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Leukemia

Definition

• Tintinalli's Emergency Medicine, p. 1329
• StatPearls - Leukemia overview

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Classification

• Robbins & Kumar Basic Pathology, p. 2411
• Goldman-Cecil Medicine, p. 2276

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Acute Leukemia

Acute Lymphoblastic Leukemia (ALL)

• Most common cancer in children; peak incidence at 3-5 years of age
• More common in boys, and in white/Hispanic children vs. African American children
• 5-year survival: 85-90% in developed countries with early diagnosis
• Treatment: Vincristine + prednisone combination induction; prophylactic intrathecal methotrexate to prevent CNS relapse (a major sanctuary site)

• 90% of children enter complete remission with minimal toxicity

• For relapsed/refractory B-cell ALL: tisagenlecleucel (CAR-T cell therapy) targeting CD19 is an option
• Terminal deoxynucleotidyl transferase (TdT) is a marker expressed in many ALL cases

Acute Myeloid Leukemia (AML)

• Most common leukemia in adults; accounts for 15-20% of childhood leukemias
• Cure rates in children: 57-70%; in adults: ~70% complete remission with induction
• Diagnosis requires >20% blasts on peripheral blood smear or bone marrow
• Environmental exposures (chemotherapy, radiation) are known causes of secondary AML
• First-line treatment: Cytarabine (Ara-C) + anthracycline (idarubicin preferred); alternative: liposomal daunorubicin + cytarabine (fixed 1:5 molar ratio)
• Consolidation chemotherapy required after remission
• Allogeneic hematopoietic stem cell transplantation (HSCT): 55-60% long-term disease-free survival in first remission; indicated for adverse/intermediate-risk disease
• Patients should have HLA typing done at diagnosis if transplant candidates

AML WHO Classification Subtypes (selected)

• AML with t(8;21) - RUNX1-RUNX1T1
• Acute Promyelocytic Leukemia (APL) - PML-RARA
• AML with mutated NPM1
• AML with biallelic CEBPA mutations
• AML with myelodysplasia-related changes
• Therapy-related myeloid neoplasms

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Chronic Leukemia

Chronic Myeloid Leukemia (CML)

• Adults aged 25-60 (peak: 4th-5th decade); ~4,500 new cases/year in the U.S.
• Pathogenesis: BCR-ABL fusion gene from t(9;22) balanced translocation (Philadelphia chromosome) - present in ~95% of cases
  • BCR-ABL encodes a constitutively active tyrosine kinase that mimics growth factor receptor signaling (activates RAS), driving excessive granulocyte/platelet production without blocking differentiation
• Lab findings: WBC often >100,000 cells/µL; predominantly neutrophils + immature granulocytes + basophils + eosinophils; thrombocytosis; hypercellular bone marrow; splenomegaly
• Clinical onset: Insidious - fatigue, weakness, weight loss, abdominal dragging (splenomegaly)
• Natural history: Three phases - chronic phase → accelerated phase → blast crisis (resembles acute leukemia)
• Treatment: Tyrosine kinase inhibitors (TKI) - imatinib was first-line standard; nearly all patients achieve complete hematologic response; 40-50% achieve complete cytogenetic response
• HSCT: Indicated for CML patients failing two or more TKIs - cure rate ~70%

Chronic Lymphocytic Leukemia (CLL)

• Most common chronic leukemia in adults
• Indolent course; multiple effective targeted therapies now available
• HSCT achieves complete remission in the majority, with ~65% disease-free survival at 3 years, but is reserved for select cases given availability of other therapies

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Clinical Features of Acute Leukemia (General)

• Rare AML finding: Chloromas (solid nodules of leukemic blasts in skin or gingiva)

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Diagnosis

1. CBC with differential - anemia, thrombocytopenia, leukocytosis or leukopenia, neutropenia
2. Peripheral blood smear - blasts >20% (for acute leukemia)
3. Bone marrow aspirate - definitive diagnosis
4. Serum chemistries: uric acid, LDH, calcium, phosphate, magnesium, liver function
5. Coagulation profile
6. Chest X-ray: anterior mediastinal mass in T-cell ALL
7. Cytogenetics/FISH/PCR: for BCR-ABL (CML), specific translocations (AML subtypes)
8. Flow cytometry: immunophenotyping (TdT for ALL, myeloperoxidase for AML)

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Key Targeted Therapies

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Leukemia - Unani Tib ka Nazar

Unani Naam - "Sartan-ud-Dam" (خون کا سرطان)

• Sartan (سرطان) = Cancer - yeh lafz Arabic mein "kekda" (crab) se aaya hai, kyunki yeh bimari apne shikaar se kekde ki tarah chipak jaati hai
• Dam (دم) = Khoon

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Unani Nazariya (Theory) - Khiltiyati Asbaab

Leukemia ka Unani Sabab (Cause)

• Tabayee Saudawi Madda (normal black bile) jab zyada bann kar jalta (burns/oxidizes) hai, to Sartan bann jaata hai
• Ghair-Tabayee Saudawi Madda (abnormal black bile) → Warm-e-Sulb (hard swelling) banaata hai
• Jab Sauda oxidize hota hai, to Sartan ka muqaddam (precursor) ban jaata hai
• Soo-e-Mizaj (temperamental imbalance) aur Sue-Khoon (blood dyscrasia) bhi aham asbaab hain

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Tasnif - Unani Mein Sartan ki Aqsaam

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Alamaat (Signs & Symptoms) - Unani Nazar se

• Zaf-e-Jism (jismani kamzori) - fatigue
• Sufedi-e-Rang (pallor) - anemia ki wajah se
• Hamdardiyat (swollen lymph nodes/spleen) - taili aur jigar ka barh jaana
• Bukhar (fever) - baarbaar aana
• Khoon-e-Baahi (bleeding tendency) - naak, mandiblain se khoon aana
• Dard-e-Uzaam (bone/joint pain)
• Qillat-e-Ishtaha (bhook na lagna)

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Usool-e-Ilaj - Treatment Principles

1. Ilaj-bil-Ghiza (Dietotherapy - Khurak se Ilaj)

• Kaddu (کدو) - Cucurbita maxima
• Khurfa - Portulaca oleracea
• Khaeer - Cucumber
• Maul-Jabn - Cheese whey
• Maul-Sha'ir - Barley water
• Cruciferous vegetables

2. Ilaj-bil-Dawa (Pharmacotherapy - Dawa se Ilaj)

• Majoon Musaffi-e-Khoon (معجون مصفی خون) - Khoon saaf karne ki mashoor dawa; ek [research study](https://www.semanticscholar.org/paper/Majoon-Musaffie-Khoon-(a-Pharmacopoeial-Unani-in-Basheer-Jahan/005993839ffd6b9a913582e22934fe05b3a95ad7) ne benzene-induced leukemia mein iske positive results bayaan kiye hain
• Sharbat-e-Bazoori - khoon ke amraaz mein
• Jawarish - hazm aur khilt ko theek karna
• Tiryaq - zaharile mawad se hifazat

3. Ilaj-bil-Tadbeer (Regimental Therapy)

• Fasd (فصد) - Phlebotomy (khoon nikaalna) - bile kharab khoon ko bahar nikaalte the
• Hammam (حمام) - therapeutic baths
• Riyazat (ریاضت) - appropriate exercise

4. Ilaj-bil-Yad (Surgery)

• Solid swellings (Warm-e-Sulb) ki surgical removal

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Ta'deel-e-Mizaj (Mizaj Correction)

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Ahem Nuqta

Unani tib ek mukammal scientific backup ke sath "holistic" nizam hai, lekin leukemia jaise serious blood cancers mein modern chemotherapy, targeted therapy aur bone marrow transplant ke sath milkaar Unani dawayein use ki ja sakti hain - akele nahi. Unani dawayein chemo ke side effects kam karne aur immunity badhane mein muawwin (supportive) kirdar ada kar sakti hain.

