1. religion and spirituality
2. hinduism

A CLINICAL ASSESSMENT ON THE
EFFICACY OF CHIRABILVADI KVATHA IN
ARSHAS
Dissertation submitted to the Rajiv Gandhi University of Health Sciences,
Bangalore, Karnataka, in partial fulfillment of the regulations for the award of the
Degree of
AYURVEDA DHANWANTHARI -- M.S.(Ay)
In
SHALYATANTRA
By
RAJASREE. G.
GUIDE:
CO-GUIDE:
Dr.RAVISHANKAR .A.G , M.S. (Ay) Prof. G.S.RAJU, M.D. (Ay),
DEPARTMENT OF POST GRADUATE STUDIES IN SHALYATANTRA
ALVA’S AYURVEDA MEDICAL COLLEGE, MOODBIDRI – 574227.
2008 – 2009
A CLINICAL ASSESSMENT ON THE
EFFICACY OF CHIRABILVADI
KVATHA IN ARSHAS
Dissertation submitted to the Rajiv Gandhi University of Health Sciences,
Bangalore, Karnataka, in partial fulfillment of the regulations for the
award of the Degree of
AYURVEDA DHANWANTHARI -- M.S. (Ay)
In
SHALYATANTRA
By
RAJASREE. G. GUIDE:
CO-GUIDE:
Dr.RAVISHANKAR .A.G, M.S. (Ay) Prof. G.S.RAJU, M.D. (Ay),
DEPARTMENT OF POST GRADUATE STUDIES IN SHALYATANTRA ALVA’S AYURVEDA MEDICAL COLLEGE, MOODBIDRI – 574227.
2008 – 2009
ALVA’S AYURVEDA MEDICAL COLLEGE
DEPARTMENT OF POST GRADUATE STUDIES IN SHALYATANTRA
MOODBIDRI, KARNATAKA.
CERTIFICATE
This is to certify that the dissertation titled “A CLINICAL ASSESSMENT ON THE
EFFICACY OF CHIRABILVADI KVATHA IN ARSHAS” submitted by Rajasree.G. in partial
fulfillment for the degree of Ayurveda Dhanwanthari - M.S (Ay) in Shalyatantra, of Rajiv
Gandhi University of Health Sciences, Bangalore, is a record of research work done by her
during the period of study in this institute, under our guidance and supervision and the
dissertation has not previously formed basis to the award of any degree, diploma, fellowship
or other similar titles.
We recommend this dissertation for the above degree to the University for
approval.
Co-Guide:
Guide:
Dr.RAVISHANKAR .A.G
Dr.G.S.RAJU.M.D.(Ay),
M.S. (Ay),
Assistant Professor,
Dept. of P.G Studies in Shalya Tantra,
Alva’s Ayurveda Medical College
Moodbidri, D.K, Karnataka 574227.
Professor,
Dept. of P.G. studies in Shalyatantra,
Alva’s Ayurveda Medical College,
Moodbidri, D.K, Karnataka - 574227.
Place: Moodbidri
Date:
ALVA’S AYURVEDA MEDICAL COLLEGE
DEPARTMENT OF POST GRADUATE STUDIES IN SHALYATANTRA
MOODBIDRI, KARNATAKA.
ENDORSEMENT
This is to certify that the dissertation titled “A CLINICAL ASSESSMENT
ON THE EFFICACY OF CHIRABILVADI KVATHA IN ARSHAS” is a bonafide
research work done by Rajasree G under the guidance of Dr.G.S.Raju M.D (Ay), Professor, Department of Post Graduate Studies in
Shalyatantra, Alva’s Ayurveda Medical College, Moodbidri, Dakshina
Kannada, Karnataka – 574227.
&
Dr.Ravishankar .A.G M.S. (Ay), Assistant Professor, Dept. of P.G Studies in
Shalya Tantra, Alva’s Ayurveda Medical College, Moodbidri 574227.
Prof.Suresh Negalaguli M.D.(Ay),
Prof.K.Laksmeesh Upadhya M.D.(Ay),
Dean & H.O.D. of Shalyatantra,
Alva’s Ayurveda Medical College,
Principal,
Alva’s Ayurveda Medical College,
Moodbidri, D.K.District,
Karnataka - 574227.
Moodbidri, D.K.District,
Karnataka - 574227.
Place: Moodbidri
Date:
ALVA’S AYURVEDA MEDICAL COLLEGE
DEPARTMENT OF POST GRADUATE STUDIES IN SHALYATANTRA
MOODBIDRI, KARNATAKA
DECLARATION
I here by declare that this dissertation entitled “A CLINICAL
ASSESSMENT ON THE EFFICACY OF CHIRABILVADI KVATHA IN
ARSHAS”
is a bonafide and genuine research work carried out by me
under the guidance of –
Dr.G.S.Raju M.D (Ay), Professor, Department of Post Graduate
Studies in Shalyatantra, Alva’s Ayurveda Medical College, Moodbidri,
Dakshina Kannada, Karnataka – 574227.
&
Dr.Ravishankar .A.G M.S. (Ay), Assistant Professor,Dept. of P.G
Studies in Shalya Tantra, Alva’s Ayurveda Medical College, Moodbidri
574227.
Place: Moodbidri
Date:
Rajasree. G,
Dept. of P.G.Studies in Shalyatantra,
Alva’s Ayurveda Medical College,
Moodbidri, D.K.District,
Karnataka - 574227.
.
COPYRIGHT
I here by declare that Rajiv Gandhi University of Health Sciences,
Karnataka shall have the rights to preserve, use and disseminate this
dissertation in print or electronic format for academic / research purposes.
Place: Moodbidri
Date:
Rajasree. G.
Dept. of P.G.Studies in Shalyatantra,
Alva’s Ayurveda Medical College,
Moodbidri, D.K.District,
Karnataka - 574227.
© Rajiv Gandhi University of Health Sciences, Karnataka.
Introduction
INTRODUCTION
Ayurveda is the most ancient system of medicine. Ayurveda was popularised to
make the suffering people free from their diseases as well as maintenance and promotion
of good health. In Ayurvedic classical texts we get the reference for both surgical and
medical treatment. Due to timely intervention of biomedical engineering, both in
diagnosis and management, current surgical practice has made enormous progress. But
some diseases are there for exception due to their recurrence after conventional surgery.
In such conditions Oushadha plays an important role in Chikitsa, as this is the tool for the
physician in treating the diseases.
Diseases which are associated with complications and aggravated by a slight
change in the daily regimen are included in the Maharoga category. Arshas is one among
them. As the name suggests, it will ruin the life like an enemy
Arshas is a fairly common condition globally. The present day career arena –
where continuous sitting is required as part of the job- predisposes this disease .As
Udavartha is the main complication of Arshas, which further causes many problems to
the patient,viz. Adhmana, Ajeerna, Shoola etc. Ayurveda, the science of life has also
studied this disease with all its sequalae. A wide spectrum of description is available
including its definite aetio-pathogenesis and a number of treatment modalities. Among
the different treatment modalities specified for Arshas, internal administration of drugs
stands first. Sushruta has advocated Bheshaja Chikitsa as first line therapy, even though
he considers Arshas primarily as a surgical disease. Moreover modern science has very
little to offer in terms of medical treatment for Haemorrhoids. Prevalent modern surgical
1
Alva’s Ayurveda Medical College, Moodbidri
Introduction
and parasurgical measures are having their own limitations and complications and need
special training, skills and equipments for their performance
Hence a medication which is clinically viable, cost effective, easy to administer,
that gives early recovery and minimises the discomfort to the patient in the present day
life style is in high demand.
According to Charaka internal usages of medicines which are having properties
like Deepana, Pachana, Anulomana, Raktasangrahi and Samshamana are aimed to relieve
the active symptoms of Arshas as well as to prevent relapse.
Chirabilvadikwatha is one among the preparation used for Arshas which is
explained in Bhaishajya Ratnavali .The ingredients of Chirabilvadikwatha has properties
like Deepana, Pachana & Anulomana.
Considering the above facts, an attempt is made to evaluate the clinical efficacy of
Chirabilvadikwatha in Arshas.
2
Alva’s Ayurveda Medical College, Moodbidri
Objectives
OBJECTIVES OF THE STUDY
1. Conceptual study of the disease Arshas (Haemorrhoids).
2. To evaluate the clinical efficacy of Chirabilvadikwatha in Arshas.
3
Alva’s Ayurveda Medical College,Moodbidri
Photographs
HARITHAKI
CHIRABILVA
Alva’s Ayurveda Medical College, Moodbidri
Photographs
SHUNTI
PIPPALI
Alva’s Ayurveda Medical College, Moodbidri
Photographs
SAINDAVA
CHITRAKA
Alva’s Ayurveda Medical College, Moodbidri
Photographs
PUNARNAVA
Alva’s Ayurveda Medical College, Moodbidri
Photographs
QUATHA CHOORNA
CHIRABILVADI QUATHA
Alva’s Ayurveda Medical College, Moodbidri
Photographs
PILEMASS SEEN WITH PROTOSCOPE
Alva’s Ayurveda Medical College, Moodbidri
Abstract
ABSTRACT
Diseases which are associated with complications and aggravated by a slight
change in the daily regimen are included in the Maharoga category. Arshas is one among
them. As the name suggests, it will ruin the life like an enemy.
The present day career arena – where continuous sitting is required as part of the
job- predisposes this disease .As Udavartha is the main complication of Arshas, which
further causes many problems to the patient, viz. Adhmana, Ajeerna, Shoola etc. In
contemporary sciences this condition is compared to Haemorrhoids.
Among the different treatment modalities specified for Arshas, internal
administration of drugs stands first. Sushruta has advocated Bheshaja Chikitsa as first
line therapy, even though he considers Arshas as primarily a surgical disease.
Chirabilvadikwatha is one among the preparation used for Arshas which is
explained in Bhaishajya Ratnavali .The ingredients of Chirabilvadikwatha has properties
like Deepana, Pachana & Anulomana.
The patients attended the IPD and OPD of Alvas Ayurveda Hospital,
Moodbidri were the material of this study. 30 patients were randomly selected and
subjected to single blind clinical trial. The signs and symptoms were recorded on the
proforma designed for the study and assessment was done on subjective and objective
criteria.
Intervention: Oral medication with Chirabilvadi kvatha was administered for
one month. During the treatment patients were assessed for the improvement in the
clinical signs and symptoms
i
Alva”s Ayurveda Medical College,Moodbidri
Abstract
The medicine was found to be statistically significant in reducing the signs and
symptoms of the disease.
ii
Alva”s Ayurveda Medical College,Moodbidri
Sl No.
LIST OF TABLES
Page No.
1. Roopa of Vathaja Arshas
16
2. Roopa of Pittaja Arshas
20
3. Roopa of Kaphaja Arshas
23
4. Roopa of Rakthaja Arshas
27
5. Sadhyasadhyata of Arshas
27
6. Bheshajachikitsa of Arshas
31
7. Anatomical relations of anal canal
40
8. Management of haemorrhoids
61
9. Treatment option in haemorrhoids
62
10. Drug review
78
11. Age incidence
85
12. Sex incidence
86
13. Incidence of religion
87
14. Incidence of chronicity
88
15. Incidence of dietary habits(mixed/veg)
89
16. Incidence of dietary habits(spicy/non-spicy)
90
17. Incidence of dietary habits(regular/irregular)
91
18. Incidence of nature of work
92
19. Incidence of prakruti
93
20. Incidence of agni
94
21. Mean and SD of bleeding
95
22. Before treatment - After treatment comparisons of bleeding 96
23. Mean and SD of itching
96
24. Before treatment - After treatment comparisons of itching
97
25. Mean and SD of mucous discharge
98
26. Before/After treatment comparisons of mucous discharge
98
27. Mean and SD of prolapse
99
28. Before treatment - After treatment comparisons of prolapse
100
29. Position of pile mass
100
30. Mean and SD of Number of pile masses
101
31. Before/After treatment comparisons of Number of pile mass 101
32. Mean and SD of degree of pile masses
102
33. Before/After treatment comparisons of degree of pile mass
102
Sl. No.
LIST OF FIGURES
Page No.
1. Age incidence
85
2. Sex incidence
86
3. Incidence of religion
87
4. Incidence of chronicity
88
5.
Incidence of dietary habits(mixed/veg)
89
6.
Incidence of dietary habits(spicy/non-spicy)
90
7.
Incidence of dietary habits(regular/irregular)
91
8. Incidence of nature of work
92
9. Incidence of prakruti
93
10. Incidence of agni
94
11. Effect on bleeding
95
12. Effect on itching
97
13. Effect on mucous discharge
98
14. Effect on prolapse
99
15. Effect on number of pile mass
101
16. Effect on degree of pile mass
102
ACKNOWLEDGEMENT
I express my deepest gratitude to my revered teacher and guide Prof.G.S.Raju
M.D.(Ay), Dept. of Shalyatantra, Alva’s Ayurveda Medical College, Moodbidri, who has
guided me throughout my research work. I offer my sincere thanks for his scholarly
guidance in carrying out this research work.
I remain much obliged to Dr.Ravishankar .A.G, M.S. (Ay), Assistant
Professor,Dept. of P.G Studies in Shalya Tantra, Alva’s Ayurveda Medical
College,Moodbidri for the relentless encouragement and guidance extended.
This thesis would have never attained its present form without the valuable
suggestions provided by Dr.K.Lakshmeesh Upadhya, Principal
& Dr.Suresh
Negalaguli, Dean, P.G.Studies, Alva’s Ayurveda Medical College, Moodbidri.
I express my deep and profound sense of respect to Prof.P.N.Mohan kumar
M.D.(Ay), Dept of P.G.Studies Shalyatantra, Alva’s Ayurveda Medical College, and to
all my respected teachers of Shalyatantra department – Dr.Manjunath Bhat M.S.(Ay),
Dr.Subhadha.V.I. M.S.(Ay) & Dr.swapna. M.S.(Ay) – Alva’s Ayurveda Medical
College, Moodbidri for their critical advice and inspiration.
I render my sincere thanks to Dr. Subramanya Padyana M D(Ay) and Dr. Ravi
Rao M D(Ayu) PhD, Dept of P.G.Studies Dravyaguna, Alva’s Ayurveda Medical
College, Moodbidri for his suggestions during my dissertation work.
I owe my sincere regards and boundless gratitude to Dr. T.SreeKumar M.D. (Ay),
PhD, Reader and Head of the Department, Kriya Sareera, Vaidyaratnam Ayurveda
College, Thaikkattussery, Thrissur, Kerala for his constructive suggestions.
I extend my sincere thanks to
Dr. Ganapathi Bhat M.B.B.S, M.D., Dr. Sriram Bhat M.B.B.S, M.S. Mangala hospital,
Manglore;
Dr.C.Suresh Kumar M.D.(Ay), PhD and Dr.Sudarsana Kumar, Triveni Nursing Home,
Trivandrum, Kerala;
Dr.Rosemary
Wilson,
Chief
Physician,
Kandamkulathy
group
of
Hospitals,
Dr.C.Sreekala M.D(Ay), Medical officer, Thrissur, Kerala;
The medical and paramedical staff of Harisree Hospital, Vinayaka Hospital Thrissur,
Kerala;
The General stores, Dealers in Indian drugs, Kottayam for providing the genuine drugs
for the study
This thesis would have never attained its present form without the valuable
suggestions provided by my husband Dr.R. Ajith kumar M D(Ay), Assistant Professor,
Vishnu Ayurveda College, Shoranur, Kerala.
