चोदकमूर्च्छितः| वर्धयेतां तदेवाम्बु स्वस्थानादुदराय तौ४६   बाह्याः सिरा इत्यादिसम्प्राप्तिकथनम्| बाह्या इति अगम्भीराः| सिराशब्देन स्रोतसां सामान्येन ग्रहणम्| बद्धमार्ग इति आवृतमार्गः| उत्सेधेनाव्यभिचारिणा लिङ्ग्यत इति उत्सेधलिङ्गः८ Pancreatitis-associated ascites can be interpreted through the Ayurvedic concepts of Srotorodha (obstruction of channels), Kapha, Udaka, and inflammatory fluid accumulation. The term Sira denotes all fluid-conducting channels (Srotas), including the peritoneal, lymphatic, and vascular pathways.   Pancreatic enzyme leakage → Pitta Dushti → Peritoneal irritation → Ascites     In acute or chronic pancreatitis, inflammation and enzymatic injury increase vascular permeability and may disrupt the pancreatic duct, allowing enzyme-rich pancreatic secretions to leak into the peritoneal cavity. Simultaneously, inflammatory edema and fibrosis may impair lymphatic drainage, creating Baddhamarga (obstructed pathways). Consequently, Kapha and Udaka become stagnant (Murchhita) within the obstructed Srotas. As described in the shloka, स्रोतःसु रुद्धमार्गेषु कफश्चोदकमूर्च्छितः| वर्धयेतां तदेवाम्बु स्वस्थानादुदराय तौ४६ the retained fluid progressively accumulates in the abdominal cavity, resulting in Udara (ascites). From a modern perspective, pancreatic ascites develops due to leakage of enzyme-rich pancreatic fluid from a disrupted pancreatic duct or ruptured pseudocyst, together with inflammation-induced capillary leak and impaired lymphatic drainage.   Thus, the Ayurvedic concepts of Srotorodha, Kapha-Udaka stagnation, and abnormal fluid redistribution provide a conceptual parallel to the modern pathophysiology of pancreatitis-associated ascites.
13)Sadhyasadhyata	Krichha Sadhya-Asadhya if arishta Lakshan develops/ found	Pratyakheya		Krichhra Sadhya	Asadhya	Asadhya	Krichhra Sadhya
14)Agni	Manda/Vishamagni
15)Sama/Nirama	Usually Sama initially, Nirama later	Sama/Nirama		Sama/Nirama	Sama	Sama	Sama
16)Vyadhi Prasar	Rasayani(Through lymphatics)
17)Vyadhi Prakar	Chirakari
18)Purvarupa	As these all are condition of complications of various diseases,so it will not be justified to find purvarupa of these terminal condition.
19)Updrava	छर्दि (Vomiting)  तृष्णा (Excessive thirst) श्वास (Dyspnea) तमक (Respiratory distress) हिक्का (Hiccup) दौर्बल्य (Weakness) पार्श्वशूल (Right hypochondrial/flank pain) अरुचि (Loss of appetite) स्वरभेद (Hoarseness, advanced disease) मूत्रसंग (Reduced urine output/Hepatorenal syndrome)	छर्दि (Uremic vomiting) तृष्णा श्वास (Due to Pleural effusion) कास तमक दौर्बल्य अरुचि मूत्रसंग(Oliguria/Anuria)		श्वास (Most prominent) तमक कास दौर्बल्य अरुचि तृष्णा हिक्का(Occasionally)	छर्दि अतीसार तृष्णा श्वास कास दौर्बल्य पार्श्वशूल अरुचि	छर्दि तृष्णा श्वास हिक्का दौर्बल्य (Very severe) पार्श्वशूल अरुचि स्वरभेद (If thoracic/laryngeal involvement)   -	छर्दि (Very common) तृष्णा हिक्का श्वास (Large ascites) दौर्बल्य पार्श्वशूल (Most prominent) अरुचि