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CVS (Cardiovascular System) Diseases - Modern + Unani Notes

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PART 1 - MODERN MEDICINE

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1. HYPERTENSION (High Blood Pressure)

Definition & Classification (ACC/AHA 2017 Guidelines)

• Fuster and Hurst's The Heart, 15th Ed., p. 2567

Types

• Primary (Essential) HTN - 90-95% cases, no identified cause
• Secondary HTN - 5-10%, causes: renal disease, Conn's syndrome, pheochromocytoma, Cushing's, thyroid disease, coarctation of aorta

Risk Factors

• Age, family history (non-modifiable)
• Obesity, high sodium diet, smoking, alcohol, sedentary lifestyle, DM, dyslipidemia (modifiable)
• Non-traditional: hsCRP (inflammation marker), Lipoprotein(a)

Pathophysiology

• Increased peripheral vascular resistance + increased cardiac output
• RAAS activation → Angiotensin II → vasoconstriction + Na retention
• Sympathetic overactivation → increased HR + contractility
• Endothelial dysfunction → reduced NO → vasospasm

Complications (4 Ts)

• Target organ damage: Heart (LVH, HF, IHD), Brain (stroke, TIA), Kidney (CKD), Eyes (hypertensive retinopathy), Peripheral arteries (PAD)
• HTN carries 2.5x risk (men) and 3.9x risk (women) for peripheral artery disease

Treatment

• Weight loss, DASH diet (low Na), exercise, alcohol restriction, smoking cessation

• ACE inhibitors (e.g., Ramipril - HOPE study) offer vascular protection beyond BP reduction

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2. HEART FAILURE (HF)

Definition

Classification

NYHA Functional Classification

Pathophysiology

• Neurohormonal activation: RAAS + Sympathetic nervous system → initially compensatory, then harmful
• Cytokines (TNF-α, IL-6) → myocyte apoptosis + cardiac remodeling
• Compensatory mechanisms: LV hypertrophy, dilatation, tachycardia → eventually fail

Symptoms

• Left HF: Dyspnea on exertion, orthopnea, PND, pulmonary edema, cardiac asthma
• Right HF: Peripheral edema, JVD, hepatomegaly, ascites, anasarca
• Congestive (Both): All of the above

Diagnosis

• ECG, Chest X-ray (cardiomegaly, pulmonary congestion, Kerley B lines)
• Echocardiography - gold standard (EF measurement, LV function)
• BNP / NT-proBNP - biomarker (elevated in HF)

Treatment - HFrEF (EF <40%)

• Carvedilol showed dose-related improvements in LV function and survival (MOCHA trial)
• Bisoprolol reduced mortality in CIBIS-II trial

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3. ISCHEMIC HEART DISEASE (IHD) / CORONARY ARTERY DISEASE (CAD)

Spectrum

Pathophysiology

• Atherosclerosis = chronic low-grade inflammation of arterial wall
  • LDL oxidation → foam cells → fatty streak → fibrous plaque → vulnerable plaque
  • Plaque rupture → thrombus → arterial occlusion → ischemia/infarction
• Risk factors: HTN, DM, dyslipidemia, smoking, obesity, family history, age, male sex

Angina Pectoris

• Chest pain on exertion, relieved by rest/nitrates
• Fixed plaque causing >70% stenosis
• ECG: ST depression during exercise

• Rest pain, increasing frequency/severity, new onset, post-MI angina
• Partial occlusion or dynamic stenosis
• Biomarkers: Troponin NEGATIVE (UA), POSITIVE (NSTEMI)
• ECG: ST depression or T-wave inversion

• Complete occlusion of coronary artery
• ECG: ST elevation, Q waves (later)
• Troponin: markedly elevated
• Treatment window: door-to-balloon <90 min

Cardiac Biomarkers Timeline

Treatment of ACS

• Morphine (pain relief)
• Oxygen (if SpO2 <90%)
• Nitrates (sublingual/IV)
• Aspirin (300 mg loading)
• Beta-blocker (if no contraindication)

• Primary PCI (percutaneous coronary intervention) - preferred if available <90 min
• Thrombolysis (streptokinase, tPA) if PCI not available within 120 min
• Heparin (anticoagulation)
• Dual antiplatelet (Aspirin + Clopidogrel/Ticagrelor)

• ACE-I, Beta-blocker, Statin, Antiplatelet (ABSA)

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4. ATRIAL FIBRILLATION (AF)

Definition

Types

• Paroxysmal - episodes <7 days, self-terminating
• Persistent - >7 days, needs cardioversion
• Permanent - chronic, cardioversion not pursued

Symptoms

• Palpitations, dyspnea, fatigue, exercise intolerance
• May be asymptomatic (detected incidentally)
• Serious complication: Stroke (due to left atrial appendage thrombus)

ECG Features

• Absent P waves, irregularly irregular QRS, fibrillatory baseline

CHA2DS2-VASc Score (Stroke Risk)

• Score ≥2 (male) or ≥3 (female) → anticoagulation needed

Treatment

• Beta-blockers (metoprolol), CCBs (diltiazem, verapamil), Digoxin (target HR <80 bpm at rest)

• Cardioversion (electrical or chemical with amiodarone, flecainide)

• DOACs (Dabigatran, Rivaroxaban, Apixaban) - preferred over Warfarin
• Warfarin (INR 2-3) if DOACs not available

• Catheter ablation (pulmonary vein isolation)
• Left atrial appendage occlusion (WATCHMAN device) - reduces stroke risk

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5. RHEUMATIC HEART DISEASE (RHD)

• Cause: Group A Streptococcal throat infection → Autoimmune cross-reaction damages heart valves
• Most affected valve: Mitral (>50%), then Aortic
• Jones Criteria (diagnosis of Acute Rheumatic Fever):
  • Major: Carditis, Polyarthritis, Chorea, Erythema marginatum, Subcutaneous nodules
  • Minor: Fever, elevated ESR/CRP, prolonged PR interval
  • Plus evidence of streptococcal infection (ASO titer, positive throat culture)
• Prevention: Benzathine Penicillin monthly injection for 5-10 years

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6. PERIPHERAL ARTERY DISEASE (PAD)

• Main symptom: Intermittent Claudication (IC) - leg pain on walking, relieved by rest
• ABI (Ankle-Brachial Index) <0.9 = diagnostic
• Risk: HTN 2.5x risk (men), 3.9x risk (women)
• Treatment: Lifestyle modification, statins, antiplatelet, revascularization if severe

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PART 2 - UNANI MEDICINE (Amraz-e-Qalb)

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Unani Basics - CVS Framework

Unani CVS Nazariya (Theoretical Framework)

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Unani Disease Correspondences

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1. Imtilaa-e-Dam / Hypertension - Unani View

• Imtilaa = excess blood (dam) accumulation in vessels
• Ghilzat-e-Dam (thick blood)
• Kasrat-e-Ghiza (overeating)
• Qillat-e-Harkat (sedentary lifestyle)
• Ghazab-o-Gham (anger and grief - emotional causes)
• Soo-e-Mizaj-e-Harr (hot temperament imbalance)

