Download Categorization of Functional Constipation in Traditional Persian

Original Article
Categorization of Functional Constipation
in Traditional Persian Medicine:
A Descriptive Study
Journal of Evidence-Based
Complementary & Alternative Medicine
2016, Vol. 21(1) 48-52
ª The Author(s) 2015
Reprints and permission:
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DOI: 10.1177/2156587215594745
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Mahin Elsagh, MD1, Farshad Amini Behbahani, MD, PhD1,
Mohammad Reza Fartookzadeh, MD1, Peyman Adibi, MD2,
Mohammad Kamalinejad, MSc3, and Majid Anushiravani, MD, PhD4
Abstract
Functional constipation (FC) is a common clinical condition without any specific physiological causes with economic cost and
adverse effects on patients’ quality of life. The present study aimed to evaluate the causes of nonobstructive constipation in
traditional Persian medicine and its prevalence in patients with functional constipation by content analysis of patients’ interviews
and clinical exams. In this study, almost two thirds of the patients with functional constipation had mild to severe cold distemperament of the gastrointestinal system, and in almost half of them the signs and symptoms were compatible with dry distemperament of the gastrointestinal. This observational study reports high prevalence of gastrointestinal system distemperaments
in patients with functional constipation. According to the results, we can consider the proposed management of distemperaments
in traditional Persian medicine for functional constipation treatment and pathophysiology explanation. This project is a novel study
that provides the opportunity for investigating the epidemiological aspects of these distemperaments and their relationship with
functional constipation.
Keywords
constipation, traditional medicine, temperament, humor
Received February 27, 2015. Accepted for publication June 7, 2015.
Functional constipation is diagnosed when no structural or biochemical abnormalities or medical disorders can cause constipation.1,2 The prevalence of constipation varies from 0.7% to
81% worldwide,3,4 whereas the prevalence of functional constipation ranges from 2.4% to 27.2%.5,6 In Iran, the prevalence of
functional constipation ranges from 2.4% to 11.2%.7
The negative effects of constipation on patients’ health system, including depression, anxiety, psychological distress,8-11
long-term complications such as hemorrhoids, anal fissure, and
rectal prolapsed, make it a major public health issue.2,12 Also,
the cost of chronic functional constipation for each patient
ranges from $1912 to $7522 per year.13 However, a high level
dissatisfaction has been reported for current conventional treatments such as laxatives,14,15 and patients seek help from complementary and alternative medicine practitioners.16
Traditional Persian medicine, with several thousand years
of history,17 has a wide view in the diagnosis of the etiology
of constipation. In traditional Persian medicine, some terms or
names such as ghabz or hasr and eteghal-e batn are used for
constipation.18,19
The most important etiologies and pathogenesis mentioned
for nonobstructive constipation are the following18-21:
1.
Low eating: In this case, because of anorexia and low
eating and drinking, the body reduces defecation.
From the view point of traditional medicine, appetite is developed as a result of production of black bile humor and its
secretion in the gastroesophageal junction. Because of its
acerbity and sourness, the black bile leads to spasm of gastric
fibers and stimulates the appetite.22(p28)
Humor or Khelt in traditional Persian medicine is a
wet substance that foodstuffs in the first stage of permutation changes to it. There are 4 types of humor in the
human body: blood (Dam), phlegm (Balgham), yellow
1
2
3
4
Iran University of Medical Sciences, Tehran, Iran
Isfahan University of Medical Sciences, Isfahan, Iran
Shaheed Beheshti University of Medical Sciences, Tehran, Iran
Mashhad University of Medical Sciences, Mashhad, Iran
Corresponding Author:
Mahin Elsagh, MD, Iran University of Medical Sciences, Research Institute for
Islamic and Complementary Medicine, Nourth Lalezar St, Pirnia Alley,
Tehran, Iran.
Email: [email protected]
Elsagh et al
2.
3.
4.
5.
6.
7.
bile (Safra), and black bile (Sauda). Each of the humors
is associated with pairs of qualities including warm and
wet, cold and wet, warm and dry, and cold and dry,
respectively. Equilibrium of quantity and quality of these
humors is important for maintaining an ideal healthy
state. Thus, the diseases caused by the imbalance of the
humors are called distemperament or quality impairment,
where one or some of the 4 elements, namely, warm, cold,
wet, and dry, are dominant over the organ or body temperament and influences the organ or body in a way that
impairs its normal and complete function.
Intestinal warm distemperament: Depletion of stool moisture due to its absorption by extreme heat produces dry
stool. This case manifests by dry mouth, belching with
smoky smell, drooling in hunger, and decreased appetite
and thirst.