	-Portal hypertension -Spontaneous bacterial peritonitis (SBP) -Hepatic encephalopathy -Hepatorenal syndrome -Variceal bleeding -Hepatic hydrothorax -Hepatocellular carcinoma	-Pulmonary edema -Hyperkalemia - Metabolic acidosis -Uremia -Severe edema -Dialysis requirement		-Congestive heart failure -Pulmonary edema -Pleural effusion -Cardiogenic shock -Arrhythmias		Cachexia -Bowel obstruction -Pleural metastasis -Severe malnutrition -Recurrent tense ascites	-Pancreatic pseudocyst -Pancreatic fistula -Secondary infection -Severe electrolyte imbalance -Recurrent pancreatic ascites
20)Nidanarthakaravta	Chronic liver disease causing Jalodara	CKD/Nephrotic syndrome causing Jalodara		Heart failure causing Jalodara	Kumbhakamla Janya Jalodara	Malignancy causing Jalodara	Pancreatitis causing Jalodara
21)Chikitsa Sutra- Samayana Chikitsa Siddhant-	दोषातिमात्रोपचयात् स्त्रोतोमार्ग निरोधनात्।संभवत्युदरं तस्मान्नित्यमेव विरेचयेत्।।च. चि. १३/६१ अपां दोषहराण्यादौ प्रदद्यादुदकोदरे||९३||मूत्रयुक्तानि तीक्ष्णानि विविधक्षारवन्ति च| दीपनीयैः कफघ्नैश्च तमाहारैरुपाचरेत्||९४||द्रवेभ्यश्चोदकादिभ्यो नियच्छेदनुपूर्वशः|९५| It may feel little surprising that all above different kind of pathology are subjected to the general line of treatment of management of Udara roga but as per the end result of all ailments is accumulation of fluid in peritoneum cavity(Ascites/Jalodara) and unless it is checked on the priority basis there will be no digestion , nutrition and required Dhatu poshana. So This principle is primary principle and applicable in almost all condition. Exception may be there in the presence of Vyadhi Sankara, Arishta Darshan, Pratyakheya or Asadhya condition in the presence of excessive Bala Mansa Parikshaya etc.
22)Dosha pratyaneek	अपां दोषहराण्यादौ प्रदद्यादुदकोदरे| (Apam/fluid /Kleda/Shleshma nashaka chikitsa   मूत्रयुक्तानि तीक्ष्णानि विविधक्षारवन्ति	Vata-Pitta shamak chikitsa		As per doshaja dominance mentioned (Ch.Su 17, Ch.Chi 26, Ch.Si 9)	Pitta-Vata shamaka chikitsa	Tridosha shamaka as per dosha dominancy	Usually pitta shamaka chikitsa and as per doshaja dominance
	These are literary indication as per the doshaja dominance in all above conditions, Avasthika chikitsa may vary as per the desha, Kala, Vaya, Satva, Satmya, etc and chief presenting features. For example if such patients have severe headache , bloating, constipation, etc. Then there may be administration of Niruha basti / Castor oil may be a good example of avasthika chikitsa.
23)Vyadhi pratyaneek	तस्मान्नित्यमेव विरेचयेत्।।	Mutrakrichra chikitsa		Hrida Balya chikitsa	Tikta rechana prayoga	Granthi/Arbud nashak Dravya prayoga	Tikta Rechana, Shool prashamana and Jwaraghna
24)Naimitik rasayana	Ushtri Ksheer Prayoga,Shilajatu, Swarnamakshika, Haritaki, Kutaki	Sthiradi Varga, Guduchi, Gokshura, Punarnava, Shilajatu, Swarnamakshika, Haritaki, Kutaki, Ushtri Ksheer Prayoga		Kupilu, Kasturi, Ambar, Keshar, Pushkarmula, Shilajatu, Swarnamakshika, Haritaki, Kutaki, Madya/Asava/ Arishta, Ardraka, Shunthi, Rasona, Ushtri Ksheer Prayoga	Tikta Rasayana herbs, Shilajatu, Swarnamakshika, Haritaki, Kutaki, Mandura, Ushtri Ksheer Prayoga	Bhallatak, Shilajatu, Gomutra Heeraka Bhasma, Swarnamakshika, Kutaki, Ushtri Ksheer Prayoga	Tikta Sheeta Rasayana, Ksheera, Shilajatu, Swarnamakshika, Haritaki, Kutaki, Ushtri Ksheer Prayoga