• Fasd (فصد) - therapeutic phlebotomy (excess blood removal)
• Ta'deel-e-Ghiza - dietary modification (light, easily digestible food)
• Munzijat - drugs to thin the blood

• Ajwain (Carom seeds - Trachyspermum ammi) - vasodilator
• Lehsun (Garlic - Allium sativum) - proven anti-hypertensive
• Adrak (Ginger) - circulatory stimulant
• Zeera (Cumin)
• Gule Surkh (Rose petals - Rosa damascena) - Mufarreh Qalb
• Zafraan (Saffron) - cardiac tonic

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2. Zo'f-e-Qalb / Heart Failure - Unani View

• Zo'f-e-Hararat-e-Ghariziyya (weakness of innate heat)
• Imtilaa (congestion/fluid overload)
• Istisqa (dropsy/generalized edema - equivalent to congestive HF)
• Excess of Balgham (phlegm/cold humor) causing cold, congested state

• Nafas-e-Tangi (shortness of breath)
• Waram-e-Qadam (foot/ankle edema)
• Zof-o-La-ghori (extreme weakness)
• Khafqan (palpitations)
• Takhamur (hepatomegaly - congested liver)

1. Khamira Abresham Hakeem Arshad Wala - antioxidant, cardiotonic, dyslipidemia
2. Khamira Abresham Sada - antioxidant, free radical scavenging
3. Khamira Gaozaban - cardiac + cerebral tonic
4. Khamira Marwareed - cardiac tonic
5. Khamira Sandal - cooling, cardiac tonic

Ibn Sina described 63 drugs of plant, mineral, and animal origin as Adwiya-e-Qalbiyah in his famous book Kitab Al-Adviya-E-Qalbiyah

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3. Sudad-e-Sharyaan / Ischemic Heart Disease - Unani View

• Sudad (سداد) = obstruction in arteries = atherosclerosis equivalent
• Ghaleez Khilt (thick humors) blocking Sharyaan (arteries) of Azae Raeesa (vital organs)
• Ghaleez Dam (thick blood) + Balgham ghaleez → sudad formation

1. Pehle Sudad resolve karo:
   • Mulattif (demulcent) + Muhallil (resolvent/anti-inflammatory) drugs
   • Care: weak muhallil → incomplete resolution; very strong → thrombus dislodgement (= embolism)
2. Phir Mizaj-e-Qalb theek karo
3. Tahaffuz (Prevention) via lifestyle + herbs

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4. Khafqan / Palpitations & Arrhythmias - Unani View

• Khafqan Harri (hot cause) - tachyarrhythmia
• Khafqan Baridi (cold cause) - bradyarrhythmia
• Khafqan Nafsi (psychological) - functional palpitations

• Excess Safra (yellow bile) → harr khafqan
• Waswas (anxiety/worry) → nafsi khafqan
• Zo'f-e-Qalb (cardiac weakness)

• Mufarreh Shaikhurais - relieves palpitations (Dafe Khafqan)
• Badranjboya (Melissa officinalis) - mild antiarrhythmic properties (proven in research)
• Gule Nilofar (Blue lotus) - sedative, anti-anxiety
• Ustukhuddus (Lavender) - calming effect

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Ibn Sina's Cardioprotective Drug Categories

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Summary Table - Modern vs Unani CVS

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Zaroori Nuqta: Unani medicine CVS diseases mein supportive aur preventive kirdar ada karti hai. Acute events (STEMI, cardiac arrest, acute HF) mein modern emergency medicine laazimi hai. Unani herbs (Arjun, Abresham, Badranjboya) ka preclinical evidence maujood hai lekin large RCTs ki zaroorat hai.

• Fuster and Hurst's The Heart, 15th Ed.
• Textbook of Family Medicine, 9th Ed.
• Cardioprotective drugs in Unani medicine - Pharma Journal
• IHD in Unani Medicine - Bangladesh Journal of Medical Science

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AMRAZ-E-DAM (خون کے امراض)

Blood Disorders - NCISM BUMS Syllabus

Modern Medicine + Unani Notes

NCISM Chapter 24 - Amraz-e-Dam Topics:

1. Soo-ul-Qiniya / Faqr-ud-Dam (Anaemia)
2. Sartan-ud-Dam (Leukaemia)
3. Thalassemia
4. Nazf-ud-Dam Mizaji (Haemophilia)
5. Qillat-e-Sufehiyat-ud-Dam (Thrombocytopenia)
6. Sickle Cell Disease
7. Lymphoma

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1. ANEMIA - SOO-UL-QINIYA / FAQR-UD-DAM

MODERN MEDICINE

Definition

• Male: Hb < 13 g/dL
• Female (non-pregnant): Hb < 12 g/dL
• Pregnant female: Hb < 11 g/dL
• Children 6-59 months: Hb < 11 g/dL

Classification by MCV (Most Important for Exams)

A - Iron Deficiency Anemia (Most Common)

• Women: Menstrual blood loss (most common)
• Men/Post-menopausal women: GI bleeding (investigate for occult blood)
• Children: Dietary deficiency

• Oral Iron (preferred): Ferrous sulfate 325 mg (65 mg elemental iron) - 2-4 tabs/day
  • 200-400 mg elemental iron/day = optimal
  • Continue 3-6 months after correction to replenish stores
• Parenteral Iron: For malabsorption, CKD on dialysis, intolerance to oral iron
• Treat underlying cause (stop bleeding source)

B - Megaloblastic Anemia (B12 & Folate Deficiency)

C - Aplastic Anemia

• Allogeneic Bone Marrow Transplant (curative, <40 years)
• Immunosuppression: Anti-thymocyte globulin (ATG) + Cyclosporine
• Supportive: Transfusions, G-CSF, Erythropoietin

D - Hemolytic Anemia

• Positive = Immune/autoimmune hemolysis (AIHA)
• Negative = Non-immune hemolysis

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UNANI - SOO-UL-QINIYA / FAQR-UD-DAM

"Soo-ul-Qiniya woh halat hai jis mein khoon ki miqdar ya khasoosiyat mein nuqs ho jaata hai"

• Ibn Sina ne pehli baar Soo-ul-Qiniya ka zikr kiya - ise Istisqa (anasarca/dropsy) ka muqaddam (precursor) kaha

• Zo'f-e-Kabid (Liver weakness) - kabd khoon banaata hai, jab liver kamzor ho to khoon ki ifrazish kam hoti hai
• Zo'f-e-Quwwat-e-Ghaziya - nutri-absorptive weakness
• Soo-e-Mizaj-e-Kabid - liver temperament imbalance
• Imtilaa - congestion blocking normal blood formation

Unani Treatment - Ilaj

• Ghiza-e-Lateef (easily digestible nutritious food)
• Kaseer-ul-Taghziya (highly nutritious diet)
• Gosht ka yakhni, anda, daliya, Anar (pomegranate), Maweez (raisins), Anjeer (figs), Palak, Methi

• Riyazat (appropriate exercise) - blood circulation improve karna
• Dalk (massage) - to stimulate blood flow

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2. LEUKEMIA - SARTAN-UD-DAM (سرطان الدم)

Quick Modern Summary:

Unani:

• Sartan-ud-Dam - excess/burnt Sauda causing leukemic proliferation
• Treatment: Musaffiyat-e-Khoon, Khamira Abresham, Muqawwiyat, supportive + modern referral