I am very much grateful to my seniors and to my classmates for their kind cooperation and help throughout the work.
I thank all my juniors and friends for their kind co-operation during the completion
of this thesis work. I thank the Librarian for providing me the necessary books at the
appropriate time. My sincere thanks to the all teaching and non teaching staff of Alvas
Ayurveda Medical College and Hospital for their help during the study.
I remember and appreciate the immense support and encouragement given by my
family members for the completion of this work.
I thank all those who have directly or indirectly contributed to the successful
completion of the thesis work
Place: Moodbidri
RAJASREE G.
POST GRADUATE DEPARTMENT OF SHALYATANTRA, A.A.M.C,
MOODBIDRI.
CASE PROFORMA FOR THE CASES OF ARSHAS.
Title of thesis:A CLINICAL ASSESSMENT ON THE EFFICACY OF
CHIRABILVADI KVATHA IN ARSHAS.
Name:
Case No:
Age:
Date:
Sex:
OPD No:
Occupation:
IPD No:
Address:
Marital status: married /unmarried
Religion: H/C/M/O
Pradhana Vedana vruttanta:
Anubandha Vedhana Vruttanta:
Adhyatana Vyadhi Vruttanta:
1. Constipation : Mild /moderate /severe
2. Pain
: Mild /moderate /severe [during defecation]
Mild /moderate /severe [after defecation]
3. Bleeding
: Mild /moderate /severe
4. Itching
: Mild /moderate /severe
124
5. Burning sensation: Mild /moderate /severe
6. Mass per rectum : Absent /present
1st degree /2nd degree /3rd degree
Poorva Vyadhi Vruttanta:
Koutumbika Vruttanta:
Vaiyaktika Vruttanta:
1 Habit and nature of diet
a) Vegetarian / nonvegetarian
b) Spicy/ nonspicy
c) Regular/ irregular
d) Addictions: Alcohol/ smoking
2. Appetite: poor/ fair/ good
3. Sleep: sound/ disturbed
4. Bowel habit: constipated/ regular/loose
If constipated: mild /moderate/ severe.
5. Nature of work: sedentary/moderate/strenuous
Ashtasthana pareeksha
Nadi :
Mootra :
Mala :
Jihva :
Shabda :
Sparsha :
125
Drik :
Akruti :
General examination
Temperature:
Respiratory rate:
Blood pressure:
Weight:
Nails:
Odema:
Cyanosis:
Lymphadenopathy:
Prakriti: V/ P/K/VP/PK/VK/VPK
Agni: S/ M/ T/ V
Systemic examination
CVS
RS
CNS
P/A
Investigations
Hb%
ESR
126
RBS
TC
DC
Bleeding time
Clotting time
Urine examination
Stool examination
Local examination
On inspection:
1. Condition of skin over anal region
2. Prolapse
3. Anal warts(polyps)
4. Discharge
5. Number of external masses
6. Sentinal tag
P/R examination
1. Tone of sphincter
2. Polyp
3. Growth
4. Hypertrophied anal papillae
5. Associated fissure
Proctoscopy
127
1. Haemorrhoidal mass
2. Position
3. Number
4. Size
5. Bleeding points
Chikitsa
ASSESSMENT RESPONSE:
Subjective criteria:
BLEEDING DAY1
DAY7
MUCOUS
DAY1
DAY14
DAY7
DAY21
DAY14
DAY21
DAY28
DAY28
DISCHARGE
ITCHING
DAY1
PROLAPSE DAY1
DAY7
DAY7
DAY14
DAY14
128
DAY21
DAY21
DAY28
DAY28
Objective criteria:
PROTOSCOPIC
DAY1
DAY7
DAY14
DAY21
DAY28
EXAMINATION
Position
Number
Size
Bleeding points
Signature of Guide
Signature of Scholar
129
Results and observations
RESULTS
Arshas is a fairly common global clinical condition. Among the different
treatment modalities specified for Arshas, internal administration of drugs stands first.
Sushruta has advocated Bheshaja Chikitsa as first line therapy. Chirabilvadikwatha is one
among the preparation used for Arshas, which is explained in Bhaishajya Ratnavali. In
the present study an attempt is made to evaluate the clinical efficacy of
Chirabilvadikwatha in Arshas. According to Proforma prepared for the present study
incidence observations and observations made before treatment and after treatment were
made during the study.
Incidence observations:
According to proforma prepared for the present study, the observations were
made regarding the incidence of Arshas with regard to age, sex, religion, dietary habits,
chronicity, and nature of work, prakruti and Agni of the patient.
84 Alva’s Ayurveda Medical College,Moodbidri
Results and observations
Age
Table no: 11
Sl.No.
Age
No of
group
patients
Percentage
1
20-30
4
13.33
2
30-40
8
26.67
3
40-50
8
26.67
4
50-60
10
33.33
The maximum number of patients in this study was reported from 50 to 60 years
having 33.33%, 26.67% of patients were of the age group of 40 to 50 years and 30 to 40
years ,13.33% of patients were from the age group of 20 to 30 years.
Graph shows age wise distribution:
Figure no:1
35
30
25
20
15
10
5
0
20-30
30-40
40-50
50-60
85 Alva’s Ayurveda Medical College,Moodbidri
Results and observations
Sex
Table no: 12
Sl. No.
Sex
No.of patients
Percentage
1
Male
25
83.33
2
Female
5
16.67
Among the 30 patients, 25 i.e.83.33% were males and 5 i.e. 16.66% were female.
Figure no:2
Sex incidence
25
20
15
10
5
0
No.of patients
Male
Female
Sex
86 Alva’s Ayurveda Medical College,Moodbidri
Results and observations
Religion
Sl.No.
Table no: 13
Religion
No. of patients
Percentage
1
Hindu
16
53.33
2
Muslim
3
10
3
Christian
11
36.67
Among 30 patients taken for the study, 16 patients i.e. 53.33% were Hindu, 3
patients i.e. 10% were Muslim and 11 patient i.e. 36.67% was Christian.
Figure no:3
Religion
16
14
12
10
8
No. of patients
6
4
2
0
Hindu
Muslim
Christian
87 Alva’s Ayurveda Medical College,Moodbidri
Results and observations
Chronicity
Sl.No.
Table no: 14
Chronicity
No of patients
Percentage
2
Less than
3 months
4-6 months
3
7-9 months
1
3.33
4
10-12 months
3
10
14
46.67
1
10
33.33
2
6.67
more than
5
1year
When severity is considered 10patients i.e. 33.33% had the history less than 3
months.2 patients i.e. 6.67% had the history between 4to 6 months.1 patient i.e. 3.33%
had the complaints for a period of 7 to9 months. 3 patients i.e. 10% had the complaints
for a period of 10 to 12 months. 14 patients i.e. 46.67% had the complaints for a period of
more than 12 months
Figure no:4
Chronisity
14
12
10
8
No of patients
6
4
2
0
Less than
3months
4-6months
7-9months
9-12months
more than 1year
88 Alva’s Ayurveda Medical College,Moodbidri
Results and observations
Dietary habits
Table no: 15
Dietary
habits
Sl.No.
No of patients
1
Mixed
30
2
Vegetarian
0
Among 30 patients, all of them i.e. 100% were having mixed dietary habits.
Figure no:5
No. of patients
30
25
20
15
No. of patients
10
5
0
Mixed
Veg
1
2
89 Alva’s Ayurveda Medical College,Moodbidri
Results and observations
Distribution of cases according to spicy or non spicy nature of diet.
Study shows that patients liking for spicy which included liking for chilies,
pickles, fried items etc. are more prone suffer from Arshas when compared to those
taking non-spicy food Among 30 patients, 28 patients i.e. 93.33% were taking spicy
foods and 2 patients i.e. 6.67% were taking non spicy food.
Table no: 16
No of
Sl. No.
Habit
patients
Percentage
1
spicy
28
93.33
2
non spicy
2
6.67
Figure no:6
Diet
30
25
20
No of patients
15
10
5
0
spicy
non spicy
90 Alva’s Ayurveda Medical College,Moodbidri
Results and observations
Regular and irregular dietary habits Table no: 17
Sl.No.
Habit
No of patients
Percentage
1
Regular
16
53.33
2
Irregular
14
46.67
Patients in terms of their regular and irregular dietary habits shows that 16
patients i.e.53.33% were regular and 14 patients i.e.46.67% were regular in their dietary
habits.
Figure no:7
Diet
16
15
No of patients
14
13
Regular
Irregular
91 Alva’s Ayurveda Medical College,Moodbidri
Results and observations
Nature of work
Table no: 18
Nature of
Sl.No.
work
No of patients
Percentage
1
Sedentary
13
43.33
2
Moderate
14
46.67
3
Straneous
3
10
Figure no:8
Nature of w ork
14
12
10
8
No of patients
6
4
2
0
Sedentary
Moderate
Straneous
One of the major contributory factor considered in the development of
haemorrhoids is the nature of work by many scientific works. The cases in present study
are divided in to 3 categories, according to nature of work viz., Sedentary, Moderate and
Straneous. Those in whom daily activities is less than 6 hours, daily sitting at one place
with no physical activity were grouped as Sedentary - for example Businessmen, office
staff, most of urban house wives of upper and upper-middle class etc. Moderate nature of
work is attributed to such people who were on walking or traveling duties for at least 6
hours a day, housewives who do their household work themselves, teachers, students etc.
Those persons whose nature of work involved hard labour and vigorous physical
92 Alva’s Ayurveda Medical College,Moodbidri
Results and observations
activities were grouped under strenuous - for example, labourers, farmers, carpenters,
mechanics etc.
Among 30 patients 3 patients i.e. 10% were doing strenuous work,14 patients
i.e.46.67% were doing moderate work and 13 patients i.e. 43.33% was doing sedentary
work.
Prakruti
Table no: 19
Sl.No.
Prakruti
No of
patients
1
vata pitta
9
30
2
vata kapha
20
66.67
3
pitta kapha
1
3.33
Percentage
Figure no:9
No of patients
20
18
16
14
12
10
8
6
4
2
0
No of patients
vata pitta
vata kapha pitta kapha
Among the 30 patients 9 were having Vaatapitta prakruti, 20 were having Vatakapha
and 1 was having Pittakapha Prakruti.
93 Alva’s Ayurveda Medical College,Moodbidri
Results and observations
Agni
Table no: 20
Sl.No.
Agni
no of patients
Percentage
1
Mandagni
8
26.67
2
Vishamagni
22
73.33
3
Tikshnagni
0
0
4
Samagni
0
0
Figure no:10
Agni
25
20
15
no of patients
10
5
0
Mandagni
Vishamagni
Tikshnagni
Samagni
Among the 30 patients 8 patients i.e. 26.67% were having Mandagni, 22 patients
i.e. 73.33% were having Vishamagni, No patient was having Samaagni or Teekshnagni.
94 Alva’s Ayurveda Medical College,Moodbidri
Results and observations
OBSERVATIONS MADE BEFORE TREATMENT AND AFTER TREATMENT:
The Subjective and Objective criteria recorded before treatment and after treatment were
analyzed for statistical significance. They are tabulated as follows.
BLEEDING
Mean and SD of bleeding
Table no: 21
Bleeding
Day 0
Day 7
Day 14
Day 21
Day 30
Mean
0.63
0.57
0.43
0.1
0
SD
0.72
0.69
0.57
0.31
0.00
Effect on bleeding
Figure no:11
Mean
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
Mean
1st day 7th day
14th
day
21st
day
30th
day
Days
95 Alva’s Ayurveda Medical College,Moodbidri
Results and observations
Before treatment - After treatment comparisons of bleeding
Table no: 22
Bleeding
t-value
p-value
Result
Day 0-day 7
1.44
0.161
p > 0.05 NS
Day 0-day 14
2.69
0.012
p < 0.05 Sig
Day 0-day 21
5.11
0.000
p < 0.05 Sig
Day 0-day 30
4.83
0.000
p < 0.05 Sig
t = 4.826. (P = <0.05)
The change that occurred with the treatment after 30 days is greater than would be
expected by chance; there is a statistically significant change (P = <0.05).
ITCHING
Mean and SD of itching
Table no: 23
Itching
Day 0
Day 7
Day 14
Day 21
Day 30
Mean
0.3
0.27
0.2
0.03
0
SD
0.53
0.52
0.37
0.18
0.00
96 Alva’s Ayurveda Medical College,Moodbidri
Results and observations
Effect on itching
Figure no:12
Mean
0.3
0.25
0.2
0.15
Mean
0.1
0.05
0
1st day
7th day
14th day
21st day 30th day
Before treatment - After treatment comparisons of itching
Table no: 24
Itching
t-value
p-value
Result
Day 0-day 7
1
0.33
p > 0.05 NS
Day 0-day 14
1.8
0.08
p < 0.05 Sig
Day 0-day 21
3.2
0.002
p < 0.05 Sig
Day 0-day 30
3.07
0.0045
p < 0.05 Sig
t = 3.071 (P = 0.005)
The change that occurred at the end with the treatment is greater than would be expected
by chance; there is a statistically significant change (P = 0.005).
97 Alva’s Ayurveda Medical College,Moodbidri
Results and observations
MUCOUS DISCHARGE
Mean and SD of mucous discharge
Table no: 25
Itching
Day 0
Day 7
Day 14
Day 21
Day 30
Mean
0.33
0.27
0.23
0.13
0.03
SD
0.71
0.58
0.57
0.43
0.18
Effect on mucous discharge
Figure no:13
Mean
0.35
0.3
0.25
0.2
Mean
0.15
0.1
0.05
0
1st day
7th day
14th day
21st day 30th day
Before treatment - After treatment comparisons of mucous discharge Table no: 26
Mucous discharge
t-value
p-value
Result
Day 0-day 7
1.43
0.16
p > 0.05 NS
Day 0-day 14
1.795
0.083
p < 0.05 Sig
Day 0-day 21
2.26
0.031
p < 0.05 Sig
Day 0-day 30
2.52
0.017
p < 0.05 Sig
98 Alva’s Ayurveda Medical College,Moodbidri
Results and observations
t = 2.523 (P = 0.017)
By the first seven days treatment showed insignificant change, but the change that
occurred at the end with the treatment is greater than would be expected by chance; there
is a statistically significant change (P = 0.017).
PROLAPSE
Mean and SD of prolapse
Table no: 27
Prolapse
Day 0
Day 7
Day 14
Day 21
Day 30
Mean
2.03
2.03
1.97
1.6
1.3
SD
0.89
0.89
0.93
1.11
1.09
Effect on mucous prolapse
Figure no:14
Mean
2.5
2
1.5
Mean
1
0.5
0
1st day
7th day
14th day
21st day 30th day
99 Alva’s Ayurveda Medical College,Moodbidri
Results and observations
Before treatment - After treatment comparisons of prolapse
Table no: 28
Prolapse
t-value
p-value
Result
Day 0-day 7
-
-
Day 0-day 14
1.44
0.16
p < 0.05 Sig
Day 0-day 21
4.71
0.000
p < 0.05 Sig
Day 0-day 30
8.93
0.000
p < 0.05 Sig
Nil
t = 8.930 (P = 0.000)
There was no change by seven days treatment. But afterwards the change that occurred
with the treatment is greater than would be expected by chance; there is a statistically
significant change (P = 0.000)
POSITION OF THE PILE MASS
Sl.No.