25)Pathya	Draksha, Tikta Shaka, Ksheera, Gulkand, Suvarchala, Grinjanaka, Patola, Mulaka ,Nimba, Yava,old Shali rice	Tikta Shaka, Suvarchala, Grinjanaka, Patola, Mula   ka ,Nimba, Yava,old Shali rice		Tikta Shaka, Suvarchala, Grinjanaka, Patola, Mulaka ,Nimba, Yava,old Shali rice	Tikta Shaka, Gulab, Utpala,Gulkand, Suvarchala, Grinjanaka, Patola, Mulaka ,Nimba, Yava,old Shali rice	Tikta Jivniya Shaka, Suvarchala, Grinjanaka, Patola, Mulaka ,Nimba, Yava,old Shali rice	Tikta Jivniya Shaka, Suvarchala, Grinjanaka, Patola, Mulaka ,Nimba, Yava,old Shali rice
26)Apathya	Shushka-shaka, Navanna, Gauda, Pishtanna, Dadhi, Tilakritam, Madyam, Amlam, Dhana, Vallura, Samashana, Guru, Asatmya, Vidahi, Svapna, Maithuna.
27)Upashaya-Anupashaya	Primarily as per Udara roga mainly Jalodara and Shotha or Arbuda as per the cause.
28)Arishta	यस्य मूत्रं पुरीषं च ग्रथितं सम्प्रवर्तते|निरूष्मणो जठरिणः श्वसनो न स जीवति११ श्वयथुर्यस्य कुक्षिस्थो हस्तपादं विसर्पति|ज्ञातिसङ्घं स सङ्क्लेश्य तेन रोगेण हन्यते१२श्वयथुर्यस्य पादस्थस्तथा स्रस्ते च पिण्डिके|सीदतश्चाप्युभे जङ्घे तं भिषक् परिवर्जयेत्१३ शूनहस्तं शूनपादं शूनगुह्योदरं नरम्|हीनवर्णबलाहारमौषधैर्नोपपादयेत्१४
1. Swelling of hands, feet, genital region and abdomen → indicates generalized fluid accumulation → peripheral edema + genital edema + ascites → when widespread, this is termed anasarca → commonly associated with renal, hepatic, cardiac or severe nutritional disorders. 2. Fluid accumulation → may result from sodium-water retention, increased hydrostatic pressure and/or reduced plasma oncotic pressure due to hypoalbuminemia → fluid shifts from the intravascular compartment into the interstitial tissues → progressive edema and ascites. 3. Heena Varna → can be correlated with pallor → may indicate anemia, nutritional deficiency or chronic disease → reduced oxygen-carrying capacity → fatigue and reduced exercise tolerance. 4. Heena Bala → indicates generalized weakness and reduced physical strength → chronic illness + anemia + inflammation + malnutrition → reduced functional capacity and physical performance. 5. Heena Ahara→ indicates poor appetite and reduced dietary intake → inadequate calorie and protein intake → protein-energy malnutrition → negative energy and nitrogen balance. 6. Malnutrition + chronic inflammation + increased catabolism → increased muscle protein breakdown → muscle wasting/sarcopenia → reduced muscle strength → calf and lower-limb wasting → difficulty in walking and progressive deconditioning. 7. Hypoalbuminemia → reduced plasma colloid oncotic pressure → increased movement of fluid into interstitial tissues → worsening peripheral edema → along with portal hypertension or fluid retention → worsening ascites. 8. Edema + ascites → abdominal distension and early satiety → further reduction in food intake → worsening malnutrition → hypoalbuminemia + muscle wasting → further edema → a vicious cycle of edema, malnutrition and sarcopenia.   So:Chronic systemic disease → organ dysfunction → fluid retention/hypoalbuminemia → edema + ascites → poor appetite → malnutrition → muscle wasting → weakness and reduced functional capacity → progressive debility → poor prognosis.