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3. THALASSEMIA

MODERN MEDICINE

Definition

Types

Clinical Features (Thalassemia Major)

• Severe anemia from 6 months (when HbF → HbA switch happens)
• Hepatosplenomegaly (extramedullary hematopoiesis)
• Bone deformities - "Crew-cut" skull X-ray, frontal bossing, maxillary hypertrophy ("chipmunk face") - due to marrow expansion
• Growth retardation, delayed puberty
• Iron overload (from repeated transfusions): cardiomyopathy, liver cirrhosis, endocrinopathy

Diagnosis

• Hb Electrophoresis - gold standard
  • Thalassemia Major: HbF ↑↑, HbA absent or ↓, HbA2 ↑
  • Thalassemia Minor: HbA2 >3.5% (key finding)
• CBC: Microcytic hypochromic anemia, ↑ RBC count
• Blood film: Target cells, nucleated RBCs

Treatment

• Thalassemia Major:
  • Regular blood transfusions (every 3-4 weeks) to maintain Hb >9-10 g/dL
  • Iron chelation (Deferoxamine/Deferasirox) - to prevent iron overload
  • Allogeneic HSCT (Bone Marrow Transplant) - only cure
  • Hydroxyurea - increases HbF (fetal hemoglobin) production
  • Gene therapy (emerging - betibeglogene)
• Thalassemia Minor: No treatment needed, genetic counseling
• Prevention: Premarital screening + Hb electrophoresis of both partners

UNANI - THALASSEMIA

• Ghair-Tabayee Takween-e-Khoon (abnormal blood formation)
• Za'f-e-Kabid (liver weakness) - since liver is the organ of blood formation in Unani theory
• Excess Safra mixing with khoon causing hemolysis

Note: Thalassemia major mein modern transfusion + chelation laazimi hai. Unani treatment supportive role mein hai (iron absorption, antioxidant support, immune boosting).

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4. HEMOPHILIA - NAZF-UD-DAM MIZAJI (نزف الدم مزاجی)

MODERN MEDICINE

Definition

• Affects males primarily; females are carriers (but can have mild disease)

Severity Classification

Clinical Features

• Hemarthrosis (bleeding into joints) - most characteristic; leads to chronic arthropathy
• Soft tissue hematomas, muscle bleeds
• Prolonged bleeding after cuts, surgery, dental procedures
• Intracranial hemorrhage (life-threatening)
• No petechiae/purpura (platelet function normal)

Investigations

Treatment

• Hemophilia A: Factor VIII concentrate (recombinant or plasma-derived)
  • Prophylactic treatment to prevent joint damage
  • Emicizumab (Hemlibra) - subcutaneous bispecific antibody mimicking Factor VIII
• Hemophilia B: Factor IX concentrate
• DDAVP (Desmopressin) - mild hemophilia A (releases stored Factor VIII)
• Avoid NSAIDs, aspirin (worsen bleeding)
• Gene therapy: Emerging - promising results in clinical trials

UNANI - NAZF-UD-DAM MIZAJI

• Nazf-ud-Dam = hemorrhage/bleeding
• Nazf-ud-Dam Mizaji = bleeding due to Soo-e-Mizaj (temperamental imbalance) - Harr (hot) mizaj causing vessels to be lax and blood to flow excessively

• Hararat-e-Harr (excess heat) → khoon patla aur zyada maayil (fluid) hota hai → vessels se bahar aata hai
• Zo'f-e-Mamsika (weakness of retentive faculty) → khoon ko rok nahi sakta
• Ghilzat-e-Dam not present → khoon bahut patla (thin)

• Qurs Hajar-ul-Yahud - urinary/general hemostasis
• Sharbat-e-Sandal - cooling, hemostatic
• Jawarish-e-Mastagi - astringent

Important: Hemophilia mein factor replacement modern medicine mein zaroori hai. Unani treatment supportive/adjunct role ada kar sakti hai - especially joint protection aur bleed prevention mein.

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5. THROMBOCYTOPENIA - QILLAT-E-SUFEHIYAT-UD-DAM (قلة الصفيحات الدم)

MODERN MEDICINE

Definition

Severity

Classification & Causes

ITP - Immune Thrombocytopenic Purpura (Key Topic)

• Autoantibodies (usually IgG anti-GPIIb/IIIa) coat platelets → splenic macrophage destruction
• Both impaired production AND T-cell mediated destruction

• Platelets <10,000/µL (any patient)
• Platelets <30,000/µL (pregnancy - 2nd/3rd trimester)
• Active bleeding

1. 1st line: Prednisolone (1 mg/kg/day) OR IV Immunoglobulin (IVIG)
2. 2nd line: Splenectomy (removes main site of platelet destruction + antibody production)
3. 3rd line: Rituximab (anti-CD20), Thrombopoietin receptor agonists (Romiplostim, Eltrombopag)
4. Platelet transfusion: Only for life-threatening bleeding (quickly destroyed)

UNANI - QILLAT-E-SUFEHIYAT-UD-DAM

• Zo'f-e-Kabid - liver mein thrombopoeisis mein kami
• Ghaleez Khilt destroying blood components
• Imtilaa-e-Tihal (splenic congestion) causing increased platelet sequestration - equivalent to hypersplenism

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6. SICKLE CELL DISEASE

MODERN MEDICINE

Definition

Pathophysiology

• Deoxygenation → HbS polymerization → RBC sickling → crescent-shaped cells
• Sickling causes:
  1. Hemolysis (intravascular + extravascular)
  2. Vaso-occlusion (microvascular occlusion → ischemia/infarction)

Subtypes (by severity)

Clinical Features

• Vaso-occlusive crisis (pain crisis) - most common; bones, chest, abdomen
• Acute Chest Syndrome - fever + chest pain + new infiltrate on X-ray (most common cause of death)
• Aplastic crisis - Parvovirus B19 infection → ↓ reticulocytes
• Sequestration crisis - sudden massive spleen/liver sequestration of RBCs → acute anemia

• Autosplenectomy (by age 5 → susceptible to encapsulated organisms: Pneumococcus, Haemophilus, Meningococcus)
• Stroke (children - TCD >200 cm/sec = high risk)
• Avascular necrosis of femoral/humeral head
• Chronic organ damage: kidney (renal papillary necrosis), heart, lung
• Priapism (painful prolonged erection)

Diagnosis

• Newborn screening: Hb Electrophoresis
• Sickledex / Sickle prep: rapid screening (but misses variants)
• Blood film: Sickle-shaped cells, target cells, Howell-Jolly bodies

Treatment

UNANI - SICKLE CELL DISEASE

• The "sickling" = Unani mein Ghilzat-e-Dam (thick/stiff blood) causing vascular obstruction (Sudad-e-Awridah)
• Vaso-occlusive crisis = Waja-ud-Dam (blood pain) due to blockage

Modern treatment essential. Hydroxyurea + gene therapy = current standard. Unani plays supportive role.