1
position
0
Day 1
0
Day 7
0
2
3,7,11
15
3
3,7
4
Table no: 29
Day 14
0
Day 21
5
Day 30
10
15
14
15
11
3
3
4
4
3
7,11
2
2
2
2
3
5
3,11
0
0
0
0
0
6
7
0
0
0
0
1
7
11
4
4
4
2
1
8
3
4
4
4
2
0
9
3,7,11,5
2
2
2
1
1
100 Alva’s Ayurveda Medical College,Moodbidri
Results and observations
NO. PILE MASS
Mean and SD of Number of pile masses
Table no: 30
No. of pile
masses
Mean
Day 0
Day 7
Day 14
Day 21
Day 30
2.36
2.36
2.33
2.1
1.7
SD
0.96
0.96
0.959
1.21
1.37
Effect on Number of pile masses
Figure no:15
Mean
2.5
2
1.5
Mean
1
0.5
0
1st day
7th day
14th day
21st day 30th day
Before treatment-After treatment comparisons of Number of pile mass Table no: 31
Number of pile masses
t-value
p-value
Result
Day 0-day 7
-
-
Day 0-day 14
1
0.326
p > 0.05 N S
Day 0-day 21
3.25
0.002
p < 0.05 Sig
Day 0-day 30
6.021
0.000
p < 0.05 Sig
Nil
t = 6.021. (P = 0.000) The change that occurred with the treatment is greater than would
be expected by chance; there is a statistically significant change (P = 0.000).
101 Alva’s Ayurveda Medical College,Moodbidri
Results and observations
DEGREE OF PILE MASS
Mean and SD of Degree of pile masses
Table no: 32
Degree of
pile masses
Mean
Day 0
Day 7
Day 14
Day 21
Day 30
2.07
2.07
2
1.67
1.3
SD
0.87
0.87
0.91
1.09
1.12
Effect on degree of pile masses
Figure no:16
Mean
2.5
2
1.5
Mean
1
0.5
0
1st day
7th day
14th day
21st day 30th day
Before treatment-After treatment comparisons of degree of pile mass Table no: 33
Degree of pile masses
t-value
p-value
Result
Day 0-day 7
-
-
Day 0-day 14
1.44
0.16
p > 0.05 N S
Day 0-day 21
4.4
0.0001
p < 0.05 Sig
Day 0-day 30
9.76
0.000
p < 0.05 Sig
Nil
t = 9.76 (P = 0.000)
No change was observed in the first week. Then the change that occurred with the
treatment is greater than would be expected by chance; there is a statistically significant
change (P = 0.000).
102 Alva’s Ayurveda Medical College,Moodbidri
Results and observations
103 Alva’s Ayurveda Medical College,Moodbidri
Scope
SCOPE FOR FURTHER STUDIES
•
Can be done in larger population for longer duration.
•
As the patients in 4th degree haemorrhoids where less, further study should be
conducted concentrating on that.
•
The patients from vata kapha category where more sufferers from haemorrhoids
so there is a scope for further study.
•
Patients who had sedentary nature of work where the sufferers of haemorrhoids,
so study can be conducted on that area.
Alva’s Ayurveda Medical College, Moodbidri
Conclusion
CONCLUSION
•
Arshas is a problem for the mankind since prehistoric period. Patients seek
medical advice only after it worsens.
•
The symptomatology of Arshas more correlates to haemorrhoids.
•
Arshas is explained under Mahagadas
•
Vitiation of Apana Vata is the prime factor for the causation of this disease.
•
Today’s life style and food habits are responsible for the vitiation of Apana Vata.
•
Present study suggests more number of patients were from age group of above 50
years, males with duration of more than 1 year.
•
More number of patients was having sedentary job and spicy non-vegetarian food.
•
All the patients had either Mandagni or Vishamagni and more number of patients
was from Vatha-Kapha Prakruti.
•
More number of patients had haemorrhoids in 3, 7 and 11’O clock positions.
•
Chirabilwadi Kwatha used for the study significantly improved Agni and helped
in reducing the symptoms of bleeding, mucous discharge and prolapse of pile
mass. The ingredients present in the formulation are having deepana, pachana,
anulomana, raktasangrahi and samsamana properties and help in breaking the
samprapti of the disease both ardra and sushka varieties.
•
Suggest further studies to be carried out by administering Chirabilwadi Kwatha
for longer duration and in a bigger population to find its long standing clinical
efficacy, along with necessary dietary changes.
109 Alva”s Ayurveda Medical College, Moodbidri
Summary
SUMMARY
The study
A CLINICAL ASSESSMENT ON THE EFFICACY OF
CHIRABILVADI KVATHA IN ARSHAS was planned with the objectives of finding
a non operative, patient friendly and cost effective, method of management of Arshas.
Conceptual study deals with literature available in Ayurveda regarding
Arshas. An attempt is made to synthesize Nidana panchaka and the treatment modalities
explained in Ayurveda. To supplement the Ayurvedic knowledge, modern literature is
also dealt, starting with anatomy, its management and prevention.
For the clinical study a detailed proforma was designed specifically and 30
cases of Arshas were selected after the patients had been screened to satisfy the inclusion
criteria. Detailed history was obtained from each patient, along with clinical findings, and
was recorded in for the study. Chirabilvadi Kwatha was selected on basis of its utility in
Arshas and prepared accordingly with classical reference from Bhaishajyaratnavali.
Internal administration of 50ml of Chirabilvadi Kwatha was given twice daily
before food. Duration of treatment was 1 month, during the treatment patients were
assessed for improvement in clinical signs and symptoms. All patients were advised non
spicy food.
The study revealed that, the drug Chirabilvadi Kwatha is found to be highly
effective in reducing the signs and symptoms of Arshas. The findings after treatment
were discussed.
110 Alva’s ayurveda Medical college, Moodbidri
ABBREVIATION
C.S.
Charaka Samhita
Su.S
Sushruta Samhita
A.H
Astanga Hridaya
A.S
Astanga Sangraha
M.N
Madhava Nidhana
H.S
Harita Samhita
B.P
Bhava Prakasha
B.S
Bhela Samhita
Y.R
Yoga Ratnakara
G.N
Gada Nigraha
CD
Chakradatta
MASTER CHART
Sl
No
Name
Age
(yrs)
Sex
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
R.Raj
Ramesh
Rajesh
G kutty
Vinod
R shetty
A khan
Seb’n
Sobha
Davis
Mallika
Thomas
U kris’n
Pauly
Antony
R Cha’n
Padmini
Sthomas
Moithen
Sanjay
TS Paul
Anand
J Varghe
Sunil
Ummar
Radha
Sabu
Alphons
Jose
Vinsent
49
34
28
59
32
59
30
34
50
53
53
35
58
37
49
53
48
29
49
43
50
38
58
27
36
45
28
48
59
46
M
M
M
M
M
M
M
M
F
M
F
M
M
M
M
M
F
M
M
M
M
M
M
M
M
F
M
F
M
M
Chroni
city in
month
s
180
1
12
36
1
12
1
5
6
3
36
2
24
12
1
10
24
1
1
3
240
8
12
3
10
36
10
180
12
24
Dietary
habits
Mixed/
Spicy/
Veg
Nonspicy
NV
S
NV
S
NV
S
NV
S
NV
S
NV
S
NV
S
NV
S
NV
S
NV
S
NV
S
NV
S
NV
NS
NV
S
NV
S
NV
S
NV
S
NV
S
NV
S
NV
S
NV
S
NV
S
NV
S
NV
NS
NV
S
NV
S
NV
S
NV
S
NV
S
NV
S
122
Diet
Reg/
Irreg
R
R
I
R
R
R
I
I
R
I
R
I
I
R
I
R
R
R
R
R
I
I
R
I
I
I
R
I
R
I
Nature
of work
Prak
ruti
Agni
Religi
on
M
M
M
M
M
SD
SD
SD
M
SD
M
M
SD
M
M
SD
SD
SD
M
SD
ST
ST
M
SD
M
SD
SD
M
ST
SD
VK
VP
VK
VK
VK
VK
VP
VK
VP
VK
VK
VK
VK
VK
VK
VP
VK
VK
VK
VP
VP
VK
VP
VK
VK
VK
VK
VP
PK
VP
M
M
M
V
M
M
V
V
V
V
V
V
M
V
V
V
V
M
V
V
V
V
V
V
V
V
V
V
M
M
H
H
H
H
H
H
M
C
H
C
H
C
H
C
C
H
H
C
M
H
C
H
C
H
M
H
H
C
C
C
Sl.No
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Name
R.Raj
Ramesh
Rajesh
G kutty
Vinod
R shetty
A khan
Seb’n
Sobha
Davis
Mallika
Thomas
U kris’n
Pauly
Antony
R Cha’n
Padmini
Sthomas
Moithen
Sanjay
TS Paul
Anand
J Varghe
Sunil
Ummar
Radha
Sabu
Alphons
Jose
Vinsent
Bleeding Itching
BT AT BT
1
0
0
0
0
0
0
0
1
2
0
0
0
0
0
0
0
0
0
0
0
1
0
0
1
0
1
1
0
1
2
0
0
1
0
0
1
0
0
1
0
0
0
0
0
0
0
0
0
0
0
1
0
0
1
0
0
1
0
1
1
0
1
2
0
0
0
0
1
0
0
0
0
0
1
0
0
0
0
0
0
0
0
0
2
0
2
0
0
0
AT
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
123
Mucous
Discharge
BT AT
0
0
0
0
0
0
2
0
0
0
0
0
0
0
0
0
0
0
2
1
2
0
0
0
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
2
0
0
0
Prolapse
Number
pile mass
BT AT BT
AT
3
2
3
3
2
2
3
3
1
0
1
0
4
4
4
4
1
0
1
0
3
3
1
1
1
0
1
0
1
0
3
0
1
0
1
0
3
2
3
3
3
3
3
3
2
1
3
3
1
1
2
2
2
1
3
2
2
1
2
2
2
1
3
3
3
2
4
3
1
0
1
0
1
1
3
1
1
0
1
0
3
2
2
2
2
1
3
2
3
2
3
3
1
0
2
0
2
1
3
0
3
2
3
3
2
1
1
0
3
3
2
2
2
2
3
3
2
1
3
3
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49. Acharya Agnivesha, CHARAKA SAMHITHA (with commentary of Chakrapani
datta) Chikitsa sthana 14/60-61, edited by R.K.Sharma Bhagwan Dash, Chowkhamba
Sanskrit Series Office , Varanasi, 4th edition,2000 , page 594.
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50. Acharya Agnivesha, CHARAKA SAMHITHA (with commentary of Chakrapani
datta) Chikitsa sthana 14/131-134, edited by R.K.Sharma Bhagwan Dash, Chowkhamba
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51. Acharya Agnivesha, CHARAKA SAMHITHA (with commentary of Chakrapani
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Sanskrit Series Office , Varanasi, 4th edition,2000 , page 610
52. Chikitsasara Samgraha of Vangasena (Vangasena samhita) , chapter Arshas 371,
edited by Dr. Nirmal saxena, Chowkhamba Sanskrit Series Office , Varanasi,
1st
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53. Acharya Agnivesha, CHARAKA SAMHITHA (with commentary of Chakrapani
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Sanskrit Series Office , Varanasi, 4th edition,2000 , page619.
54. Acharya Agnivesha, CHARAKA SAMHITHA (with commentary of Chakrapani
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Sanskrit Series Office , Varanasi, 4th edition,2000 , page625
55. Acharya Agnivesha, CHARAKA SAMHITHA (with commentary of Chakrapani
datta) Chikitsa sthana 14/215-2166, edited by R.K.Sharma Bhagwan Dash, Chowkhamba
Sanskrit Series Office , Varanasi, 4th edition,2000 , page625.
56. Acharya Agnivesha, CHARAKA SAMHITHA (with commentary of Chakrapani
datta) Chikitsa sthana 14/224-229, edited by R.K.Sharma Bhagwan Dash, Chowkhamba
Sanskrit Series Office , Varanasi, 4th edition,2000 , page619.
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57. Acharya Agnivesha, CHARAKA SAMHITHA (with commentary of Chakrapani
datta) Chikitsa sthana 14/121-129, edited by R.K.Sharma Bhagwan Dash, Chowkhamba
Sanskrit Series Office , Varanasi, 4th edition,2000 , page607,608.
58. Acharya Sushrutha, SUSHRUTHA SAMHITHA (with commentary of Dalhana)
Nidana
sthana 6/3, edited by kaviraj kunjalal bhishagratna, chowkhambha Sanskrit
Series Office, Varanasi, 2nd edition, 2002, page20.
59. Bailey & Love’s, SHORT PRACTICE OF SURGERY, 24th Edition, edited by R.C.G.
RUSSELL, Publishers edward Arnold, 2004,page 1255.
60. Richard S Snell’s, CLINICAL ANATOMY FOR MEDICAL STUDENTS, 16th
Edition, Lippincott- Williams and Wilkins , page356.
61. Richard S Snell’s, CLINICAL ANATOMY FOR MEDICAL STUDENTS, 16th
Edition, Lippincott- Williams and Wilkins , page362.
62. Richard S Snell’s, CLINICAL ANATOMY FOR MEDICAL STUDENTS, 16th
Edition, Lippincott- Williams and Wilkins , page362.
63. Richard S Snell’s, CLINICAL ANATOMY FOR MEDICAL STUDENTS, 16th
Edition, Lippincott- Williams and Wilkins , page362.
64. Richard S Snell’s, CLINICAL ANATOMY FOR MEDICAL STUDENTS, 16th
Edition, Lippincott- Williams and Wilkins , page362.
65. Toratora and Grabowsik’s, PRINCPALS OF ANATOMY AND PHYSIOLOGY ,10th
edition, Publisher Wiley , Page 859.
66. Bailey & Love’s, SHORT PRACTICE OF SURGERY, 24th Edition, edited by R.C.G.
RUSSELL, Publishers edward Arnold, 2004,page 1256.
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67. Somen Das, A CONCISE TEXT BOOK OF SURGERY, 2nd edition, Chapter 54,
Publisher Dr.S. Das, 1999, Page 1056.
68. Maingots Abdominal Operations Volume 2, 10th edition, Publisher Mc Graw Hill ,
Page 1440.
69 . Somen Das, A CONCISE TEXT BOOK OF SURGERY, 2nd edition, Chapter 54,
Publisher Dr.S. Das, 1999, Page 1056.
70. Somen Das, A CONCISE TEXT BOOK OF SURGERY, 2nd edition, Chapter 54,
Publisher Dr.S. Das, 1999, Page 1055
71. Somen Das, A CONCISE TEXT BOOK OF SURGERY, 2nd edition, Chapter 54,
Publisher Dr.S. Das, 1999, Page 1057
72. Somen Das, A CONCISE TEXT BOOK OF SURGERY, 2nd edition, Chapter 54,
Publisher Dr.S. Das, 1999, Page 1056.
73. Somen Das, A CONCISE TEXT BOOK OF SURGERY, 2nd edition, Chapter 54,
Publisher Dr.S. Das, 1999, Page 1057.
74. Somen Das, A CONCISE TEXT BOOK OF SURGERY, 2nd edition, Chapter 54,
Publisher Dr.S. Das, 1999, Page 1057
75. Sabiston’s, TEXTBOOK OF SURGERY VOLUME 1, 15th edition, Publisher
Harcourt Asia and Sounders, Page 1036.
76. David Carter’s, ATLAS OF GENERAL SURGERY , 3rd edition, edited by RCG
Russell and Henry A Pitt, Publisher Chapman and Hall Medical, Page 816.
77. Somen Das, CLNCAL SURGERY, 7th edition, Chapter 36, Publisher Dr.S. Das,
2008, Page 398.