Intestinal dry distemperament: Dry distemperament is characterized by thinness, dry mouth, thirst, and takhazkhoz23
(after drinking some water, patients sense the stomach to
be like water in a leather bottle).
Weak repulsion power: Ancient Iranian doctors believed
that 4 powers or energies are responsible for the functioning
of the digestive system, including attraction, retention,
digestion, and repulsion, and the proper functioning of the
gastrointestinal tract depends on the powers. Although
‘‘warm’’ causes all the powers to strengthen, ‘‘moist’’ weakens all of them, except for digestion power. All the powers
of the stomach will weaken with all distemperaments, but
repulsion is more often weakened by wet and cold.
Weak repulsion power causes the stool to stay in the lumen
for a long time, and thus patients have to use manual
maneuvers (eg, digital evacuation) to facilitate defecation.
Intestinal cold distemperament: Patients present this distemperament with sour taste mouth in the morning, weak
digestion, bloating, belching with sour smell, borborygmi,
and increased appetite.
Weak digestion is when, after digestion, there is fullness or
heaviness in the stomach or there is belching accompanied
by smell of food that was eaten earlier.
Increase of melancholic humor (sauda) in intestines:
Increase of sauda in the digestive system leads to permanent bloating as the chief complaint.
Lack of necessary bile to intestines: Normally, some bile
from the gallbladder passes through a conduit that is connected to the intestine. The hot and spicy nature of bile
seeks to induce a sense of defecation.24 Obstruction of this
conduit due to any cause leads to a reduction of bile flow
into the intestine to stimulate defecation. The presence of
jaundice and acholic stool suggests lack of passage of the
bile to the intestines.
The aim of this study is to evaluate prevalence of these
causes in patients with functional constipation by content analysis of patients’ interviews and clinical exams. These finding
can be important elements in designing treatment plans and
in the management of constipation.
49
Materials and Methods
Eligible patients were males and females aged 18 to 65 years
and diagnosed with functional constipation according to the Rome
III criteria25 by a gastroenterologist. Patients were excluded if they
met criteria for irritable bowel syndrome with constipation or if they
had structural bowel disease or constipation secondary to other diseases or medications. Other major exclusion criteria included current
laxative, history of gastrointestinal surgery (except appendectomy
and cholecystectomy), active anal fissure, and pregnant/lactating
women.
We evaluated 110 patients with functional constipation who were
referred by the gastroenterologist. The evaluation was done via clinical history and examination by a well-educated doctor of traditional
medicine. Categorization was based on visual scales, signs, and
symptoms (rated from 0 [never] to 2 [most of time]), including the
following:
Digestion assessment
Taste of mouth in the morning
The condition of the mouth: assessed by patient’s interview and
sublingual examination
Thirst
The sense of water movement in the stomach (takhazkhoz)
Belching
Bloating
Appetite
Borborygmus
Stool color
Thinness: by focus on the chick, orbit, and temporal hypotrophy
Hose or digital evacuation
Results
From December 2013 to October 2014, of 172 patients who
visited with complaints of constipation, 128 patients with functional constipation were referred by the gastrointestinal clinic.
Sid of the participants were excluded (2 had eating disorders
and 4 because of ongoing usage of proton pump inhibitor, H2
receptor antagonist consumption), and 12 participants refused
to answer the questions. Majority of the referred patients
(70.9%) were females, and only 29.1% were males. Among the
participants, 43.6% were <40 years of age and 48.2% were aged
between 40 and 59 years. The most common presenting complaints included weak digestion (84.5%), bloating (67.3%),
dry mouth (65.4%), borburygmus (60%), thirst (45.5%), and
takhazkhoz (33.6%). Hose or finger was used to exit stool in
49 patients, which was more prevalent among females. Fifteen
case had anorexia and they were all young females. Overall,
24 patients (22%) reported frequent belching and sour odor burping, and 10 cases complained of sour taste of the mouth in the
morning. None of the visiting patients in study reported acholic
stool or smoky smelling belching. Table 1 shows the prevalence
and severity of gastrointestinal symptoms and signs in patients
with functional constipation.
The final decision and determination were made by a traditional clinician. All patients were categorized into 7 main diagnoses, as mentioned earlier. The final categorization is
described in Figure 1. Almost two thirds (60%) of the patients
50
Journal of Evidence-Based Complementary & Alternative Medicine 21(1)
Table 1. The Prevalence and Severity of Gastrointestinal Symptoms and Signs in Patients With Functional Constipation.