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7. LYMPHOMA

MODERN MEDICINE

Classification

Hodgkin Lymphoma - Subtypes

Staging (Ann Arbor / Lugano Classification)

• A = No B symptoms | B = Fever >38°C, night sweats, weight loss >10% in 6 months

Investigations

• CBC, LDH (prognostic marker), ESR
• CT scan chest/abdomen/pelvis
• PET-CT - gold standard for staging + response assessment
• Bone marrow biopsy (if stage IV suspected)
• Excision biopsy of lymph node - definitive diagnosis

Treatment

• ABVD chemotherapy (Adriamycin/Doxorubicin, Bleomycin, Vinblastine, Dacarbazine) - standard
• Radiotherapy for localized disease
• Advanced: BEACOPP, BV-AVD (brentuximab vedotin based)

• DLBCL (aggressive): R-CHOP (Rituximab + Cyclophosphamide + Doxorubicin + Vincristine + Prednisolone)
• Follicular (indolent): Watch-and-wait or Rituximab + chemo
• CAR-T cell therapy: Relapsed/refractory DLBCL

UNANI - LYMPHOMA (WARM-E-GHUDAD)

• Warm-e-Ghudad (ورم الغدد) = lymph node swelling/malignancy
• Sartan-e-Ghudad = lymphoid cancer
• Caused by excess Sauda (black bile) accumulation in lymph nodes + Imtilaa-e-Ghudad

• Warm-e-Ghudad Saudawi - malignant lymphoma (hard, fixed, painless nodes)
• Warm-e-Ghudad Balghami - reactive lymphadenopathy (soft, painful)

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SUMMARY TABLE - NCISM Amraz-e-Dam

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Exam Tip (NCISM BUMS): Har disease mein Asbaab (Causes), Alamaat (Symptoms), Tashkhees (Diagnosis), Usool-e-Ilaj (Treatment Principles), aur Ilaj (Treatment) - Modern + Unani dono likhen. Key Unani terms yaad rakhein: Soo-ul-Qiniya, Faqr-ud-Dam, Zo'f-e-Kabid, Musaffiyat-e-Khoon, Mowallid-e-Dam.

• Katzung's Basic and Clinical Pharmacology, 16th Ed.
• Quick Compendium of Clinical Pathology, 5th Ed.
• Harriet Lane Handbook, 23rd Ed.
• Soo-ul-Qiniya - IJUIM Journal
• NCISM BUMS Syllabus - Amraz-e-Dam

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COR PULMONALE

Modern Medicine + Unani Notes

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MODERN MEDICINE

Definition

Important exclusion: RV disease caused by left ventricular failure or congenital heart disease is NOT cor pulmonale.

• Accounts for 6-7% of all adult heart diseases in the United States
• If pulmonary artery pressure exceeds 25 mmHg, 5-year survival is reduced by 50%

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Types

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Causes / Etiology

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Pathophysiology (Step by Step)

Lung Disease (COPD/Fibrosis/Embolism)
         ↓
Alveolar Hypoxia (↓ PaO2) + Hypercapnia (↑ PaCO2)
         ↓
↓↓ Hypoxic Pulmonary Vasoconstriction (HPV)
+ Loss of pulmonary vascular bed (emphysema)
+ Increased blood viscosity (Polycythemia from chronic hypoxia)
+ Lung hyperinflation compresses pulmonary vessels
         ↓
Pulmonary Hypertension (↑ PA pressure)
         ↓
Right Ventricular Pressure Overload (Increased afterload)
         ↓
RV Hypertrophy (Compensatory)
         ↓
Chronic overload → RV Dilatation
         ↓
Cor Pulmonale = Right Heart Failure

• NOT simply from pump dysfunction
• Due to: reduced renal plasma flow → ↓ Na excretion
• Hypercapnia → kidney retains HCO3 and excretes H+ → also retains Na/H2O
• RAAS activation adds to fluid retention

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Morphology (Pathological Changes)

From Robbins & Kumar (Fig. 9.16B): "Right ventricle is markedly dilated and hypertrophied with thickened free wall; shape of LV is distorted by enlarged RV"

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Clinical Features

• Dyspnea (exertional → rest)
• Productive/non-productive cough
• Cyanosis (central + peripheral)
• Fatigue, exercise intolerance
• Right heart failure symptoms (late):
  • Ankle/leg edema
  • Abdominal distension (ascites)
  • Right hypochondrial pain (hepatomegaly)

---

Investigations

1. ECG (Electrocardiogram)

• P Pulmonale - tall, peaked P waves in lead II (>2.5 mm) - Right Atrial hypertrophy
• Right Axis Deviation (RAD)
• Right Ventricular Hypertrophy (RVH) - tall R in V1, deep S in V5/V6
• Right Bundle Branch Block (RBBB)
• S1Q3T3 pattern (if acute pulmonary embolism cause)
• Supraventricular arrhythmias (AFib, AFL, MAT) - during acute exacerbations

2. Chest X-Ray (CXR)

• Enlarged pulmonary artery - prominent hilar shadows
• Cardiomegaly (RV enlargement) - boot-shaped heart
• Evidence of underlying lung disease (hyperinflation in COPD, fibrosis in ILD)

3. Echocardiography (Key Investigation)

• RV enlargement and hypertrophy
• Increased tricuspid regurgitant velocity (estimates PA pressure)
• RV/LV ratio increased
• Eccentricity index - D-shaped LV (septal flattening due to RV pressure overload)
• TAPSE (Tricuspid Annular Plane Systolic Excursion):
  • Normal ≥16 mm
  • Severe RV dysfunction: TAPSE <10 mm
• Paradoxical septal motion

4. Right Heart Catheterization (Gold Standard for PH)

• Direct measurement of Mean Pulmonary Artery Pressure (mPAP)
• PH defined as mPAP >20 mmHg at rest
• Also measures: PCWP, CO, PVR

5. ABG (Arterial Blood Gas)

• Hypoxemia (↓ PaO2) - key driving factor
• Hypercapnia (↑ PaCO2) - in COPD/hypoventilation
• Type II Respiratory Failure in advanced cases

6. Other

• CBC: Polycythemia (↑ Hb, ↑ Hct) from chronic hypoxia
• LFTs: ↑ in hepatic congestion
• BNP/NT-proBNP: elevated in RV failure
• CT Pulmonary Angiography: if PE suspected
• 6-Minute Walk Test (6MWT): functional capacity assessment

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Treatment

1. Treat Underlying Cause

2. Supplemental Oxygen (Most Important)

• Continuous O2 therapy - proven to improve survival in hypoxemic COPD
• Indications:
  • PaO2 <55 mmHg at rest (ambient air)
  • PaO2 ≤59 mmHg + edema/polycythemia/P pulmonale on ECG
• Target: SpO2 ≥90%
• Reduces HPV → lowers PA pressure

3. Diuretics (Use with Caution)

• Furosemide - for symptomatic edema/fluid overload
• Caution: Can reduce intravascular volume → worsen renal function + disturb acid-base balance in chronic respiratory failure

4. PAH-Targeted Therapies (Controversial in Cor Pulmonale)

• Generally disappointing results in cor pulmonale (unlike PAH)
• Sildenafil (PDE5 inhibitor) - showed worsening gas exchange in COPD with no hemodynamic improvement
• Riociguat (guanylate cyclase activator) - trial discontinued due to excess mortality
• Ambrisentan (ERA) - no benefit in ILD patients
• PAH therapies considered only when PH is severely disproportionate to lung disease severity (PAH-like phenotype)

5. Ventilatory Support

• NIV (BiPAP/CPAP): Nocturnal noninvasive ventilation for hypercapnia in stable patients
• Venturi mask: Controlled O2 delivery for patients sensitive to high O2 (COPD)

6. Lung Transplantation

• For far-advanced disease
• RV function can normalize after lung transplant (afterload reduction)