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78. Govind Das,BHAISHAJYA RATNAVALI
Arshoroga Chikitsa Prakaranam-34
Edited by Bhiagratna shri Brahmashankar Mishra18th edition, Published by Chowkamba
Sanskrit sansthan,Varanasi , 2005,page no:301.
79. Sujana priya vyakya, Sahasra yoga, Arshohara kashaya, edited by Gopala pillai, 22nd
edition, Vidyarambha publication, Alapuzha, 1998, page no: 50.
80
K M Nadakarni’s.-INDIAN MATERIA MEDICA , Volume 1-Popular prakashana
pvt ltd,2000Edition, Page no:202,965,990,1001,1205,1308
121
Alva’s Ayurveda medical College, Moodbidri
CONTENTS
Page No. 1. Introduction
1-2
2. Objectives of the study
3
3. Review of literature
Disease review -Ayurvedic part
-Modern part
Drug review
4-37
38-76
77-78
4. Materials and methods
79-83
5. Results and observations
84-102
6. Discussion
103-108
7. Conclusion
109
8. Summary
110
9. Bibliography
111-121
10. Annexure
122-129
Discussion
DISCUSSION
Healthy discussion guides and inspires the new comers in the concerned
field of work. Also it promotes critical and creative lateral thinking.
The discussion of the present study is done under the following divisions:Arshas
Intervention
Observations
Arshas
Sedentary lifestyle and fast food habits of these days have presented several
diseases to the mankind. These changes in the life style disturb the digestive system and
play an important role in formation of Arshas.
Arshas is one among the
Ashtamahagadas, as it is difficult to cure. The vast number of etiological factors, detail of
its pathogenesis and the different treatment modalities described to manage this condition
prove that this disease is the most ideal one to be explained under Ashtamahagadas
Analysing the descriptions said in earlier pages, it can be understood that Arshas
includes not only haemorrhoids, but ano-rectal growths like anal epithelioma, polyps,
hypertrophied papillae, sentinel tags, carcinoma of
rectum etc. can also be considered
under this heading.
103Alva’s Ayurveda Medical College, Moodbidri
Discussion
Intervention
Arshas is caused by Mandagni, it may be due to the change in lifestyle and food
habits. Viruddha Ahara and sedentary job are the common cause for increasing the
number of Arshas patients. This disease entity can be described as the local manifestation
of systemic derangement of doshas and agni.
From olden days Arshas and its management had been a challenge to the
medical profession. Among the different treatment modalities specified for Arshas,
internal administration of drugs stands first. Sushruta has advocated Bheshaja Chikitsa as
first line therapy, even though he consider Arshas as primarily a surgical disease .Internal
use of medicines which are having properties like Deepana, Pachana, Anulomana,
Raktasangrahi and Samshamana are aimed to relieve the active symptoms of Arshas, as
well as to prevent relapse. A number of single and compound drugs for Arshas are
explained by our Acharyas.
Chirabilvadikwatha is one among the preparation used for Arshas which is explained in
Bhaishajya Ratnavali .The ingredients of Chirabilvadikwatha has properties like
Deepana, Pachana & Anulomana.
The study shows that it significantly helped in improving the Agni, relieving the
symptoms of constipation, bleeding, pain, burning sensation and also in the regression of
pile mass.
Reference regarding Chirabilvadikwatha is available in text books like
Bhaishajya Ratnavali and Sahasrayoga
104Alva’s Ayurveda Medical College, Moodbidri
Discussion
Observations of the clinical study
On the vital data:Age and sex
The maximum number of patients in this study was reported from 50 to 59 years
having 33.33%, 26.67% of patients were of the age group of 40 to 49 years and 30 to 39
years ,13.33% of patients were from the age group of 20 to 29 years.
Among the 30 patients, 25 i.e.83.33% were males and 5 i.e. 16.66% were female.
This figure may not represent the true incidence of Arshas in general.
Chronicity
When severity is considered 10patients i.e. 33.33% had the history less than 3
months.2 patients i.e. 6.67% had the history between 4to 6 months.1 patient i.e. 3.33%
had the complaints for a period of 7 to9 months. 3 patients i.e. 10% had the complaints
for a period of 10 to 12 months. 14 patients i.e. 46.67% had the complaints for a period of
more than 12 months
Dietary habits
All the patients under present study were having mixed dietary habits.
Study
shows that patients who consume spicy food which included chilies, pickles, fried items
etc. are more prone to suffer from Arshas, when compared to those taking non-spicy
food. Among 30 patients, 28 patients i.e. 93.33% were taking spicy foods and 2 patients
i.e. 6.67% were taking non spicy food. Patients in terms of their regular and irregular
dietary habits shows that 16 patients i.e.53.33% were regular and 14 patients i.e.46.67%
were irregular in their dietary habits.
105Alva’s Ayurveda Medical College, Moodbidri
Discussion
Nature of work
One of the major contributory factors considered in development of haemorrhoids
is the nature of work by many scientific works. The cases in the present study are divided
in to 3 categories, according to nature of work viz., Sedentary, Moderate and Strenuous.
Those in whom daily activities is less than 6 hours and daily sitting at one place with no
physical activity were grouped as Sedentary - for example Businessmen, office staff,
most of urban house wives of upper and upper-middle class etc. Moderate nature of work
is attributed to such people who were on walking or traveling duties for at least 6 hours a
day, housewives who do their household work themselves, teachers, students etc.
Those persons whose nature of work involved hard labour and vigorous physical
activities were grouped under strenuous - for example, labourers, farmers, carpenters,
mechanics etc.
Among 30 patients 3 patients i.e. 10% were doing strenuous work,14 patients
i.e.46.67% were doing moderate work and 13 patients i.e. 43.33% was doing sedentary
work.
Prakruti, Agni
Among the 30 patients 9 were having Vatapitta prakruti, 20 were having Vatakapha and
1 was having Pittakapha Prakruti. Among the 30 patients 8 patients i.e. 26.67% were
having Mandagni, 22 patients i.e. 73.33% were having Vishamagni, and No patient was
having Samaagni or Teekshnagni.
Before treatment /After treatment observations:The readings of the observations made in 30 patients, included in the
present study, with internal administration of 50ml of Chirabilvadi Kwatha given twice
daily before food, were divided into subjective and objective criteria for easy assessment.
The subjective criteria were bleeding; itching and mucous discharge and objective
criteria were number of the pile mass and degree of haemorrhoids. All patients were
106Alva’s Ayurveda Medical College, Moodbidri
Discussion
assessed according to the grading given before and after treatment and were analyzed for
statistical significance.
Subjective criteria
Bleeding
It was noted that 15 out of 30 patients had bleeding before treatment. The mean
of the bleeding was 0.63 before treatment, where 11 patients had mild bleeding and 4
patients moderate bleeding. The change showed after seven days of treatment was having
no significance. After treatment all the patients were completely recovered from
bleeding.
The change that occurred with the treatment is greater than would be expected by chance;
there is a statistically significant change (P = <0.005).
Itching
8 patients among 30 had the complaint of itching; with mild and moderate degree
before treatment. After 30 days of treatment all patients were completely relieved.
(P = 0.005).
Mucous discharge
Among 30 patients, 6 had this symptom of mild to severe degree. By the first
seven days treatment showed insignificant change. After treatment only 1 patient had
mild degree of mucous discharge. (P = 0.017)
Prolapse
Among 30 patients, 10 patients had 1st degree, 10 patients had 2nd degree
prolapse, 9 patients had 3rd degree prolapse and 1 patient had 4th degree prolapse. There
107Alva’s Ayurveda Medical College, Moodbidri
Discussion
was no change by seven days treatment. The mean of
prolapse of pile mass before
treatment was 2.03, after treatment 8 patients were relieved from prolapse completely
with mean 1.03 and p= 0.000, which gives statistical significance.
Objective criteria
Number of pile mass
The mean before treatment was 2.37, after treatment patients were relieved with
mean 1.73. But there was no result by seven days of treatment Value of P=0.000, which
gives statistical significance.
Degree of pile masses
No change was observed in the first week.2.07 was the mean before treatment and
it reduced to1.3. In this study only one patient was suffering from 4th degree pile mass
and after the treatment there was no change in this case. This figure may not represent the
true incidence as the population from 4th degree was less. Then the change that occurred
with the treatment is greater than would be expected by chance; there is a statistically
significant change (P = 0.000).
108Alva’s Ayurveda Medical College, Moodbidri
Review of Literature
REVIEW OF LITERATURE AYURVEDIC PART
REVIEW OF ARSHAS
Vyutpatti
The word Arshas is derived from Rush+Ach dhatu, a disease having fleshy sprouts or shoots
in the guda pradesha.
Nirukti
Charaka has explained Arshas as an abnormal fleshy growth in guda pradesha. Such growths
in other sites like nasa, karna etc are called Adhimamsa. Vagbhata defines that Arshas are the
fleshy growths that create obstruction in anal passage and troubles continuously1
.Madhukosha defines it as a disease which tortures the life like an enemy and kills2. He has
used the word Srinati, a derivative meaning to tear into pieces. Hence generally Arshas
means growth in anorectal region even though there are other terms like Nasarshas,
Yoniarshas etc. as it occurs very frequently and is more troublesome than any other type of
Arshas. By the above definitions, it can be inferred that it is a clinical condition where the
patient has agonising pain.
Paryaya pada
Adhimamsa - Extra growth of muscles at the anal verge.
Mamsa keela - Extra growth of muscles that obstructs the anal passage.
Anamaka - Not famous
Durnamaka -That which predisposes an ignominy.
4
Alva’s Ayurveda Medical College, Moodbidri
Review of Literature
Gudakeela - That which obstructs like a nail, the passage of anus.
Gudankura - Sprout like growth in the anus.
Gudaja - Arising from guda.
Gudapraroha - meaning sprout or growth in the anus.
Gudavalipraroha - meaning sprouts from the gudavali.
Gudankura - meaning a growth like a sprout at gudapradesha.
Payuroga - Disease of anus.
ANATOMICAL CONCEPTS OF GUDA
As the disease Arshas is mainly related to guda , it is essential to know the anatomical
relations and structure of guda for a better understanding of Arshoroga.
Embryology
Antra (intestines), Basti (bladder) and Guda of the foetus are formed out of the essence of
Rakta and Kapha , the entire process being helped by Pitta and Vayu 3 . It takes its origin
from Matrjabhava4 .
Location and structure
Guda is located in the lower part of the large intestine which passes into flexure of
the rectum and has a measurement of 4½ angulas5,6 . Guda has been enumerated along with
the koshtangas of the body by Charaka and is having two parts viz uttaraguda and
adharaguda7. Cakrapani explains uttaraguda as the seat of faecal collection and adharaguda
helps for the evacuation of faeces8.
5
Alva’s Ayurveda Medical College, Moodbidri
Review of Literature
This seems to indicate that Charaka held the extent of uttaraguda upto
pelvic colon. Adharaguda forms the part of anorectum because, as soon as the faecal matter
reaches the ampulla of rectum, the reflexes start resulting into desire for defaecation.
Gudoshta:
A part of the channel when measured from outer margin of guda for ½ an angula width in
length is furnished by the name gudoshta or anal lip9. Sushruta has described that the interior
of guda (anorectal canal) contains 3 valis. They are pravahini,visarjini and samvarani. These
are situated one above the other at an interval of 1 ½ angula10. They are arranged in spiral
form (shankavarta nibha) and resembles the colour of palate of an elephant 11 .
Pravahani:
First vali, situated in the upper part of the guda as it pushes the mala downwards is called
pravahani.
Visarjani:
It is the second vali, situated 1½ angulas below the pravahani and 1½ angula above the
samvarani, which helps in expulsion of mala.
Samvarani:
This is the third vali situated one angula above the gudoshta and helps in the closure of
guda.
When constricted these valis measure about 4 angulas.
6
Alva’s Ayurveda Medical College, Moodbidri
Review of Literature
Guda as a marma and srotas:
Sushruta has described guda as the mamsa marma12 which is attached to sthoolantra
through which vata and purisha are excreted .It is considered as sadyapranahara marma ie
any injury occuring to this organ results in immediate death13 . There are 10 Snayus in groin
and sixty in the pelvis, three Pesis and three Sandhis (samudga sandhi) in this region14 .
Guda is included in mahasrotas having opening to exterior that is one among the
bahirmukhasrotas.
Vascular aspect of guda:
Among the thirty four siras carrying vayu found in kosta, eight siras supply to
guda,medra and sroni15 .
Two dhamanis which are taking downward course carry apanavayu, mutra, purisha, sukra
and arthava to respective organs.
Relations:
Basti , pourushagrandhy, vrushanam and guda are interrelated and situated in gudasthi
vivara16 .
Physiology of guda
Dosha : Apana vayu
Dathu : Mainly mamsa
Mala : Pureesha
Guda is known as karmendriya because it does the function of defecation.
7
Alva’s Ayurveda Medical College, Moodbidri
Review of Literature
NIDANA
By reviewing the references mentioned in the classical texts regarding the disease Arshas,
the causative factors can be classified as follows:Sahaja factors:
This morbidity is caused by the unwholesome behavior of the parents and the past deeds.
These are the cause of other congenital disorders which manifest along with the body So Sahaja
Arshas is caused by beeja dosha which may result from bad deeds of the past life or due to
defects in beeja bhaga and beeja bhagavayava of male and female partners.
Agnimandyakara factors:
Majority of acquired diseases occur due to mandagni. Among the nidana of Arshas
agnimandyakara ahara and vihara can be enlisted as adhyasana, pramitasana,
snigdha
bhojana, avyayama, divaswapna, soka etc. Hence general causes like consumption of
decomposed and incompatible substances that lead to Vibandha, adhyasana, inordinate
sexual intercourse, sitting on the haunches, excessive riding17 . Intake of abhisyandi, vidahi
and viruddha food , intake of meat of cow, fish, pig, buffalo, goat and improper and irregular
practice of shodhana Karma will lead to Arshas18 .
Vegavarodha factors:
It is said that diseases occur because of suppression of natural urges19. Among natural
urges,Pureesha vega dharana may lead to Arshas. It may also be due to alpasana, langhana,
katu tikta kashaya rasa pradhana ahara, ruksha ahara etc.
8
Alva’s Ayurveda Medical College, Moodbidri
Review of Literature
Other factors:
General debility and emaciation caused by prolonged illness like udara, grahani etc. can
cause Arshas. Use of rough irregular and hard seats, excessive indulgence in sex, improper
insertion of enema nozzle, frequent injury in the anal region, frequent application of cold
water etc. can cause aggravation of apana vayu which brings down the accumulated waste
products to afflict the anal sphincters. Because of this, piles are manifested in the sphincter.20
Arshas,Grahani and Atisara are causative factors for each other due to imbalance of agni.
So by going through the above we can conclude the causes of Arshas as follows that
those dietetic indulgence which vitiate dosha and interfere with the digestive agni leading to
poor digestion, those acts which would vitiate Vata, pressure or irritation in the anal region,
general weakness and emaciation from prolonged illness. Anyway this does not include
causes of Sahajarshas which seems idiopathic in nature arising from the bad deeds of parents
or individual sin.
SAMPRAPTI
Charaka explains that vitiated doshas follows bahya and abhyantara rogamarga to produce
Arshas and considers only gudarshas under the heading of Arshas and believes that they are
produced due to the vitiation of all the doshas and affecting gudavalitraya..