Age (years)
Dry mouth
Thirsty
Takhazkhoz
Bloating
Borburygmus
Weak digestion
Mild
Severe
Mild
Severe
Mild
Severe
Mild
Severe
Mild
Severe
Mild
Severe
Sour taste, mouth
Sour taste, belching
Frequent belching
Decreased appetite
Hose or digital evacuation
Much saliva mouth
20-29
30-39
40-49
50-59
9 (8.2%)
5 (4.5%)
7 (6.4%)
4 (3.6%)
8 (7.3%)
6 (5.4%)
3 (2.7%)
10 (9%)
8 (7.3%)
10 (9%)
7 (6.4%)
10 (9%)
2 (1.8%)
0
3 (2.7%)
8 (7.3%)
9 (8.2%)
3 (2.7%)
15 (13.6%)
2 (1.8%)
15 (13.6%)
3 (2.7%)
7 (6.4%)
1 (0.9%)
14 (12.7%)
7 (6.4%)
7 (6.4%)
9 (8.2%)
5 (4.5%)
19 (17.3%)
4 (3.6%)
2 (1.8%)
0
5 (4.5%)
13 (11.8%)
6 (5.4%)
12 (11%)
6 (5.4%)
12 (11%)
2 (1.8%)
5 (4.5%)
2 (1.8%)
3 (2.7%)
16 (14.5%)
10 (9%)
7 (6.4%)
9 (8.2%)
17 (15.4%)
3 (2.7%)
3 (2.7%)
6 (5.4%)
2 (1.8%)
14 (12.7%)
3 (2.7%)
4 (3.6%)
10 (9%)
4 (3.6%)
1 (0.9%)
5 (4.5%)
2 (1.8%)
7 (6.4%)
9 (8.2%)
5 (4.5%)
7 (6.4%)
4 (3.6%)
14 (12.7%)
2 (1.8%)
3 (2.7%)
4 (3.6%)
0
11 (10%)
0
Figure 1. Categorization of patients with functional constipation
according to causes in traditional Persian medicine.
with constipation had mild to severe cold distemperament of
the gastrointestinal system. Signs and symptoms of almost half
of the patients (49%) were compatible with dry distemperament of the gastrointestinal tract. Weak repulsion power and
increase of melancholic humor constituted 44.5% and 17.3%
of diagnoses, respectively. A further 13.6% of the patients were
categorized as low eating. Among the patients, 13 did not have
any specific gastrointestinal complaints, or had mild complaints, so they were not classified.
It should be noted that a patient may be listed in more than one
category; for example, a patient with weak repulsion power may
have intestinal cold distemperament symptoms or low eating.
60
5
4
2
0
2
0
5
0
2
1
5
3
1
2
1
0
2
2
(4.5%)
(3.6%)
(1.8%)
(1.8%)
(4.5%)
(1.8%)
(0.9%)
(4.5%)
(2.7%)
(0.9%)
(1.8%)
(0.9%)
(1.8%)
(1.8%)
had history and physical examination in favor of cold distemperament, and 20% had increased gastrointestinal moisture. For
the other patients, no specific causes were determined. In the
current study, among the participants with lack of appetite, some
had symptoms of abnormal phlegm and black bile humor.
From the perspective of traditional Persian medicine, several causes have been considered for loss of appetite. For
instance, heat has been considered as a cause, which exerts its
effect on the appetite by relaxation of the gastric fibers at this
region, similar to what happens in fever, and this effect varies
based on the severity of heat. Moreover, any abnormal humor
in the gastroesophageal junction that prevents the effect of
black bile causes loss of appetite. In this regard, presence of
abnormally high levels of black bile or phlegm in the gastroesophageal junction causes loss of appetite. The symptoms of
abnormal phlegm in the stomach are bloating, sour belching,
nausea, decreased appetite, and not feeling thirsty.18 According
to sages of traditional medicine, the causes of diseases must be
eliminated. So, as a first step, the following measures are
recommended18-21:
Avoid foods that increase dryness of bowels such as fried
foods, beef, oak, millet (Panicum miliaceum), and high
consumption of rice
Regular and proper eating
Avoid drinking water and juices immediately before and
after a meal
Avoid overindulgence and eating foods with different
digestion times in one meal
Regular passing of stools
Discussion
Surprisingly, none of the participants of the study had warm distemperament. Moreover, none of the patients were diagnosed to
have biliary duct obstruction or reduced bile production.
Considering the causes for abnormal excretion ability, among
the 49 patients who used manual maneuvers for purging, 61%
The following foods are beneficial: laxative foods such as
porridge and soup including chicken, pigeon, and sparrow porridges; prune soup; fatty gruel made of bran, sugar, and oil; and
fruits such as plums, apricots, and peaches.
Elsagh et al
Based on the cause of disease, some treatments have been
recommended: In cases where the distemperament cause is the
cold and dry (sauda) temper of the intestines, cathartic compound drugs for sauda temper, such as cuscuta, Epithymum,
and Polypodium vulgare compounds, should be used. Borage
distillate (Borago officinalis) or lemon balm (Melissa officinalis) is also helpful instead of having water.