7. Phlebotomy

• If severe polycythemia (Hct >55%) worsening pulmonary vascular resistance

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Prognosis

• Once cor pulmonale is established, prognosis is poor
• mPAP >25 mmHg → 5-year survival reduced by 50%
• Acute cor pulmonale (from COPD exacerbation) may be reversible with treatment of underlying cause

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UNANI MEDICINE

Unani Concept of Cor Pulmonale

1. Riya (ریا) = Lungs
2. Qalb (قلب) = Heart

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Unani Pathogenesis

• Chronic lung disease = accumulation of Balgham Ghaleez (thick phlegm) in lungs
• Causes Sudad (obstruction) in lung vessels → Soo-e-Mizaj-e-Barid (cold temperament imbalance)
• Lung fails to properly prepare Ruhe Haiwani (vital spirit) for heart

• Obstructed lungs → heart cannot receive proper blood return
• Hararat-e-Ghariziyya (innate heat of heart) becomes weakened
• Imtilaa (congestion) in pulmonary vessels → heart overloaded

• Heart weakness → Quwwat-e-Dafi'a ka Zo'f (impaired expulsive faculty)
• Fluid accumulates in tissues → Istisqa Zahri (peripheral edema) + Istisqa Batni (ascites)

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Unani Treatment (Usool-e-Ilaj)

Principle 1 - Ilaj-e-Riya (Treat the Lung)

• Tukhm-e-Katan (Linseed) formulation - clinical trial showed effectiveness in mild-moderate COPD

Principle 2 - Muqawwiyat-e-Qalb (Cardiac Strengthening)

Principle 3 - Mudirrat (Diuretics for Edema/Istisqa)

Principle 4 - Ta'deel-e-Mizaj (Temperament Correction)

• Cor pulmonale mein Soo-e-Mizaj-e-Barid (cold imbalance) hota hai (COPD/balgham)
• Ilaj-bil-Zid: Harr-Yabis (hot-dry) drugs prescribe karein
• Examples: Zanjabeel (Ginger), Darchini (Cinnamon), Filfil Siyah (Black pepper)

Principle 5 - Ilaj-bil-Tadbeer (Regimental Therapy)

• Hammam (therapeutic bath) - circulation improve karna, respiratory function help
• Riyazat-e-Khafifa (mild exercise) - cautious pulmonary rehabilitation
• Tila (topical application) on chest - camphor + eucalyptus oils
• Dhumiyat (steam inhalation) - Eucalyptus, Peppermint - airway relief

Principle 6 - Ilaj-bil-Ghiza (Diet)

• Ghiza-e-Lateef (light, easily digestible)
• Warm, dry foods (countering cold-moist balgham): Kahwa (herbal tea), Adrak chai, Shahad (honey) + Lehsun (garlic)
• Avoid: Cold drinks, dairy products (kasir-ul-balgham = phlegm-producing)

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Key Compound Unani Formulas

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SUMMARY - Cor Pulmonale at a Glance

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NCISM Exam Tip: Cor pulmonale = Right-sided heart failure. Differentiate from Left Heart Failure (which is NOT cor pulmonale). Key: P Pulmonale on ECG + RVH + underlying lung disease. Unani mein: Amraz-e-Riya → Zo'f-e-Qalb → Istisqa - yeh sequence yaad rakhein.

• Fuster and Hurst's The Heart, 15th Ed., p. 1773-1777
• Robbins & Kumar Basic Pathology, p. 363
• Fishman's Pulmonary Diseases and Disorders, p. 734
• Cor Pulmonale - StatPearls

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Kya karunga:

• Modern Medicine explanation
• Unani concept + Asbaab + Alamaat
• Usool-e-Ilaj + Ilaj (Modern + Unani dono)
• Important drugs/formulas

---

Kaise upload karein:

1. PDF file ko drag & drop karein chat mein
2. Ya attachment button (📎) use karein
3. Main automatically read karke kaam shuru kar dunga

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Note:

• Ek baar mein ek subject/chapter upload karein to better aur detailed notes milenge
• Bade syllabuses mein ek ek chapter ke liye alaida session behtar rahega

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Aapke PDF ka Syllabus - Pura Structure

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PAPER II - Topics List:

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PAPER III - Topics List:

PAPER I (from blueprint pages):

• Psychiatric Disorders (Amrad-i-Nafsani)
• Endocrine Disorders (Amrad-i-Ghudud la Qanati)
• Metabolic Disorders (Amrad-i-Naqs-i-Istihala)
• Genetic Disorders (Amrad-i-Turath)
• Nervous System (10 parts - Headache, CNS infections, Cerebrovascular, Epilepsy, Cognitive, Peripheral, Autonomic)
• Fevers (Hummayat)

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Aage Ka Plan - Aap Batayein!

1. Respiratory System (COPD, Pneumonia, ARDS, Pleura)
2. CVS (IHD, Myocardium, Valves, Arrhythmias, Pericardium)
3. GIT (GERD, PUD, Hepatitis, Cirrhosis)
4. Renal System (Renal failure, Nephrotic, Stones)
5. Infectious Diseases (Malaria, Dengue, Typhoid, HIV)
6. Nervous System (Headache, Stroke, Epilepsy)
7. Musculoskeletal (RA, Gout, OA)

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PAPER 3 - Poori Disease List

Topic 32 - Amrad-i-Mari (Oesophagus) - 4 diseases

1. Tagahqur-i-Mari (GERD)
2. Usr al-Bal' (Dysphagia)
3. Intibaq al-Mari (Achalasia Cardia)
4. Waram-i-Mari (Esophagitis)

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Topic 33 - Amrad-i-Mi'da (Stomach) - 14 diseases

1. Du'f al-Hadm / Dyspepsia
2. Waram-i-Mi'da (Gastritis)
3. Qurlih-i-Mi'da (Peptic Ulcer Disease)
4. Qay' al-Dam (Hematemesis)
5. Fuwaq / Hichki (Hiccup)
6. Bulimia / Food Aversion
7. Waja' al-Mi'da (Gastralgia)
8. Du'f al-Mi'da (Gastric debility)
9. Nafkh-i-Mi'da (Abdominal bloating)
10. Hurqat-i-Mi'da (Burning sensation)
11. Du'f wa Butlan Ishteha (Poor Appetite)
12. Fasad al-Shahwa (Pica)
13. Qay', Tahawwu', Ghathayan (Vomiting/Nausea)
14. Saratan-i-Mi'da (Carcinoma of Stomach)

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Topic 34 - Amrad-i-Am'a (Intestines) - 11 diseases

1. Diqq al-Am'a' (Intestinal Tuberculosis)
2. Tehrik Mi'vi Sindrom (IBS)
3. IBD - Crohn's disease + Ulcerative Colitis
4. Ishal (Diarrhoea)
5. Dhilsantariya (Bloody Diarrhoea)
6. Zahir (Dysentery)
7. Nuqs Injidab (Malabsorption + Celiac)
8. Qillanj wa Ila'ts (Intestinal colic)
9. Didan al-Am'a' (Intestinal worms)
10. Qabd (Constipation)
11. Bawasir (Haemorrhoid)

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Topic 35 - Amrad-i-Kabid (Liver) - 9 diseases