 

Conclusive remarks:

1)Ascites is a common clinical manifestation, not a single disease. It can occur due to liver disease, kidney disease, heart failure, malignancy, pancreatitis and other conditions. Though, It seems that Ayurveda doesn’t describe the Ascites except Jalodara only, but that is a superficial observation because Charaka and all Acharyas have described Shotha as an independent disease entity that covers almost all kind of Ascites as mentioned above, but treatment may differ as per Srotas, Udbhava-sthana, Dhatu-dushti and Rogamarga etc. As per the concept of inflammation (that we know as dosha prakopa as Sthan-sanshrita) mentioned in contemporary science, must be understood as a preliminary condition of any kind of fluid secretion or collection if there is no proper outlet to circulate/discharge as oozing. There are certain types of ascites/fluid accumulations that are seen in various pathologies like Hepatitis, Pulmonary pathology, Hydrocele in genital pathology, Pancreatic pathology etc; These all are Uttana with marked srotorodha / sanga (Rasa-Raktagata बाह्याः सिरा इत्यादिसम्प्राप्तिकथनम्| बाह्या इति अगम्भीराः-Chakrapani) pathologies as per Ayurveda principles where hardly tissue necrosis or fibrosis presents Hence these are easily curable because no Gambhira Dhatu (Meda, Asthi, Majja, Shukra) are involved.  There are other terminal variants of said pathologies (Discussed above) where tissue destruction/ Organ failure condition led to fluid accumulation that usually has tendency as prolonged terminal illness; while Uttana pathology usually responds to almost all kind of management very well. 

2)Therefore, the same Ayurvedic concept cannot be applied in exactly the same way to every type of ascites. Dosha, Dushya, Srotas, Agni, Samprapti, Uttana-Gambhira and Vyadhi Sankara etc should be assessed according to the underlying disease and its stage. A treating physician should always remember the Pratyakheya / Asadhya lakshan and Arishta with the concept of ‘Bala-mansa-parikshaya’ etc. instructed very well in all classics.

3)The concept of Nidanarthakara Vyadhi helps in understanding secondary ascites. For example, chronic liver disease, CKD or heart failure may act as the primary disease, while ascites develops later as a consequence.

4) अत्यम्बुपानान्नष्टेऽग्नौ मारुतः क्लोम्नि संस्थितः४५ स्रोतःसु रुद्धमार्गेषु कफश्चोदकमूर्च्छितः| वर्धयेतां तदेवाम्बु स्वस्थानादुदराय तौ

Srotorodha (ruddha-marga) must be considered a major component in the pathogenesis of ascites. It may be correlated with portal hypertension etc., where increased hydrostatic pressure promotes fluid exudate/trasudate into the peritoneal cavity. Kapha (in above shloka) may be functionally correlated with the albumin-mediated oncotic component, while Udaka can be understood in relation to altered body-fluid homeostasis due to decreased plasma oncotic pressure. Ambu may represent the leaked and accumulated abdominal fluid, which can manifest as transudate or exudate depending on the underlying pathology as Shotha /Jalodara at Gambhira  dhatu level. Thus, Srotorodha, increased hydrostatic pressure and reduced oncotic pressure collectively contribute to fluid accumulation in the abdomen.

बाह्याः सिराः प्राप्य यदा कफासृक्पित्तानि सन्दूषयतीह वायुः| तैर्बद्धमार्गः स तदा विसर्पन्नुत्सेधलिङ्गं श्वयथुं करोति As per this shloka Uttana type may be concerned to Shotha Roga where Rakta, Pitta along with Kapha dosha have most active metabolic component while in samprapti of Jalodara there is no role of Pitta and Rakta have been mentioned because active pitta generating hepatocytes are fibrosed there.

अत्यम्बुपानान्नष्टेऽग्नौ: Pre existing prolonged/ Chronic digestive issues

मारुतः क्लोम्नि संस्थितः४५ Being mool sthan of Udakavaha srotasa (All fluid movements governed by Vata)

स्रोतःसु रुद्धमार्गेषु: Loss of hepatocytes/ compromised hepatic filtration leading to portal and splenic hypertension.

कफ: Hypoalbuminemia 

श्चोदकमूर्च्छितः Decreased oncotic pressure and increased hydrostatic pressure

वर्धयेतां तदेवाम्बु: By leaking of fluid

स्वस्थानादुदराय तौ: In peritoneal cavity

 

 

Efforts are being made to differentiate the Uttana and Gambhira Jalodara/Ascites as per basic Ayurveda principles:

S.No.	Differentiating points	Uttana	Gambhira
1.	Disease stage	Relatively superficial or early-stage pathology	Advanced or chronic pathology with deeper structural involvement
2.	Predominant pathology	Srotorodha/Sanga with functional disturbance	Persistent Srotorodha with significant structural or organ dysfunction
3.	Dosha involvement	Mainly Pitta-Rakta,Kapha/Vata बाह्याः सिराः प्राप्य यदा कफासृक्पित्तानि सन्दूषयतीह वायुः| तैर्बद्धमार्गः स तदा विसर्पन्नुत्सेधलिङ्गं श्वयथुं करोति	Mainly Vata-Kapha अत्यम्बुपानान्नष्टेऽग्नौ मारुतः क्लोम्नि संस्थितः४५ स्रोतःसु रुद्धमार्गेषु कफश्चोदकमूर्च्छितः| वर्धयेतां तदेवाम्बु स्वस्थानादुदराय तौ
4.	Dushya and Dhatu involvement	Rasa,Rakta, Mansa	Meda,Asthi,Majja,Shukra,Oja
5.	Srotas	Udaka Rasa, Rakta,Mansavaha	Udaka,Meda,Asthi,Majja,Shukravaha
6.	Agni	Agnimandya may be present, with reversible functional disturbance	Chronic Agnidushti does coexist with Dhatvagnimandya and advanced systemic dysfunction
7.	Modern pathophysiological correlation	Fluid collection in Hepatits, Pulmonary, Hydrocele, Pancreatic like conditions.	Fluid accumulation associated with advanced cirrhosis, portal hypertension, Pancreatic fibrosis, CKD, severe cardiac dysfunction/ Myopathies and other advanced disease.
8.	Tissue changes	Structural distortion generally absent	Fibrosis, tissue destruction or irreversible organ dysfunction is present

 

 

6) Kloma is described as a root of Udakavaha Srotas and is associated with regulation of thirst and body water. Therefore, Jalodara  is linked with disturbed fluid homeostasis. Fluid(Apa/Ambu) accumulation is the final manifestation.

Disturbed regulation of body fluid ultimately results in pathological accumulation of Udaka in the abdominal cavity.

The principle “अपां दोषहराण्यादौ प्रदद्यादुदकोदरे” highlights that controlling and expelling out excessive fluid is an important part of managing Jalodara.

This principle is differ from Shotha chikitsa because Pitta and Rakta are not considered in the management being Dhatu paka (Fibrosis- Loss of hepatocytes, a basic functioning unit) at the level of Yakrita. Rakta and Pitta are always dominant in Dosha Paka Avastha like Hepatitis/ Hepatomegaly (शोणितं वा रसादिभ्यो विवृद्धं तं विवर्धयेत्). On the basis of this deep analysis, it may be concluded that the concept of Dosha paka and Dhatu paka must not be restricted to Jwara samprapti only, This must be applied in each serious disease or pathogenesis because Dhatu paka (Fibrosis/ Necrosis) is the ultimate result of the concept of Dhatugatava where doshas penetrate deeper into the tissues gradually. This may be a reason that Acharya Charak didn't use the term 'Jalodar' in symptomatogy of 'Kumbhakamala', while this termilogy itself indicates massive Shoth/edema or even the treatment is also doesn't comply that indicated in Jalodar. 'Kumbhakamala' may convert to 'Jalodar' then only classical Jalodar chikitsa can be applied. We may understand that any chronic advanced GI pathology may  terminate as Jalodar.

 

7) The underlying cause, whether hepatic, renal, cardiac, malignant or pancreatic ascites also needs to be identified and managed. ‘Nitya Virechana’ is a key treatment principle. It is not simply intended to “remove water”; its broader objective is Dosha elimination and correction of the pathological process e.g. tissue regeneration with appropriate suitable or required dietary restrictions.

 

8) The treatment of Jalodara should primarily aim at Samprapti Vighatana. Deepana–Pachana helps to correct Mandagni and improve metabolic processing, while Srotoshodhana targets/removes Srotorodha, thereby facilitating the normal movement and regulation of fluid. Since disturbed Vata plays an important role in the abnormal movement and distribution of Udaka, Vatanulomana & 'Nitya-virechan' are also essential. Along with these principles, appropriate Shamana chikitsa should be selected according to the patient's Dosha, Agni, Bala, Arishta, Sadhyasadhyata assessment and other organ/multi organ involvement, and associated complications.

 

9) Localisation of Shotha/ Edema

Ayurveda describes Shotha and Dosha relation as per the physiological locations of the Doshas. This description not much highlighted in Shotha chikitsa or Jalodara chikitsa but the management has complied this principle. Urdhva Shotha is edema of the upper part of the body is considered as Kapha pradhana. Middle part- Pitta pradhana and Lower part is considered as Vata dominant. These are very much superficial concept as per the physiological classification. While in the management of any kind of Shotha requires the analysis of Dosha, Dushya , Agni, Srotasa, Sattva, Satmya, Vaya, Sanhanana, Prakriti, Desha, Kaala, Saara etc. to decide the final management.