If the distemperament cause is decline in the flow of bile
into the intestines, rubbing cow butter or olive oil on the abdomen and the use of pennyroyal suppositories (Mentha pulegium) and honey or lily root (lilium) are recommended.
Where the disease cause is extreme intestinal heat and
drought, drinking violet syrup (Viola odorata), lily syrup
(Ipomoea tricolor), manna (Alhagi pseudoalhagi), pumpkin
juice (Cucurbita pepo), and the juice of purslane seed (Portulaca oleracea) are helpful. Daily consumption of psyllium
(Plantago oleracea) to relieve dry distemperament of bowels
is another treatment. The use of nutritious and restorative oils
such as Qest oil (installment or Kvshnh) and Bydanjyr (castor
oil) on abdomen and pelvic to strengthen the repulsion strength
and the muscles of these areas are useful.
In cases where distemperament cause is cold temper
colons, using anisette distillate (fennel) and rose water or
honey instead of water and adding spices such as cinnamon
(Zeylanicum cinnamomum), ginger (Zingiber officinale), and
mint to patients’ foods may help.
To improve appetite in patients who suffer from loss of
appetite, mint syrup and Skanjebin Sefrejly (a mixture of
matured quince juice [Cydonia oblonga] and mildly boiled
honey and vinegar to have a honey-like form) are recommended. As mentioned earlier, none of the patients met the criteria for warm distemperament, while 53.3% of them had
abnormal phlegm and 20% considered permanent bloating
(increased level of black bile humor). However, this was not
the case for 2 patients among those with this diagnosis.
As the results showed, most patients with some degrees of
moderate to severe dry distemperament were young. This can
be due to the higher frequency of taking dry foods such as chips
and fast foods or due to higher physical activity or less sleep. In
traditional Persian medicine, sleep is considered as calmness
and awakening is regarded as movement. It is believed that
calmness leads to higher moisture in the body while physical
movement leads to waste of the moisture and as a result causes
dryness. This is where insomnia affects the digestion process as
it is believed that the digestion process is completed during
sleep.18,25
So far, functional gastrointestinal disorders cannot be completely explained by biochemical or anatomical phenomena.25
In the Canon of Medicine, in the chapter on gastrointestinal diseases, Avicenna explains that an individual has distemperament when the digestive system does not completely fulfill
its function, and it is not caused by ulcer or the food taken.18
It seems that this definition comprises the description currently
used in modern medicine for functional disorders.
Since in modern medicine temperament is not taken into
account for the development of gastrointestinal disorders, it
51
is suggested to carry out studies on functional gastrointestinal
disorders based on the temperaments. In the current study, most
patients with functional constipation had cold temperament of
the gastrointestinal system, which can be due to not observing
the basics of eating and drinking according to the traditional
Persian medicine; for instance, drinking water before, during,
or just after taking food; when fasting in the morning; immediately before exercise or physical activity; after taking bath; or
after having intercourse. Other examples could be taking
foods with different digestive properties in one meal. Also,
prevention of defecation and gas passing is very bad and
harmful, particularly in constipated patients. Continuing any
of the above-mentioned practices would influence the digestion in a negative manner and consequently lead to problems
and dysfunction of the gastrointestinal system.18,20 So these
principles should be followed.
Conclusion
High prevalence of distemperaments of the gastrointestinal system in constipated patients shows that management of distemperaments can be used for the treatment of functional
constipation. This project is a novel study that provides the
opportunity for investigating epidemiological aspects of these
distemperaments and their relationship with functional constipation. Furthermore, it gives us the opportunity to investigate
the presumable role of lifestyle and nutritional factors in functional constipation symptoms and their severity.
Authors’ Note
The study was conducted at the Gastroenterology Clinic of the Shariati
University Hospital, Isfahan city, Iran.
Acknowledgments
We are thankful to patients who participated in the study and personnel of the Gastroenterology Clinic of the Shariati Hospital, Shahid
Abbaspour Internal Medicine Polyclinic, as well as Esmaeil Nazem,
who helped us in conducting the study.
Author Contributions
ME: grant writing, data gathering, drafting of the manuscript; PA:
subject recruitment, data gathering; MRF, MK, and MA: study idea
and design, grant writing; FAB: study design, data analyses, and interpretation. All authors read the manuscript and revised and approved its
final version including the authorship list.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the
research, authorship, and/or publication of this article: This article is
the portion of the PhD thesis of the first author and was financially
supported by Tehran University of Medical Sciences, Tehran, Iran.
52
Ethical Approval
The study complies with current ethical consideration, and informed
consent was obtained from each participant included in the study.
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