Sushruta describes the pathogenesis of Arshas as the nidanas resulting in the vitiation
of doshas in single, combination of two or more along with raktadosha move downwards
9
Alva’s Ayurveda Medical College, Moodbidri
Review of Literature
through the mahadhamani reaching guda and affecting the gudavalitraya resulting in Arshas
to the individuals suffering from mandagni and other local causes21 .
According to Vagbhata, vitiation of doshas leads to mandagni and vitiation of apana vayu
result in stagnation of mala in gudavali and the prolonged contact of mala lead to the
development of Arshas.
The description of Samprapti of Arshas according to Ayurveda indicates that this disease is a
local manifestation of systemic derangement in the equilibrium of doshas which occurs
mainly due to mandagni suplimented by various causative factors
10 Alva’s Ayurveda Medical College, Moodbidri
Review of Literature
Nidana sevana
Vitiation of Tridoshas
Jataragni mandya
Formation of Ama
Vitiation of
Apanavata
Vitiated Tridoshas singly, double or with
Raktha moves throught the body
Comes downwards in guda
pradesha through dhamanis
Leads to
Vibhanda or
Malabhadhata
Vitiation of twak, rakta, mamsa and
meda In guda pradesha
Guda and gudavali are affected
Protrution of mamsa in guda pradesaha
Giving rise to arshas
11 Alva’s Ayurveda Medical College, Moodbidri
Review of Literature
Samprapti ghatakas:
Dosha- Tridoshaja
Dooshya- Tvak, mamsa, medas22
Srotas- Raktavaha, mamsavaha
Srotodushti- Sanga, siragranthi
Udbhavasthana- Amapakvasayotbhava
Vyaktastana- Gudavalitraya
Rogamaarga- Bhahya and Abhyantara
Classification of Arshas
A. Based on origin23
1. Sahaja arshas
2. Janmottara Kalaja:
Vataja
Pittaja
Kaphaja
Dwidoshaja
Tridoshaja
B. Based on character of bleeding24
1. Shushka arshas2. Ardra arshas-
vatakaphaja
pittaja, raktaja
12 Alva’s Ayurveda Medical College, Moodbidri
Review of Literature
C. According to site of origin: 25
1. Bahya Arshas –Bahya vali(Samvarani)
2. Abhyantara Arshas –Madhya vali(Visarjani), Antharvali(Pravahini)
Sushruta has used the word ‘Drisya’ probably to denote those occurring in Bahya
Vali that is Bahya Arshas and Adrisya, probably arising from Madhya and Antarvali that is
Abhyantara Arshas where other symptoms were present but there were no Gudankura.
D. Based on chikitsa26
1. Bhesaja sadhya
2. Kshara sadhya
3. Agni sadhya
4. Shastra sadhya
E. According to Sadhyasadhyata27
1. Sadhya
2. Kashta Sadhya
3. Yapya
4. Asadhya
13 Alva’s Ayurveda Medical College, Moodbidri
Review of Literature
POORVAROOPA:
In the Nidana of Arshas, after ‘Doshadushyasammurchanam’, the symptoms in vague
alarm the person in the manifestation of premonitory symptoms like anna asraddha,
krchratpakti, amlika, vistambha, pipasa, tandra etc. If these symptoms are taken care with due
priority by an eminent physician with proper line of management, never land up in further
progress. If these premonitory symptoms are neglected it results into Vyaktavastha ie. full
manifestation of disease.
Charaka described prodromal symptoms as vishtambha i.e. as if food is stagnated in the
stomach, dourbalya, kukshiratopa, karshya, udgara bahulya, sakthisada and alpa vitkata. The
patient feels as if he is suffering from Grahaniroga, Pandu or Udara Roga. Sushruta has also
described similar symptoms preceeding manifestation of Arsha except that he has added a
few more symptoms like.amlika, paridaha, pipasa, akshi svayathu, antrakujana and guda
parikartana. The patient also suffers from shosha, shwasa and kasa, balahani, bhrama, tandra,
nidra and indriyadourbalya.
Vagbhata is elaborate in his description of prodromal symptoms and has enumerated several
common symptoms in descriptive language. He has added few more- e.g.pindikodwestana,
bahumutrata, antrakujana, atopa, agnimandya, shirashoola, urushoola and prushtashoola.
The role of Vayu and Mandagni has been emphasized as the principal cause leading to
Arshas. A close observation of the above mentioned prodromal symptoms leads to the
conclusion that all these result from poor digestion and hypo-motility of the alimentary tract.
14 Alva’s Ayurveda Medical College, Moodbidri
Review of Literature
ROOPA
Arshas are the fleshy growths that create obstruction in anal passage and kill the life
like an enemy. Charaka has described the appearance of Janmottarakalaja and Sahajarsha to
differentiate them from each other.
Sahajarshas develops due to vitiated Beejadosha of the parents. Among the congenital
piles some are small and others big, some are long and others short; some are round and
others spread unevenly, some are bent internally and others externally, some are matted
together and others with opening internally. They have colour according to associated
Doshas.
Sushruta explains as a person having such type of Arshas will be emaciated, with
decreased appetite, the veins turn prominent, sterility, and sukradushti, feeble voice,
decreased appetite, develops diseases of head, eye, nose and ear, gurgling sound in intestine,
hridayopalepa, tastelessness etc.
15 Alva’s Ayurveda Medical College, Moodbidri
Review of Literature
VATAJA ARSHAS
STHANIKA
Table No:1
CS
SaS
AS
AH
MN
Şuśka
+
+
+
+
+
Mlāna
+
+
+
+
Kaţhina
+
+
Paruşa
+
+
+
+
HS
+
Sitatva
BS
GN
YR
BP
CD
+
+
+
+
+
+
+
+
+
+
+
+
+
Vit Sanga
+
Khara
+
+
+
+
+
+
+
+
+
+
SAMANYA
Vişama Visŗta
+
Ākşepa
+
Sphuraņa
+
Cimicima
+
Sāmharsha
+
Pravāhika
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
Śiśna Vrsana Basti
+
Vanksana Graha
16 Alva’s Ayurveda Medical College, Moodbidri
Review of Literature
Hrt Graha
+
+
+
+
+
+
Anga Marda
+
Hrddrava
+
Śirotāpa
+
+
+
+
+
+
Ksavathu
+
+
+
+
+
+
Udgāra
+
+
+
+
+
+
Pratata Vibadha
Vāta Mūtra Varcas
Pratiśyāya
+
+
+
+
Kāsa
+
Āyāma
+
Mūrcha
+
Aruci
+
Mukha Vairasya
+
Timera
+
Kandū
+
Svara bheda
+
+
+
+
+
+
+
+
+
+
+
+
Karkandhu
+
+
+
+
+
Siddhārtha
+
+
+
+
+
Stabdha
+
+
+
+
+
Swāsa
+
+
+
+
+
17 Alva’s Ayurveda Medical College, Moodbidri
Review of Literature
Agni Vaisamya
+
+
+
+
+
Karna Nāda
+
+
+
+
+
Bhrama
+
+
+
+
+
Atisāra
+
Parva Bheda
+
Trsnā
+
Grahanī
+
Vinidrā
Śosa
+
+
VARNA
Śyāva
+
+
Aruna
+
Vivarna
+
+
+
+
+
+
+
+
+
+
+
+
+
+
ROOPA
Tikşnāgra
+
+
Vakra
+
+
+
+
Sphuţita Mukha
+
+
+
+
+
+
+
+
+
18 Alva’s Ayurveda Medical College, Moodbidri
Review of Literature
VEDANA
Śūla
+
Toda
+
+
+
+
+
+
+
+
Ūru Kati Prstha
Trika Pārśwa Kuksi
+
+
+
+
+
+
+
+
Basti Śūla
Nāsākarna
Śankha
+
+
Śūla
AGGRAVETING FACTOR
Snigdhoşnopaśaya
+
UPADRAVA
Ādhmāna
+
Udāvarta
+
Śotha
+
Gulma Asthilā Pliha
+
Udara Visūcikā
19 Alva’s Ayurveda Medical College, Moodbidri
Review of Literature
SIMILI
Bimbī Kharjūra
Phala Pramāna
Ruk Phene Picchā
Yukta Srāva
+
+
+
+
+
+
+
+
+
+
+
PITTAJA ARSHAS
STHANIKA
Mrdu Śithila
Sukmāra Asparśa
Saha
Visra Gandhi
Tanupita Rakta
Srāva
Pāka
Table No:2
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
Dāha
+
Kandū
+
Sambhinna Pīta
Harita Varcas
Pīta visra Gandhi
+
Usna Drava Srava
+
+
+
+
+
+
+
+
+
+
+
+
+
20 Alva’s Ayurveda Medical College, Moodbidri
Review of Literature
VARNA
Rakta Pīta Nīla
Krsna
Pāndu Varna
+
+
+
+
+
+
+
+
+
AGGRAVETING FACTOR
Sweda Kleda Bahula +
Sītopaśaya
+
Bhojana Dveśa
+
Yava Madhya Vat
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
VEDANA
Śūla
+
Toda
+
SAMANYA
Praciura Vit Mūtrā
+
Hrudhiravahani
+
Tamaka
+
+
+
Sammoha
+
+
+
+
21 Alva’s Ayurveda Medical College, Moodbidri
Review of Literature
Tanu
+
Visarpi
+
Pīta Avābhāsa
+
Yakrt Prākāśa
+
+
+
+
+
+
+
Śukajihwā Kāra
+
+
+
+
+
+
+
Sarudhirātisāra
+
+
+
+
Aruci
+
+
+
+
Bhrama
+
+
+
UPADRAVA
Pipāsa
+
+
+
+
+
+
+
+
+
Jwara
+
+
+
+
+
+
+
+
+
Nīlāgra
+
+
+
+
+
+
+
Jalavuka Vaktra
Sadrśa
+
+
+
+
+
+
+
22 Alva’s Ayurveda Medical College, Moodbidri
Review of Literature
KAPHAJA ARSHAS
SAMANYA
Table No:3
Pramānavān
+
Upacita
+
+
+
+
+
+
+
+
+
+
+
+
+
+
Guru
+
+
+
+
+
+
+
Stabdha
+
+
+
+
+
+
+
Stimita
+
+
+
+
+
+
+
Supta Suptā
+
+
Sthira Śvayathu
+
Guru Picchila Sweta +
Mūtra, Purīsa
Pravāhikā
+
+
+
+
+
+
+
Utthāna Vinkasana
+
+
+
+
+
+
+
Ānāha
+
+
+
+
+
+
+
Nisthīvana
+
+
+
+
+
+
+
Kāsa
+
+
+
+
+
+
+
Pratiśyāya
+
+
+
+
+
+
+
Gaurava
+
Chardi
+
+
+
+
+
+
+
Mūtra krcchra
+
+
+
+
+
+
+
+
+
23 Alva’s Ayurveda Medical College, Moodbidri
Review of Literature
Śosa
+
Pāndu Roga
+
Hrdayendriyopalepa
+
Āsya Mādhurya
+
Āma Vikāra
+
+
+
+
Vit Bandha
Śukla, Nakha
Nayana Vadana
Twak Mūtra Purīsa
Hrllāsa
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
Ślaksna
+
+
+
+
+
+
+
Sparśasaha
+
+
+
+
+
+
+
Picchila
+
+
+
+
+
+
+
Bahukandū
+
+
+
+
+
+
+
+
+
+
+
+
+
Agni Māndya
+
+
+
STHANIKA
Bahu Pratata, Pinjra,
+
Śweta, Rakta, Picchā
Srāva
Parikartikā
+
+
+
Māmsadhāvana
24 Alva’s Ayurveda Medical College, Moodbidri
Review of Literature
Prakāśa Srāva
Na Bhidyante
Nasravanti
Guda Bhangura
+
+
+
+
+
+
+
Mrudu
+
VARNA
Snigdha, Śweta,
Pāndu
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
AGGRAVETING FACTOR
Rūksosnopaśaya
+
UPADRAVA
Aruci
+
+
Śotha
+
+
Sīta Jwara
+
+
+
+
+
+
+
Aśmarī
+
Śarkarā
+
Prameha
+
+
+
+
+
+
+
Dīrghakālānubandhi
+
Klaibya
+
+
+
+
+
+
+
25 Alva’s Ayurveda Medical College, Moodbidri
Review of Literature
Avipaka
+
Swāsa
+
+
+
+
+
+
Śiro Gaurava
+
+
+
+
+
+
Gulma
+
Nidrā
+
ROOPA
Vrtta
+
+
+
+
+
+
+
Karīra Panasāsthi
Gostanīkakāra
Vasā Prakāśa Srāva
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
VEDANA
Manda Ruja
+
Sūlā
+
Toda
+
26 Alva’s Ayurveda Medical College, Moodbidri
Review of Literature
RAKTAJA ARSHAS
Nyagrodha Praroha
Vidruma
Kākananta Kā Phala
Sadrśa
Other Pitta Laksana
Table No:4
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
Rakta Srāva
+
SADHYASADHYATA 28
Sushruta has enumerated Arshas as one among the eight Mahagadas and difficult to
treat .However, he has based his prognostic assessment mainly on the site of manifestation
and its doshic involvement. So the sadyasadyata of Arshas depends on the site , involment of
doshas and chronicity. All types of Arshas can be classified in the following prognostic
groups:
Table No: 5
Saadhya
Kruchrasaadhya
Ekadoshaja
Dvidoshajas
Bahaya vali
Madhyama vali
Less than 1 year
Yapya
Asaadhya
Tridoshaja with
alpa lakshanas
Tridoshaja
Sahaja
Antarvali
More than 1 year
Upadravayukta
The patient of piles having edema on hands, feet, face, navel, anus and scrotum as
well as pain in cardiac region and sides is incurable.
27 Alva’s Ayurveda Medical College, Moodbidri
Review of Literature
UPADRAVA
Upadravas occurring due to Untreated Arshas described by various Acharyas are as follows.
According to Sushrutha- Trishna, Aruchi, Shula, excessive bleeding, Shopha & Atisara.29
Madhavakara explains Swelling in hand, feet, face, umbilical region, anus, scrotum along
with pain in flanks & cardiac region.30 Vagbhata told Udavarta, obstruction of flatus,
retension faeces, urine & pain in abdomen, flanks & chest region31.
VISHESHOPADRAVA 32
•
Vataja Arshas- Gulma, asthila, pliha, udara
•
Pittaja Arshas - Jwara, daha, pipasa, murcha are the upadravas.
•
Kaphaja Arshas – Avipaka, shopha, shita jwara, aruchi, shiro gaurava are the
upadravas.
CHIKITSA
Classical texts of Ayurveda suggest avoiding such factors, which are enumerated as
causative factors in the development of any disease. As already discussed Mandagni or poor
digestion and constipation may be regarded as principal factors. Therefore all measures
which keep the Agni improved and bowels regular would prevent development of Arshas.
Besides, other factors enumerated in the aetiology which are responsible in the causation of
Arshas should also be avoided, e.g. constipation and the person should follow Dinacharya
and Ritucharya
28 Alva’s Ayurveda Medical College, Moodbidri
Review of Literature
Ayurveda describes various measures in connection with the treatment of Arshas.
Acharya Charaka and Acharya Sushruta have mentioned four types of treatment for Arshas
viz.Bheshaja chikitsa, Kshara karma, Agni karma & Sastra karma. Charaka Samhita, a
treatise on medicine gives importance to medical treatment and has advised many recipes for
the treatment of the disease and later he advises surgical or Para surgical measures.
Acharya Sushruta has given a detailed description of all the four types of treatments
along with their indication.33 If the disease is not very chronic and the associated symptoms
are very less (Alpadosha Lingopadravani) then it can be included in the category of Bheshaja
Sadhya.