1. Waram al-Kabid (Hepatitis)
2. Istisqa' (Dropsy/Ascites)
3. Tashahhum al-Kabid (Fatty Liver Disease)
4. Du'f al-Kabid (Hepatic Insufficiency)
5. Suqoot al-Kabid (Hepatic Failure)
6. Dubayla al-Kabid (Liver Abscess)
7. Tal'yif al-Kabid (Cirrhosis)
8. Sartan al-Kabid (Hepatic Carcinoma)
9. Yarqan (Jaundice)

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Topic 36 - Amrad-i-Kulya (Kidney) - 7 diseases

1. Suqoot al-Kulya (Renal Failure)
2. Du'f-i-Kulya (Renal Insufficiency/Atrophy)
3. Waja' al-Kulya (Renal Pain)
4. Waram al-Kulya (Nephritis)
5. Hasa wa Raml al-Kulya (Renal Stones)
6. Diqq al-Kulya (Renal Tuberculosis)
7. Nephritic + Nephrotic Syndrome

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Topic 37 - Amrad-i-Mathana (Bladder) - 7 diseases

1. Hurqa al-Bawl / UTI
2. Bawl al-Dam (Haematuria)
3. Salas al-Bawl (Urinary Incontinence)
4. Kathra al-Bawl / Qilla al-Bawl (Polyuria/Oliguria)
5. Waram al-Mathana (Cystitis)
6. Hasa wa Raml al-Mathana (Vesicolithiasis)
7. Ihtibas al-Bawl (Urinary Retention)

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Topic 38 - Male Genital - 5 topics

1. Du'f al-Bah (Sexual debility/Oligospermia/Infertility)
2. Sur'a al-Inzal (Premature ejaculation)
3. Kathra al-Ihtilam (Nocturnal emission)
4. Sailan Mani (Spermatorrhea)
5. Nuqse Na'tid (Erectile Dysfunction)

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Topic 39 - Amrad-i-Muta'di (Infectious) - 18 diseases

1. Influenza
2. SARS
3. Coronavirus (COVID-19)
4. Leptospirosis / Q-Fever
5. Humma Mi'viya (Enteric/Typhoid fever)
6. Hummai Ajamiyya (Malaria)
7. Humma Danj (Dengue)
8. Chikungunya
9. Kala Azar (Leishmaniasis)
10. Ta'un (Plague)
11. Ebola
12. Zika Virus
13. Monkey Fever / KFD
14. HIV/AIDS
15. Cholera (Hayda Waba'i)
16. Japanese B Encephalitis
17. Lymphatic Filariasis
18. Taeniasis/Cysticercosis

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Topic 40 - Amrad-i-Mafasil-o-Izam (Musculoskeletal) - 9 topics

1. Inflammatory Arthritis (RA, Gout, Ankylosing Spondylitis)
2. Infective Arthritis (Septic, Viral, Osteomyelitis, TB)
3. Osteoarthritis
4. Upper + Lower Backache
5. Kyphosis + Koch's Spine
6. Ankylosing Arthritis
7. Sciatica (Irq al-Nasa)
8. Osteomalacia + Osteoporosis
9. Myopathies (Genetic + Acquired)

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Ab aap batayein - konsa topic/system se shuru karein? Main ek ek system ke complete Modern + Unani notes banaunga. Ek session mein ek system best rahega. 📚

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TOPIC 32 - AMRAD-I-MARI (امراض مری)

Diseases of the Oesophagus

III BUMS - NCISM Syllabus | Modern + Unani Notes

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OESOPHAGUS - QUICK ANATOMY REVIEW

• Unani naam: Mari (مری) - gullet/food pipe
• Length: ~25 cm (pharynx to stomach)
• 3 parts: Cervical, Thoracic, Abdominal
• Key structure: Lower Esophageal Sphincter (LES) - prevents reflux
• Unani view: Mari = passage between mouth (Dahan) and stomach (Mi'da) - carries food bolus via peristaltic waves (Harakate Dafiya)

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32.1 - TAGAHQUR-I-MARI

GERD (Gastro-Esophageal Reflux Disease)

MODERN MEDICINE

Definition

Frequency: 20% healthy adults mein weekly heartburn - most common GI complaint

Pathophysiology

LES tone ↓ (Transient LES relaxations - TLESRs)
        ↓
Gastric acid + pepsin → esophagus mein reflux
        ↓
Esophageal mucosal injury
        ↓
Symptoms + Complications

• Hiatal hernia (most important anatomical cause)
• Fatty/spicy food, alcohol, caffeine, chocolate
• Smoking, obesity, pregnancy
• Drugs: CCBs, nitrates, anticholinergics, theophylline
• Scleroderma

Symptoms

• Heartburn (Seene mein jalan) - most common; worse after meals, bending, lying down
• Regurgitation (Khatta paani منہ mein aana) - acid/bitter taste in mouth
• Water brash (sudden mouth full of saliva)

• Chronic cough (especially at night)
• Hoarseness of voice (laryngitis)
• Asthma worsening
• Chest pain (non-cardiac)
• Sore throat
• Dental erosion

Complications

Diagnosis

• Grade A: <5 mm mucosal breaks
• Grade B: >5 mm mucosal breaks, not continuous
• Grade C: Multiple mucosal breaks, continuous
• Grade D: Circumferential mucosal breaks

Treatment

• Weight loss (obesity ↑ intraabdominal pressure)
• Head-end elevation (HOB raised 30°)
• Small frequent meals
• Avoid: fatty food, caffeine, chocolate, alcohol, spicy food, smoking
• Avoid lying down 2-3 hours post meals
• Loose clothing

• Nissen Fundoplication (laparoscopic) - stomach fundus wrapped around LES → strengthens anti-reflux barrier
• Indications: Failed medical therapy, large hiatal hernia, young patient preferring surgery

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UNANI - TAGAHQUR-I-MARI (تَعَهُّرُ المَری)

Unani Concept

• Tagahqur = deterioration/corruption of Mari
• Ibn Sina described Hurqat-i-Mari (burning of food pipe) = GERD equivalent
• Caused by Khilt-e-Safra (yellow bile/hot humor) refluxing from Mi'da into Mari

Asbaab (Causes - Unani)

• Imtilaa-e-Mi'da (stomach overloaded) - overeating
• Ghilzat-e-Ta'am (heavy, fatty food)
• Soo-e-Mizaj-e-Harr (hot temperament imbalance) of Mi'da
• Zo'f-e-Fam-e-Mi'da (weakness of cardiac orifice of stomach) = LES weakness
• Khilt-e-Safra excess → burning reflux

Alamaat (Symptoms - Unani)

• Hurqat-i-Mari (esophageal burning = heartburn)
• Qay' wa Ghathayan (nausea/regurgitation)
• Humoodat-i-Dahan (sour taste in mouth)
• Su'al (cough) from reflux
• Waja'-ul-Sadr (chest pain)

Usool-e-Ilaj (Treatment Principles)

1. Ta'deel-e-Mizaj - correct hot imbalance with cold drugs (Ilaj-bil-Zid)
2. Tanqiyah-e-Balgham/Safra - eliminate excess humors
3. Taqwiyat-e-Fam-e-Mi'da - strengthen cardiac orifice (LES)
4. Ilaj-bil-Ghiza - dietary control

Unani Treatment

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32.2 - USR AL-BAL' (عُسْرُ البَلع)

DYSPHAGIA

MODERN MEDICINE

Definition

• Odynophagia = Painful swallowing (alag cheez hai)
• Affects 15% of persons >65 years

Classification

Causes - Important Classification

• Carcinoma esophagus (progressive, weight loss)
• Peptic stricture (GERD history)
• Schatzki ring (episodic, intermittent)
• Eosinophilic esophagitis