उरःस्थितैरूर्ध्वमधस्तु वायोः स्थानस्थितैर्मध्यगतैस्तु मध्ये| सर्वाङ्गगः सर्वगतैः क्वचित्स्थैर्दोषैः क्वचित् स्याच्छ्वयथुस्तदाख्यः||९||

(चरकचिकित्सास्थान-12/9)

चक्रपाणिदत्त कृत:

उरःस्थितैरित्यादिना विशिष्टशोथानां सम्प्राप्तिविशेषमाह| ऊर्ध्वमिति उरःप्रभृत्यूर्ध्वशरीरे| अध इति पक्वाशयप्रभृतौ| वायोः स्थानं पक्वाशयः| मध्यगतैरिति उरःपक्वाशयमध्यगतैः| क्वचिदिति कण्ठताल्वादिदेशे| तदाख्य इति ‘गलशोथ’ इत्यादिशब्दाख्य इति; किंवा ऊर्ध्वशोथाधःशोथ इत्यादिशब्दाख्य इति सर्वत्र योजनीयम्||९||

 

 

 

Shloka	Ayurveda explanation	Modern understanding	Examples
उरःस्थितैरूर्ध्वम्	It means Urdhva as the body above the chest. The shloka describes upper-body Shotha in relation to the location of doshas.	Swelling of the face, eyelids, or neck may have renal, allergic, inflammatory, venous, or other causes.	Facial oedema; periorbital oedema; neck swelling. Renal disease; angioedema; local inflammation; venous obstruction, Hydrocephalus
अधः वायोः स्थानस्थितैः	It means Adhaḥ with reference to Pakvashaya and regions below it, describing Shotha affecting the lower part of the body. The commentary states: वायोः स्थानं पक्वाशयः- Pakvashaya is described as the site of Vata in this context.	Lower-limb swelling can be associated with dependent fluid accumulation, venous insufficiency, systemic fluid retention, lymphatic disease, or medication effects. Pedal oedema; ankle oedema; dependent oedema. Heart failure; chronic venous insufficiency; renal disease; medication-induced oedema; deep-vein thrombosis.
मध्यगतैस्तु मध्ये	Doshas situated in the region between Uraḥ and Pakvashaya are associated with Shotha in the middle region.	Abdominal or central-body swelling may arise from fluid accumulation, organ enlargement, intestinal distension, or abdominal-wall pathology. These conditions are distinct.	Ascites; abdominal-wall oedema; abdominal distension due to intestinal gas or contents.
सर्वाङ्गगः सर्वगतैः	When the pathology described extends throughout the body, Shotha is generalized rather than confined to one region.	Generalized oedema may occur with systemic disorders affecting fluid balance, plasma proteins, venous pressure, renal sodium handling, or lymphatic drainage.	Generalized oedema; severe widespread oedema may be called anasarca. Nephrotic syndrome; renal dysfunction; heart failure; advanced liver disease; severe hypoalbuminaemia
क्वचित्स्थैर्दोषैः क्वचित् स्याच्छ्वयथुस्तदाख्यः	When doshas are situated in a particular region, Shotha may be localized to that region. The Chakrapani teeka explains that Shotha may be named according to its site, e.g., Galashotha; it also allows terms such as Urdhva Shotha and Adhaḥ Shotha.	Localized swelling may result from inflammation, infection, trauma, venous thrombosis, venous obstruction, or lymphatic obstruction. Modern terminology also describes swelling by site and distribution.	Localized inflammatory swelling; swelling confined to one limb or one anatomical site. Galashotha; facial oedema; pedal oedema; generalized oedema.

Presented By:

Dr. Shubham Tripathi

B.A.M.S.

MD IInd Yr. Scholar

P. G. Dept. of Kayachikitsa

Govt. Akhandanand Ayu. College,

Bhadra, Ahmedabad, Gujarat, India

Mob.- +91-6260097626

Guided by 

Prof. Surendra  A. Soni

H.O.D., 

P. G. Dept. of Kayachikitsa

Govt. Akhandanand Ayu. College,

Bhadra, Ahmedabad, Gujarat, India

Email: kayachikitsagau@gmail.com