When the vitiated blood is accumulated in the pile mass and having solid round
swelling, Raktamokshana is indicated. If the pile masses are soft, reddish and slightly
protruding then it comes under the heading of Kshara Sadhya.
The pile mass having the following signs and symptoms can be treated with
Agnikarma, i.e. rough, stable and profuse. When the line of treatment is considered on the
basis of Doshas, Acharya Sushruta says that, Vataja and Kaphaja Arshas should be treated
with Ksharakarma and Agnikarma; whereas Pittaja and Raktaja Arshas should be treated
only with Mridu Ksharakarma.34
Shastrasadhya varieties should have the following characteristics like reddish, thin
rooted, protruded and having Kleda.
29 Alva’s Ayurveda Medical College, Moodbidri
Review of Literature
BHESHAJA CHIKITSA
Sushruta being basically a surgeon was also aware of the nature of Arshas as a surgical disease
and has advocated treatment for certain groups of patients with the help of medicines only.
Ayurveda beholds Arshas as local manifestation of systemic derangement of Dosha and
Agni; therefore the Bruhatryies have devoted one independent chapter on the treatment of
Arshas mostly with the help of internal medicines. Medicines were used for the treatment of
active symptoms of Arshas, for preparatory to surgical and para surgical measures and for
prevention of recurrence. Charaka has enumerated a number of medicinal preparations to be
taken regularly to prevent further progress of Arshas, and medicines to be taken during active
symptoms like bleeding, pain etc. In the end of the chapter he has described the general
properties of these medicines for internal use and dietetic regimen should be Dipana
(Appetizers), Pachana (Digestive), Anulomana (Drugs improving intestinal peristalsis),
Samshamana (Supressive of Symptoms)and Rakta Sangrahi (Haemostatic)
Acharya Charaka has mentioned the treatment of Shushkarshas and Raktarshas
separately. For the treatment of Shushkarshas, a number of measures have been mentioned
viz. Snehana, Svedana, Lepana, Dhupana, Varti, Avagahana, Raktamokshana, Basti,
Takrapana, Choorna, Arishta, medicated Ghruta, Mamsarasa etc.
In case of Raktarshas where it is Vatanubandha, should be treated with Snigdha and
Shita drugs as well as the dietetic regimens having similar qualities. Kaphanubandha
Raktarshas should be treated with Ruksha and Shita drugs along with similar dietetic
regimens.35
30 Alva’s Ayurveda Medical College, Moodbidri
Review of Literature
If the vitiation of Pitta and Kapha Doshas is more, then the patient should be
subjected to the Shodhana procedure. The bleeding in such cases may either be ignored or
treated with Langhana. In Raktarshas, if the blood is more vitiated one should not stop the
bleeding, but if the blood is not vitiated adequate measures should be done to stop the
bleeding. The bleeding due to excess of Pitta and which occurs during summer must be
invariably stopped immediately.
A good physician should ignore the bleeding so long as it is not causing an
emergency, later the patient should be treated with the help of Tikta Dravyas for the
stimulation of Jataragni, Raktasthambhana and Dosha Pachana.
In patients with Raktarshas, if Vata vitiation is more and Pitta, Kapha vitiation is less,
then administration of Snehapana, Snehabhyanga and Sneha Basti should be done.36
Bheshaja chikitsa advised by Acharya Sushruta is as follows.37
Table No:6
Disease
Measures
Vataja Arshas
Snehana, svedana, vamana virechana & vasti.
Pittaja Arshas
Virechana
Raktaja Arshas
Samshamana karma
Kaphaja Arshas
The administration of Shunti & Kulattha
Sannipataja Arshas
Uses of Tridoshaghna dravyas
31 Alva’s Ayurveda Medical College, Moodbidri
Review of Literature
All the Acharyas have stressed the use of drugs, which are Deepana, Pachana,
Anulomana and Raktasthambhaka in their action. Vagbhata give Special emphasis has on
administration of Bhallataka in Shuskarshas
38
and Kutaja Twak in Sravi Arshas39 .
Takrapana is common for both variety of Arshas.40
PARA-SURGICAL TREATMENT:
Those patients who are not relieved by medical treatment should be treated on lines of
parasurgical methods. These are Ksharakarma, Agnikarma and Raktamokshana.
Ksharakarma 41
Kshara is a Caustic chemical, alkaline in nature obtained most often from the ashes of
medicinal plants. Kshara Karma is a milder procedure compared to surgery and thermal
cautery. According to Acharya Sushruta, patients anus is smeared with ghee into which the
instrument smeared with ghee is introduced straight parallel to opening while he stains
slowly. Thus the haemorrhoids should be observed, pressed with a rod, cleaned with cotton
swab or cloth and then caustic alkali should be applied there to, after applying the surgeon
should close the opening of the instrument with hand and should wait for 100 matra kala.
Then after cleaning, considering the strength of the caustic alkali and the patient it should be
applied again. When the haemorrhoid becomes like jambu phala , shrunken and slightly bent,
the application should be stopped and the caustic alkali should be washed away with sour
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gruel or curd water, vinegar and sour fruit juice. Then after applying ghee mixed with
yashtimadhu, the instrument should be removed and the patient should get up and sit in hot
water while being sprinkled with cold water. If there is still more remnant, it should be burnt
again. In this way, each haemorrhoidd should be treated after an interval of week. In case of
multiple piles, at first, the right one should be tackled, then the left one, then the posterior
one and lastly the anterior one.
Agnikarma
Agnikarma is regarded superior to other surgical and para surgical measures because
of its capacity to destroy the diseased tissue completely and its wide applicability even in
such lesions which are incurable by other measures. Thermal cauterization is an important
para surgical measure and is still used extensively in the surgical practice in modified form
by way of electric cautery. Agnikarma is also indicated for the treatment of Arshas. Rough,
firm, thick and hard pilemass are curable by Agnikarma42 .This procedure is done with hot
Shalaka.
Raktamokshana
In addition to all such measures mentioned by Acharya Sushruta, Acharya Vagbhatta
has advised Raktamokshana to be done with the help of Jalauka, Suchi and Kurcha, in those
pile masses which are of hard consistency, elevated and when ever the vitiated blood is
accumulated in the piles.
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SURGICAL TREATMENT
The total excision of the pile mass is done, followed by the cauterization of the
bleeding points by hot Shalaka. The pile, which has narrow pedicle, projecting and moist
should be treated by Shastrakarma.43 With all the preoperative procedures, pile mass is to be
excised by incising with the help of sharp instruments such as kharapatra etc, and the excised
part is to be treated with Agnikarma. This procedure is very much similar to that of ligation
and excision procedures in present day.
The treatment of arshas can be classified as
•
Shushkarsa chikitsa
•
Ardra or sravi arsha chikitsa
SHUSHKARSA CHIKITSA
Abhyanga – It is done with oil prepared from chitraka, vilwa and yavakshara.44
Swedana – indicated in pain, swelling and stiffness
It can be done in two ways
Pinda sweda – It is done with a pottali of yava, masha and kulatha. It can also be
done with thila, thusha,vacha,sathahwa or with leaves of sigru,eranda,vasa,arka etc.45
Avagaha sweda – It is done with gomuthra or dhanyamla or thakra or decoction of
leaves of thriphala, moolaka,venu and varuna.46
Dhoopana – Done with drugs like (i) dhanyaka, vidanga,devadaru mixed with ghee
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(ii) Vasa of black cobra, camel etc.47
Varthi – It is made out of dhanyamla and jeemootha beeja.
Pralepana – Done with (i) milk of sudha mixed with turmeric powder (ii) powder of
Pippali and turmeric prepared as a paste in cows urine (iii) sap of arka, stem of sudha,
Katukalabu pallava, karanja and goat’s urine.48
These drugs are used in case of induration, oedema, itching and pain.
Rakthamoksha – If the disease is not responding to any of the measures, the disease
may be due to vitiated blood. So rakthamoksha can be done by the application of
leeches, sasthras, needles etc.49 It is indicated in hard and indurated pile mass also.
Anuvasana vasthi – It can be done by using pippalyadi vasthi thaila.50 It is done in arshas
patient who is suffering from misperistalsis who is extremely dehydrated and in whom
vathagathi is reversed and those who suffers from colicky pain.
Nirooha vasthi – It can be done with dasamoola kwatha, milk, cow’s urine, sneha
dravya, saindhava, madanaphala, etc51 .
Ksharasoothra – Firm thread having been impregnated with haridra powder and snuhi
several times cuts the arshas52 .
SRAVI ARSHA CHIKITSA
It is pitta dominant. Hence ahara and vihara which will increase pitta and raktha
should be avoided. Charaka says if blood flow is immediately stopped it will result in udara.
So this bleeding should be ignored till it does not cause any emergency related to nidana,
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lakshana, kala, and prakruthi. Later thikta rasa kashaya can acheive haemostasis as well as
agni vridhy and doshapachana.
The treatment of raktharshas differs according to doshanubandha.
Vatanubandha – The oushada and ahara should be snigdha and seetha.
Kaphanubandha- It should be treated with rooksha and seetha.
In raktharshas, if predominance of pitta and kapha is there , the patient should be
subjected to sodhana process.
Prashamana therapy53
1. Kutaja rasakriya
2. Decoction of dadima with shunti
3. Decoction of kutaja with shunti
4. chandana with shunti
Parishechanam54
It is done with kashaya of sthambaneeya dravyas. Kashaya of madhuka,
pancavalkala, badara, udumbara,dhava and patola can be used .
Avagaha55
It is done with kashaya of madhuka, mrnala, chandana, pathmaka, kasa and kusha.
Vasthi56
Pichavasthi can be given with ghee, honey and sugar. It is indicated in pravahika,
Gudabhramsa, rakthasrava and in jwara.
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Pathya57
• Grains of Shali and shashtika
• Godhumanna
• Grains like vasthuka, thaduliya, jeevanthi, kalaya
• Sarpi as a anupana
• Food which improves agni
• Paya
• Decoction of Nimba
• Decoction of Patol
Apathyas58
•
Vegavarodham
•
Maithuna
•
Yanam
•
Utkutasan
•
Doshalanna
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38 Alva’s Ayurveda Medical College, Moodbidri
Materials and methods
MATERIALS AND METHODS
SOURCE OF DATA:
Patients were selected from the outpatient and inpatient departments of P.G. studies
in Shalya Tantra of Alva’s Ayurveda Medical College Hospital, Moodbidri, Karnataka.
METHOD OF COLLECTION OF DATA
Out of 36 diagnosed patients of Arshas (haemorrhoids), 30 patients were screened
and selected irrespective of sex, religion, occupation and socio economic status for this
study.
a) Procedure of administration of drug
Internal administration of 50ml of Chirabilvadikwatha was given twice daily
before food.
b) Observation period
Duration – 1month
During the course of treatment, patients were assessed at an interval of seven days
about the clinical signs and symptoms.
c) Inclusion criteria
• Patients between the age group of 20-60 years.
• Haemorrhoids of any degree
d)Exclusion Criteria
•
Haemorrhoids associated with fissure/ fistula.
•
Thrombosed, strangulated ,and infected haemorrhoids
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•
Haemorrhoids secondary to systemic diseases like Crohn’s disease,
Ulcerative colitis, Carcinoma of Rectum etc.
•
Pregnancy, Diabetes mellitus, Hypertension.
•
Patients suffering from severe anemia (less than 8 gm/ 100ml)
•
Suffering from disorders like prolonged bleeding time and clotting time.
e) Diagnostic Criteria
o Bleeding
o Mucous discharge
o Pruritus ani
o Prolapse of haemorrhoids
o Anaemia
o Proctoscopic examination
f) Assessment criteria
Patient’s response were based on subjective and objective parameters.
Subjective
Grading was done on the basis of presentation by the patient.
1. Bleeding
Table No:11
Bleeding
Grading
Absent
0
Mild
1
Moderate
2
Profuse
3
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Absent - No bleeding
Mild Bleeding – Bleeding in drops while defaecation occurring once or twice a
week.
Moderate Bleeding – Bleeding in drops while defaecation continuous for 7 to 10
days.
Profuse Bleeding – Bleeding in streams or drops while defaecation continuous for
more than 10 days.
2. Mucous discharge
Table No:12
Mucous discharge
Grading
Absent
0
Mild
1
Moderate
2
Severe
3
Grading was done according to the description given by the patient
Absent- No mucous discharge
Mild - Occasional mucous discharge.
Moderate-Frequent mucous discharge
Severe- Continuous mucous discharge
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3. Itching
Table No:13
Itching
Grading
Absent
0
Mild
1
Moderate
2
Severe
3
Absent-No Itching
Mild- Occasional Itching
Moderate- Frequent Itching
Severe – Regular Itching
4. Prolapse
1st degree – Haemorrhoidal mass does not come out of the anus while defeacation
2nd degree – Haemorrhoidal mass come out only during defaecation and is
reduced spontaneously after defeacation.
3rd degree – Haemorroidal mass come out during defecation and need to be
replaced manually, and then stay reduced.
4th degree - The haemorrhoidal mass that are permanently prolapsed.
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Table No:14
Prolapse
Grading
No prolapse
0
1st degree
1
2nd degree
2
3rd degree
3
4th degree
4
Objective criteria
1) External masses on examination- position, number and size.
2.) Proctoscopic examination-position, number, size and bleeding points.
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MODERN REVIEW
HAEMORRHOIDS
Just like swallowing, the evacuation of feces and urine is also pleasure of life.
Many people are disturbed if they do not have clear motion in the morning. Nearly one
third of the population suffers from anal diseases. Haemorrhoids is a common anal
disease.
DERIVATION59
The term haemorrhoids has derived from the Greek words like haema means
blood and rhoos means flowing so Haemorrhoids means blood to ooze.
The term piles is coined from the Latin word pila which means ball or mass
Thus the word haemorrhoid emphasizes bleeding where as the word piles denotes the
swelling.
SYNONYMS
The synonyms which are mentioned for the disease haemorrhoids are as follows
1. Piles: This is derived from ‘pila’ means ball like mass, present in the anal region.
2. Figs: This is a Latin word, derived from ‘Fig’ or ‘growth’.
3. Golden veins: This word enumerates the importance of disease in terms of its
pathophysiological conditions and also throws light on surgeon, how these “pathological
vein” earn Gold to surgeons.
HISTORICAL ASPECT
Hippocrates (460 BC):
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He considered piles are vascular tumors of rectal mucosa and first to practise excision on
Haemorrhoids,
Galen (131 – 200 AD);
Ligation therapy in internal piles.
John Arderene (1370):
First English surgeon who mentioned, common people call them as piles. Aristocrats call
them as Haemorrhoids and French call them as figs.
Petit (1774 AD):
Suggested submucosal haemorrhoidectomy.
Cusack (1846):
Explained excision of piles with clamp and cautery.
Morgan of Dublin (1869 AD):
First person to practise sclerotherapy.
Mitchell Clinton (1871):
First mentioned injections in pile masses by using carbolic acid.
Gabriel (1948):
Complications of sclerosing agents like necrosis, submucosal abscess.
John Barron (1962) :
First person introduced rubber band ligation.
Fraser and Gill (1967):
Invented cryosurgery in internal piles.
Lord (1968):
Described manual anal dilation for internal piles.
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ANATOMY OF ANAL CANAL.
Anal canal is a tubular structure which is the terminal portion of the intestinal tract. It
begins at the ano-rectal junction, is 3-4 cms in length and terminates at the anal verge.