• Achalasia (regurgitation of undigested food)
• Diffuse esophageal spasm (chest pain)
• Scleroderma (Raynaud's + Heartburn)

• Stroke, Parkinson's disease, MND/ALS
• Zenker's diverticulum (regurgitation of old food)
• Pharyngeal tumour

Clinical Clues

Diagnosis

• Barium swallow - first-line for esophageal dysphagia
• Endoscopy (OGD) - direct visualization + biopsy
• Manometry - motility disorders (achalasia)
• Video fluoroscopy - oropharyngeal dysphagia
• CT chest/abdomen - tumour staging

Treatment

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UNANI - USR AL-BAL' (عسر البلع)

Unani Concept

• Usr al-Bal' = difficulty in swallowing
• Sidd-i-Mari (obstruction of food pipe) - structural cause
• Zo'f-e-Mari (weakness of Mari) - motility cause

Asbaab (Causes - Unani)

• Waram-e-Mari (inflammation causing swelling → narrowing)
• Sudad-e-Mari (obstruction - foreign body, tumor)
• Yo'bs-e-Mari (dryness of Mari = mucosal dryness)
• Zo'f-e-Harakat-e-Dafiya (weak peristalsis)
• Khilt-e-Balgham accumulation causing sluggish movement

Unani Treatment

• Laooq-e-Sapistan (lohoch) - demulcent, soothes throat + Mari
• Laooq-e-Aslussous - mucoprotective
• Sharbat-e-Unnab - soothing, anti-inflammatory

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32.3 - INTIBAQ AL-MARI (اِنتِبَاقُ المَری)

ACHALASIA CARDIA

MODERN MEDICINE

Definition

1. Primary aperistalsis of esophageal body (no peristaltic waves)
2. Failure of LES to relax (nonrelaxation of lower esophageal sphincter)

• Incidence: 1 in 100,000/year
• Age: Any age, peak 30-60 years

Pathophysiology

Loss of inhibitory neurons (NO + VIP neurons)
in Auerbach's (myenteric) plexus
        ↓
Impaired LES relaxation (LES stays closed)
+ Aperistalsis of esophageal body
        ↓
Food accumulates in esophagus
        ↓
Esophageal dilatation
        ↓
Dysphagia + Regurgitation

• Associated with: viral infection (HSV-1), genetic factors
• Secondary achalasia (Pseudoachalasia): Carcinoma of gastric cardia

Symptoms (Classic Triad)

1. Dysphagia - to BOTH solids AND liquids (key feature)
2. Regurgitation - bland, undigested food (not acidic - no LES relaxation)
3. Weight loss
4. Nocturnal cough/aspiration
5. Chest pain/fullness

Diagnosis

• Type I - Classic: aperistalsis, minimal pressurization
• Type II - Panesophageal pressurization (best prognosis)
• Type III - Spastic: premature contractions

Treatment (Ilaj)

• Sublingual Nifedipine (CCB) - relaxes LES before meals
• Isosorbide dinitrate (nitrates) - LES relaxation
• Limited long-term benefit

1. Pneumatic Balloon Dilation (PBD) - forceful dilation tears LES muscle fibers; good response, risk of perforation
2. Botulinum Toxin (BTX) injection into LES - inhibits Ach release → LES relaxation; temporary (6-12 months), repeated injections needed; for elderly/poor surgical candidates

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UNANI - INTIBAQ AL-MARI (اِنتِباقُ المری)

Unani Concept

• Intibaq al-Mari = obstruction/tightening of Mari (esophageal obstruction)
• Corresponds to achalasia/stricture causing inability to pass food
• Yo'bs-e-Fam-e-Mi'da (dryness/spasm of cardiac orifice) - LES non-relaxation equivalent

Asbaab (Causes - Unani)

• Tashannuj-e-Mari (esophageal spasm) - Balgham Khushk (dry phlegm) causing spasm
• Waram-e-Ghaleez (thick inflammation at LES level)
• Sudad-e-Fam-e-Mi'da (obstruction at cardia)
• Soo-e-Mizaj-e-Barid Yabis (cold-dry temperament) causing constriction

Usool-e-Ilaj

• Mulayyinat wa Muhallilat - loosen the obstruction
• Muqawwiyat-e-Harakat-e-Dafiya - restore peristalsis
• Ilaj-bil-Tadbeer - regimental therapy

Unani Treatment

Note: Achalasia mein modern endoscopic/surgical treatment zaroori hai. Unani treatment mild cases mein supportive role ada kar sakti hai.

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32.4 - WARAM-I-MARI (وَرَمُ المَری)

ESOPHAGITIS

MODERN MEDICINE

Definition

Types & Causes

Risk Factors for Esophageal Strictures (Complications)

• GERD-induced scarring
• Eosinophilic esophagitis
• Nasogastric tube injury
• Caustic injury
• Radiation

Symptoms

• Odynophagia (painful swallowing) - hallmark of esophagitis
• Dysphagia
• Heartburn (if GERD-related)
• Chest pain
• Nausea

Diagnosis

• Endoscopy (OGD) + Biopsy - gold standard
  • Candida: white plaques/pseudomembranes
  • HSV: vesicles/punched-out ulcers
  • EoE: rings, furrows, white exudates; ≥15 eosinophils/HPF on biopsy
  • Reflux: erythema, erosions, ulcers (LA Classification)
• KOH preparation - Candida
• Viral cultures/PCR - Herpes, CMV

Treatment by Type

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UNANI - WARAM-I-MARI (ورم مری)

Unani Concept

• Waram = swelling/inflammation
• Waram-i-Mari = inflammation/swelling of food pipe
• Classified by Khilt involved:
  • Waram-e-Dami (sanguineous) - hot, red, painful
  • Waram-e-Balghami (phlegmonous) - cold, soft
  • Waram-e-Safrawi (bilious) - hot, burning
  • Waram-e-Saudawi (melancholic) - hard, chronic

Asbaab (Causes - Unani)

• Khilte Fasida (corrupt humors) causing Waram
• Maakoolat-e-Haar Teez (hot spicy foods) - direct irritation
• Adwiya Muzirra (harmful drugs/medicines) passing through Mari
• Taskheen-e-Shart (external heat) - radiation equivalent
• Qay' Mutawaatir (repeated vomiting) - mechanical trauma
• Fungi/Infection = Unani mein Fasa-ul-Akhtal (humoral imbalance with putrefaction)

Usool-e-Ilaj

1. Taqteer-e-Waram - reduce inflammation
2. Mubarridat - cooling if hot (Safra-based)
3. Muhallilat - resolving inflammation
4. Muqawwiyat-e-Mari - strengthen the mucosa

Unani Treatment

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SUMMARY TABLE - TOPIC 32

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NCISM Exam Tips:

• GERD mein "Barrett's esophagus" = pre-malignant → endoscopy surveillance zaroori
• Achalasia = "Bird's beak sign" on barium + POEM treatment (latest)
• Dysphagia mein solids vs liquids discrimination = most important clinical point
• Esophagitis mein Odynophagia = hallmark symptom
• Unani mein: Aslussous (Mulethi) = BEST drug for ALL Mari diseases - mucoprotective

• Sleisenger & Fordtran's GI & Liver Disease
• Goodman & Gilman's Pharmacological Basis
• Fischer's Mastery of Surgery, 8th Ed.
• Tintinalli's Emergency Medicine