The surgical anal canal extends from the anal verge to the anorectal ring.
Anal canal passes downwards and backwards from the perineal flexure. It has greatest
surgical importance both, because of its role in the mechanism of rectal continence and
because it is prone to certain diseases. In normal living subject, the anal canal is
completely collapsed owing to the tonic contraction of the anal sphincter, and the anal
orifice is represented by an antero-posterior slit in the anal skin.
Relations
Both sexes
Table No:7
Anterior
Posterior
Lateral
Perineal body
Anococcygeal
Ischiorectal fossa
ligament
Males
Membranous urethra
Tip of the coccyx
bulb of penis
Females
Lower end of vagina
Tip of the coccyx
Interior of the anal canal 60
This can be divided into 3 parts.
Upper part:
It extends from ano rectal ring to the pectinate line and about 15 mm long. It is lined by
columnar epithelium. The mucous membrane shows anal columns of Morgagni, anal
valves, anal sinuses, anal papillae, and pectinate line. Anal glands are 4 – 8 in number
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and each has a direct opening into apex of anal crypt and occasionally two glands open
into same crypt.
Middle part:
It lies between the pectinate line above and white line of Hilton below and is about 15
mm long. This part of anal canal is lined by a stratified squamous epithelium which is
thin and glossy and is devoid of sweat glands. The Hilton`s line is situated at the level of
interval below the subcutaneous part of the anal sphincter and the lower border of internal
anal sphincter. On digital examination in living subject an anal inter-sphincteric groove
can be felt at this site.
Lower part:
It is about 8 mm long and is lined by true skin containing the sweat and sebaceous glands.
Goligher described the lining of the anal canal as mucous in the upper part and cutaneous
in the lower part. Junction of these 2 parts is marked by dentate line or pectinate line,
situated 2 cms from anal orifice. It also marks the junction of posterior allentoic and
endoderm. One can recognize the dentate line, which is important, both morphologically
and surgically. It divides anal canal as follows.
Above: Cubical epithelium. Autonomic nervous system and portal venous system.
Below: Squamous epithelium. Spinal nerves and systemic venous system.
Above this line mucous membrane is thrown into 8 – 12 vertical folds known as
Morgagni. Each column is connected by anal wall below the pectinate line. Each column
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contains terminal radical of superior rectal artery and vein. These radicals being largest at
left lateral 3
o
clock , right anterior 7
o
clock and right posterior 11o clock quadrants of
wall of anal canal. Enlargement of venous radicals at these three sites constitutes primary
haemorrhoides.
Ano-rectal ring61: This term was coined by Milligan and Morghan to denote the
functionally important ring of the muscle, which surrounds the junction of the rectum and
anal canal. This is composed of the upper borders of the internal and external sphincters,
which completely encircles the junction and on the posterior and lateral aspects, by the
strong puborectalis sling. As a consequence, the ring is stronger posteriorly and laterally
than it is anteriorly and its definition on the posterior aspect is accentuated by the forward
angulations of the bowel at this level. Recognition of the ano-rectal ring is of great
importance in the treatment of abscess and fistula in the anal region, for its complete
division inevitably results in rectal incontinence, while its preservation, despite the
sacrifice of all the rest of sphincter musculature at least ensures that there will be no gross
lack of control, though minor degree of incontinence may result.
MUSCULATURE OF THE ANAL CANAL62
Anal sphincter:
Internal sphincter:
It is formed by the thickened 5-8 mm circular muscle coat and is involuntary in nature. It
lies above the subcutaneous part and deep to the superficial and deep parts of external
sphincter and ends below at the white line of Hilton.
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External sphincter:
It is made up of striated muscles and is under voluntary control. It surrounds the whole
length of anal canal and constitutes of 3 parts.
Subcutaneous part: This encircles the lower end of the anal canal and has no bony
attachments.
Superficial part: This is attached to the coccyx behind and the perennial body in front.
Deep part: This surrounds the upper part of internal sphincter and is fused with the
puborectalis.
BLOOD SUPPLY OF RECTUM AND ANAL CANAL 63
Arterial supply of rectum and anal canal:
Superior rectal artery: it is continuation of inferior mesenteric artery. The left and right
branches of superior rectal artery supply the upper and middle rectum.
Middle rectal artery: it arises at anterior division of iliac artery and supply the lower
part of the rectum and upper part of the anal canal.
Inferior rectal artery: it supplies external and internal sphincters below the pectinate
line.
Median sacral artery: it supplies to the posterior wall of the ano rectal and anal canal.
Venous supply of rectum and anal canal:
Superior rectal veins: the upper and middle rectum are drained by superior rectal veins
which enter the portal system via inferior mesenteric vein.
Middle rectal vein: drains the lower rectum and upper anal canal, which open into the
internal iliac veins and then into inferior venacava.
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Inferior rectal veins: it begins from the external rectal plexus and drains the lower part
of anal canal.
Internal rectal venous plexus ( haemorrhoidal plexus)
It lies in the submucosa of anal canal and drains mainly into the superior rectal veins, but
communicate freely with the external plexus and thus with middle and inferior rectal
veins.
Anal veins : These are arranged radially around the anal margin. They communicate with
the internal rectal plexus and inferior rectal veins.
LYMPHATIC SUPPLY OF ANAL CANAL:
Lymphatics from more than the upper half of rectum pass along the superior rectal
vessels to the inferior mesenteric nodes. Lymphatics from the lower half of the rectum
pass along the middle rectal vessels to the internal iliac nodes. Above the pectinate line,
the lymphatics drain with those of the rectum into the internal iliac nodes. Below the
pectinate line, the Lymphatics drain into the median group of superficial inguinal nodes.
NERVE SUPPLY OF THE RECTUM AND ANAL CANAL64
The rectum is supplied by both, sympathetic (L1, L2) and para sympathetic (S2, S3, S4)
nerves through superior rectal and inferior hypogastric plexus.
Above the pectinate line:
The anal canal is supplied by autonomic nerves and both sympathetic (inferior
hypogastric plexus L1, L2) and parasympathetic (pelvic splanchnic S2, S3, S4).
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Below the pectinate line:
It is supplied by somatic (inferior rectal S3, 4) nerves.
Anal sphincters:
The internal sphincter contracts by sympathetic nerves and relaxes by the
parasympathetic nerves. The inferior rectal and perineal branch of 4th sacral nerve
supplies external sphincter.
Physiology of defaecation
Act of emptying the contents of colon from splenic flexure through anal orifice is
defaecation. This act is initiated by increasing the intra luminal pressure in rectum. The
pressure receptor present in the rectum can differentiate the pressure due to gas, liquid or
solid. The reflex center is at hypothalamus, lower lumbar and upper sacral segment.
The faecal matter is stored in sigmoid and pelvic colon, not in rectum. The urge
for defaecation develops as soon as faecal matter reaches rectum due to mass peristaslsis.
In addition, the reflex of appropriate posture, voluntary relaxation to external sphincter
and abdominal compression adds to the mechanism of defaecation.
SURGICAL PHYSIOLOGY OF ANAL MUSCLE AND PELVIC FLOOR65
Function of anal canal and pelvic muscle is not only to contain the content of rectum, but
to allow unimpeded voiding at defaecation. Interference with the integrity of anatomy
and physiology of muscles of anus and pelvic floor can lead to extreme of intractable
constipation or incontinence. Puborectalis fails to relax approximately then obstructed
defaecation ensues, which may over come by excessive voluntary straining. Excessive
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voluntary straining may lead to rectal prolapse.
DEFINITION OF HAEMORRHOIDS:
Haemorrhoids or piles are dilated veins within anal canal in the sub epithelial region
formed by radicles of superior, middle and inferior rectal veins.
Incidence
Recent statistics reveals that irrespective of age, sex, socio-economic status, people suffer
from haemorrhoids.
ETIOLOGY66,67
Primary or Idiopathic causes: Hereditary factors
Evidence suggests that there may be familial tendency. It is seen in the members
of the same family, due to congenital weakness or absence of vein valves, abnormally
large arterial supply to rectal plexus and congenital dilatation of capillary plexus.
Anatomical factors
It has long been suggested that internal pile is natural consequence of adaptation of erect
posture by mankind. Absence of valves in superior haemorrhoidal veins and Radicles of
superior haemorrhoidal veins remain unsupported in very loose submucous connective
tissue of anorectum are subjected to constriction by the muscular tissue while defaecation
and it may lead to haemorrhoids.
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Exciting causes
Straining accompanying constipation & dysentery results in engorgement of
internal haemorrhoidal plexus. In both instances, descent & swelling of anal cushion is a
prominent feature. In addition, faulty habit of defaecation is equally responsible where a
person has to strain more than in regular squatting posture. Further dietary habits
containing less of cereal fibers leads to considerable delay in the faecal transit, which
results in chronic constipation & ultimately haemorrhoids. Once dilatation of the venous
plexus as well as partial prolapse would occur with each bowel movement it would
stretch the mucosal suspensory ligament. Over purgation and diarrhoea due to
colitis,dysentery,enteritis etc. aggravate latent haemorrhoids.
Morphological causes
In humans, weight of column of blood unsupported by the valves produces a high
venous pressure to lower rectum which leads to haemorrhoids. In quadrupeds, the venous
return from the rectum is not affected by the gravity. So, haemorrhoids is extremely rare
in animals.
Diet
Low roughage diet may excite haemorrhoid formation whereas adding bulk or bulk
forming compound can prevent haemorrhoid formation.
Sedentary habits
Prolonged standing and sitting increase the rectal pressure thereby precipitate
piles.
Secondary causes for haemorrhoids :-
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Haemorrhoids may be secondary to few conditions, which must be excluded before the
treatment is decided.
Chronic constipation
The common reason for haemorrhoids to develop is due to chronic constipation,
passing of hard stools and straining during defaecation as a result of which there will be
increased pressure on rectal veins, which precipitates pile formation.
Other factors
Sitting on hard seat, excessive vehicle riding, and loss of muscle tone in old age,
obesity, rectal surgery, episiotomy, anal intercourse etc.
Pregnancy
Due to pressure effects on the body and the hormone effects on the veins. It
compresses superior rectal veins and also causes secondary laxity of smooth muscles of
the veins. Uterine tumors may similarly compress the superior rectal vein.
Abdominal tumors
It may exert pressure in a similar way as in pregnancy.
Ca of the rectum
It compresses on the superior rectal veins and gives rise to piles.
Straining during micturition
Enlarged prostate or urethral strictures will cause rise in intra abdominal pressure
and will raise the venous pressure in the superior rectal veins to cause the piles.
Portal obstruction
Superior rectal veins are one of the tributaries of portal venous system. Portal
hypertension with hepatomegaly leads to formation of piles.
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PATHOGENESIS68,69
Hemorrhoids have long been considered to be varicosities of the haemorrhoidal veins.
However, their nature is more complex. Current theories of the development of
hemorrhoids consider the nature of “anal Cushions’. Such cushions are aggregations of
blood vessels, (arterioles, venules and arterio -venular communications), smooth muscles
& elastic connective tissue in the submucosa, that resides in the anal canal.Smaller
discrete secondary cushions may reside between the main cushions.
Hemorrhoids are likely as a result of sliding downwards of these anal cushions. It appears
that anchoring and supporting connective tissue above the haemorrhoids disintegrates,
thereby allowing these structures to slide distally.
Internal haemorrhoids are divided into three parts
a) Pedicle
Each internal haemorrhoid has a pedicle in the rectum just above the anorectel ring. The
pedicle is covered with pale pink mucosa and through it a large tributary of the superior
rectal vein can be seen. Occasionally a pulsating artery may be felt at the pedicle.
b) Body of the internal haemorrhoids After the pedicle, the body of internal haemorrhoid
continues distally and ends at the dentate line. The body is covered by bright red or
purple mucous membrane.
c) Associated external haemorrhoids
Associated external hemorrhoids contains main terminal divisions of superior rectal
artery and vein. There are three main terminal divisions of such superior rectal vessels
arranged in the left lateral right anterior and right posterior positions. In lithotomy
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position these correspond with the 3, 7, and 11 O’ clock positions.
Goligher states that except in the early stage of internal haemorrhoids, the subcutaneous
or external haemorrhoidal venous plexus of the corresponding segment of the anal canal
also participate in the varicose process.Therefore, the internal haemorrhoid is really often
more accurately an interno-external pile. Whatever may be the cause but vascular stasis
seems most important factor in its development.
Boyd’s described morbid anatomy of a common and characteristic variety of piles
consisting of a much dilated venules to which passes an artery, a terminal branch of the
superior haemorrhoidal artery. This clump of vessels forms an elongated mass which lies
in one of the column of Morgagni. Secondary changes like fibrosis of surrounding tissue
due to irritation and occurrence of infection with the production of periphlebitis and often
phlebitis and thrombosis are important. The thrombosis may result in fibrosis with
obliteration of the haemorrhoid or if the thrombus is septic and becomes loosened, septic
emboli may be setup in liver.
The patient may get periodic attacks of phlebitis and periphlebitis which tend to be selfcurative owing to the occurrence of thrombosis.
Thompson states that the anal mucosa of long standing prolapsed haemorrhoid may
undergo a squamous metaplasia. Recurrent attacks of thrombosis followed by fibrosis of
the clot results finally in the formation of a fibrous polyp.
Lord (1969) believes that haemorrhoids constitute a reversible condition and that they are
caused by a narrowing of the lower rectum and/or anal canal. The narrowing interferes with
the normal process of defaecation and leads to an abnormal raising of the intrarectal pressure
during the act causing venous congestion and hence haemorrhoids. He has quoted pectin
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bands also, one of the constriction or bands in the lower rectum and anal canal. He was able
to detect such circular constriction in an anaesthetized patient if one or two fingers of both
hands were inserted.
CLASSIFICATION OF HAEMORRHOIDS
According to site of origin70
1. Internal haemorrhoids - it is within anal canal and internal to anal orifice. It is
covered with mucous membrane and is bright red or purple in colour. It usually commences
at the anorectal ring and ends at dentate line.
2. External haemorrhoids - it is situated outside the anal orifice and is covered by skin.
3. Intero external haemorrhoids- when above both varities coexists the condition is
called intero external haemorrhoids.
According to pathological anatomy: 1. Primary haemorrhoids : located at 3, 7, 11 O’ clock positions related to the branches
of superior haemorrhoidal vessel which divides on the right side into two, left side it
continues as one.
2. Secondary haemorrhoids: one which occurs between the primary sites.
According to prolapse71
¾ 1st degree. haemorrhoids: it does not come out
of the anus during
defaecation.
¾ 2nd degree haemorrhoids: it comes out only during defaecation and is
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reduced spontaneously after defaecation.
¾ 3rd degree haemorrhoids: it comes out only during defaecation and do not
return by itself.
¾ 4th degree haemorrhoids: these are permanently prolapsed.
Vascular haemorrhoids
Here, vessels are involved significantly.
Mucosal haemorrhoids
In this variety thickened mucous membrane slides downwards. This mucosal
haemorrhoides along with the prolonged dilated component may cause 3rd degree or
prolapsed haemorrhoids.
Arterial pile
It is haemangiomatous condition of superior rectal artery entering the pedicle of internal
haemorrhoid which will bleed profusely.
CLINICAL FEATURES
Gabriel (1938) described progressive bleeding and prolapse as chief symptoms. Third
degree piles often produce mucoid discharge and irritation, slight faecal incontinence and
bleeding into the clothing apart from defaecation. He further stated that pain is not
prominent but may be produced by thrombosis or by the onset of infection and abscess
formation. Bailey and Love and Thompson regard presence of pain only when
complication supervenes. Thompson observed bleeding during defaecation as the first
symptom. Goligher and few other surgical text books have included secondary anaemia
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and its symptoms (e.g. breathlessness on exertion, dizziness on standing, lethargy, pallor
etc) also in the symptomatology.
Mac Intyre (1972) noted bleeding in 85%, prolapse in 87% pain and discomfort in 54%
and pruritus in 50% in his 66 cases of haemorrhoids.
Bennet et al (1963) in the analysis of symptoms in 138 cases found bleeding in 119,
prolapse in 114, pain in 106, discomfort in 13, discharge in 31, pruritus in 63 patients.
Walls (1976) recorded frequency of symptoms in 100 cases as bleeding 86, prolapse 85,
pain/discomfort 50, and pruritus in 52 patients.
Bleeding72: However, as is evident from the etymology of the word ‘haemorrhoid’,
bleeding seems the principal and earliest symptom of internal haemorrhoids recognized
by all the authors on this subject. Buie Stated that “… if blood comes from haemorrhoids
(with the exception of that which comes from haemorrhoids of the ruptured thrombosed
external type) it is almost always associated with haemorrhoids of the internal variety,
moreover, it is usually bright red, unmixed with stool, may occur before, in the course of,
or after defaecation and may be expelled in large or small quantities.”
Nesselrod observed that amount of bleeding is not necessarily proportional to the
haemorrhoidal tissue present.
Prolapse73: A first degree internal pile bleeds only but does not prolapse. In the course of
their development, they attain sufficient size to be displaced distally through the anal
canal, at the time of defaecation. Initially it appears at the orifice during expulsive
movement and slips back automatically. Later, they tend to remain prolapsed and require
digital displacement. At a still later stage slight exertion such as coughing, lifting may
cause prolapse of the internal haemorrhoids. Further progression results into constant
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prolapse of a part, or all of the haemorrhoidal mass outside the anus all the time. It can be
reduced digitally but the sphincteric musculature is unable to restrain it.
Thompson (1975) does not believe in progression of first degree pile to third
degree and calls its description in degrees a misleading label.
Discharge: Mucoid discharge as a frequent accompaniment of prolapsed piles has been
described in many text books.
Pruritis ani: Soiling of underclothes and pruritis would almost certainly follow this
discharge
Pain: In simple internal haemorrhoids pain is absent. Pain would follow only when there
are acute complications like thrombosis etc, where a portion of external haemorrhoidal
plexus lying below dentate line is also involved by inflammatory process or some other
acute anal lesion is present e.g anal fissure, abscess etc. Nesselrod states that pain is
directly proportional to the amount of tension of the overlying anal skin. Bennet et. al
(1963) reported some degree of pain present in 86% of his 138 cases and 18% of his
cases had pain as main complaint.
Anaemia: Goligher attributes bleeding from internal haemorrhoids, next to excessive
menstrual loss, to be the commonest cause of secondary anaemia. Boyd believes it as the
most important symptom. If the bleeding continues for a longer period it may lead to
profound anaemia and may not be guessed properly because actual blood lost at one time
may be comparatively slight.
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Specific features according to type of piles:
External haemorrhoids:Symptoms:
It may cause minimal discomfort to severe pain if they are thrombosed. The pain
of thrombosed haemorrhoids usually peaks 48 -72 hrs after the onset and is self limited to
7 – 10 days period of symptoms. Bleeding may occur if the clot erodes through the skin.
This may be infrequent and is often evident on underwears.
Signs:Bluish, soft bulging vessels covered by skin may be seen.
Skin tags are very common and should not be confused with external
haemorrhoids as they do not contain dilated blood vessels.
Internal Haemorrhoids:
Symptoms:- Bleeding -
at first bleeding is slight, bright red and occurs during
defecation .
Prolapse – later symptom.
Discharge – it is frequent accompaniment of prolapsed haemorrhoids. Pruritis will almost
certainly follow this discharge.
Signs:The perineum may appear normal if there is a non-prolapsed internal
haemorrhoid. The perineum may be macerated from chronic mucous discharge causing
local irritation. Proctoscopy may reveal tissue with evidence of chronic venous dilatation,
friability, mobility and squamous metaplasia.
Bluish, soft bulging vessels covered by mucosa may be seen on examination if
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internal haemorrhoids have prolapsed.
DIAGNOSIS
A thorough evaluation and proper diagnosis is important in bleeding from the rectum or
blood mixed with the stools.Examination begins with inspection and examination of the
entire perianal area.Anal fissures and perianal dermatitis are easily visible without
internal probing. Normal corrugation of the anoderm and a normal anal wink with
stimulation confirm intact sensation. Swollen blood vessel indicates haemorrhoids.
External piles can be seen directly on the anal margin. The internal haemorrhoids may be
seen during straining by the patient in second and third degree piles. In 4th degree
prolapsed piles can be seen in 3, 7, and 11 O’ clock positions.
Digital examination:Digital examination of the anal canal can identify any indurated or ulcerated
areas. As internal haemorrhoids are soft vascular structures, they are usually not palpable
unless local tissue induration has occurred due to episode of thrombosis.
Proctoscopy: A hollow, lighted tube, known as a proctoscope is used to look for internal haemorrhoids
and examine the lining of the rectum. Lubricated proctoscope has to be introduced fully
with prior intimation to the patient. The obturator is then removed and with an
illuminator the inside of the anal canal visualized. Then the proctoscope is slowly
withdrawn and pile mass will be seen bulging into the lumen just below the anorectal
ring. The position, number, degree of piles and bleeding can be assessed.
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Sigmoidoscopy: To rule out causes of gastro intestinal bleeding above the rectum, the doctor may
examine the rectum and lower colon (Sigmoid) with a rigid or flexible tube known as a
sigmoidoscope.
Colonoscopy and Barium enema:These procedures are reserved for cases of bleeding without an identified anal
source. Precaution in every case for suspicion of colonic disorders. The entire colon can
be examined with a flexible colonoscope, but this examination can only be done in a fully
equipped hospital after prior preparation to empty the bowel.
DIFFERENTIAL DIAGNOSIS
External Haemorrhoids: Anal epithelioma: It is a rare condition, a swelling is firm, nodular and characterized by pebbled
appearance, and biopsy confirms the diagnosis.
Condyloma acuminata:These lesions are multiple and characterized by cauliflower like appearance,
secretes excess mucus with irritation and unpleasant odour.
Condyloma latum: It is secondary lesion of syphilis. It appears as a small, flat topped, wart like
perianal growth. Serological test and dark field study are essential for diagnosis.
Sentinel tags:A sentinel tag is so called because it guards the distal margin of the anal fissure
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generally situated in 6 O’ clock position and always accompanies fissure in ano.
Internal Haemorrhoids: Pedunculated polyps: It arises from rectal mucosa and is painless.
Sessile and adenomatous polyps: These are true carcinomas and easily palpated. Biopsy confirms the diagnosis.
Hypertrophied anal papillae: A firm mass, arising from a pedicle in dentate line.
Haemangioma and lymphosarcoma:In both conditions the mucous is coarsely pebbled, but intact. Easily traumatized,
involvement does not confirm the zone of internal haemorrhoids.
Carcinoma of the rectum:It is disease of old age, present with bleeding per rectum. The growth appears
indurated ulcer with everted edges. A biopsy is taken to prove the diagnosis.
Rectal prolapse: Partial prolapse affects either a part or a circumference of anal outlet. The
prolapsed portion is composed of longitudinal folds (from center to periphery) complete
rectal prolapse is characterized by concentrically arranged mucosal folds.
COMPLICATIONS 74
1. Bleeding: is the main symptom of haemorrhoid particularly in the 1st degree and early
stage of 2nd degree. A patient with 1st degree
haemorrhoid for a quite long time will
become anaemic. Bleeding usually occur externally. Only when a bleeding haemorrhoid
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is retracted, it may bleed internally into the rectum.
2. Thrombosis: external anal thrombosis is common and is often seen in patients who
have no other stigmata of haemorrhoids. The patient notices an acute swelling at anal
verge which is extremely painful. This possibly occurs due to high venous pressure
during excessive straining efforts.
Thrombosis of internal haemorrhoid is comparatively rare. The affected haemorrhoid
becomes dark purple or black and feel hard. The anal margin becomes oedematous and
there is severe anal pain. Pain may continue for a week or so until the oedema subsides
and the thrombosis is absorbed.
3. Strangulation: When the internal haemorrhoid prolapses and becomes griped by the
external sphincter, further congestion occurs as a venous return becomes impeded and
strangulation occurs. Strangulation is associated with considerable pain and it is called
‘acute attack of piles’, unless the internal haemorrhoid is reduced immediately
strangulation is followed by thrombosis.
4. Gangrene : Only occurs when the arterial supply of haemorrhoid is somehow or other
constricted. Sloughing occurs which is usually superficial but occasionally the whole
haemorrhoid may slough off leaving an ulcer which gradually heals by itself.
Occasionally massive gangrene may initiate spreading infection and portal pyaemia.
5. Fibrosis: Usually follows thrombosis of internal haemorrhoid. Fibrosis also follows
transient strangulation. Fibrosis of external haemorrhoid is more common and in
beginning and is sessile, but by repeated traction during defaecation it becomes
pedunculated.
6. Suppuration: It is very rare and only occurs as a result of infection of thrombosed
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haemorrhoid. Throbbing pain with a perianal swelling is a feature. Perianal or submucous
abscess may follow.
7. Pylephlebitis: With the advent of antibiotics this has considerably been reduced. This
usually follows infection and suppuration of the haemorrhoid, which ultimately causes
portal pyaemia and liver abscess.
8. Ulceration : the exposed mucous membrane of the thrombosed haemorrhoidal mass
may ulcerate.
Decision about Haemorrhoids:
All other cases should be excluded by a careful history and examination. If
symptoms are minor and do not interfere with daily activities, conservative treatment
such as dietary modifications and symptomatic relief may be suitable. If symptoms are
severe, particularly profuse bleeding, extreme pain or severely affected daily living, then
secondary surgical therapies are necessary. If symptoms develop during pregnancy, they
should resolve after delivery, but conservative measures are appropriate in the interim.
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Table No:8
Management of the Haemorrhoids:
Preventive
Medical
Curative
Non
operative
/
para Operative
surgical
Warm sitz bath
Sclerotherapy
Open haemorrhoidectomy.
Topical anesthesia
Rubber band ligation
Closed
haemorrhoidectomy.
Analgesics
Cryosurgery
Submucous
haemorrhoidectomy.
Laxatives
Lords anal dilation
Stapled
haemorrhoidectomy.
Anti inflammatory drugs
Bipolar diathermy
Protectants
Laser therapy
Vasoconstrictors
Infrared photocoagulation
Antiseptics
Ultroid
Suppositories
DGHAL
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Treatment option75
Table No:9
CONDITION
SIGNS AND SYMPTOMS
First degree
Painless bleeding
Second degree
Third degree
Fourth degree
Prolapsed,
strangulated
haemorrhoids
Thrombosed
external
haemorrhoids
MANAGEMENT
Exclusion of other causes of
bleeding, diet, rubber band ligation,
infrared coagulation, bipolar electro
coagulation, sclerotherapy, DGHAL.
Protrusion on defaecation Rubber band ligation, infrared
with spontaneous reduction, coagulation, sclerotherapy, DGHAL.
bleeding.
Protrusion spontaneous or
with
bowel
movement,
requiring manual reduction,
bleeding.
Permanently
prolapsed,
irreducible, bleeding,
Rubber band ligation, infrared
coagulation,
bipolar
electro
coagulation, haemorrhoidectomy.
Haemorrhoidectomy,
Painful, oedematous, tender, Emergency haemorrhoidectomy.
unreducible mass.
If painful
Excision
In the treatment of haemorrhoids there is gradual increase in management modality
according to degree or severity of haemorrhoids,as it goes from conservative treatment to
surgical excision of haemorrhoids. Treatment of haemorrhoids should start with bowel
regulation which has a prophylactic effect
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Non – Surgical treatment
Bowel Regulation is vital and has a prophylactive effect. Many haemorrhoidal symptoms
can be relieved by avoiding excessive defaecation straining.
High residue diet with raw vegetables, fruits, whole grain cereals and mild laxative are
given for regulation of bowel movements, and can reduce all symptoms.
Topical ointments for local application may do well by reducing oedema and pruritis.
High fiber diet, stool softeners, avoid straining during defaecation, avoid heavy lifting are
important factors.
Warm sitz bath twice daily and lubrication with glycerin suppositories may help to
reduce symptoms.
1. Injection Therapy : (Sclerosant Injection)
- Used in 1st degree and small 2nd degree haemorrhoids.
- Albright solution i.e. 5% phenol in almond oil with 140 mg of menthol to make
30 ml solution.
-3 ml is given just above the mass of haemorrhoides,in to the submucosa. So it will
spread upwards to the pedicle and downwards to the pile mass.
Injection should produce elevation and pallor of the mucosa. This solution is injected
into the submucosa around the pedicle of the haemorrhoid with two object in view.
Firstly to produce a chemical thrombosis in the internal haemorrhoidal plexus and
secondly to produce a fibrous reaction in the submucous layer which will fix the loose
redundant mucous membrane to the inner muscle layer and draw up the pile so that it no
longer prolapses or is grasped by the sphincters.
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2. Rubber band ligation:
Rubber banding (Barron banding) is an ideal method of treatment of treating large first
degree and second degree internal haemorrhoids in absence of associated tags or external
haemorrhoidal component.
The upper part of mucocutaneous line is grasped by an instrument and small elastic band
slipped over it. The tissue distal to the elastic band undergoes necrosis and excess mucosa
in the anal canal is removed.
Care must be taken to insert the band so that it occludes the base of haemorrhoid at least
1 cm above the dentate line. 2 bands are simultaneously inserted over each haemorrhoid
as this reduces the risk of secondary haemorrhage.
The main disadvantage is, this procedure is associated with pain which is more or less
always experienced for the first 24 to 48 hrs.Sometimes pain is very severe.Secondary
haemorrhage is another problem.The patients with bleeding diathesis or with portal
hypertension are not
good – candidates for ligation.
3. Cryosurgery:
Cryotherapy involves freezing in the tissues of the haemorrhoid for a sufficient time to
cause necrosis.
Cryosurgical probe using liquid nitrogen at a temperature – 196o c according to Bailey
and love, -160o c according to Das is used at the pedicle of the haemorrhoid for 3 minutes
each.
If carefully used and applied only to the upper part of the haemorrhoidal area at anorectal
junction, it achieves similar results to elastic band ligation.
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Advantage:
Procedure is completely without pain.
Disadvantage:
Profuse watery discharge which starts within 3 hours of procedure and last for 2 to 4
weeks.
4. Anal dilatation (Lord’s dilatation):
Tightness of internal sphincter has been made responsible for any symptoms of
haemorrhoids. Maximal anal dilatation was introduced in an attempt to disrupt these tight
bands.
The whole of the anal canal and lower rectum are slowly and uniformly dilated with the
fingers until 3 fingers of both hands are inserted. Tight bands which Lord called ‘pecten’
are broken out and irregularities in anal canal are ironed out.
It is important to avoid tearing so that the dilatation must be gentle and combined with
rotating movements.
5. Photocoagulation76
Infrared coagulation
Instruments: The infrared coagulator has a 15.v tungsten-halogen lamp as a infrared
energy source. The light is reflected by 24 carat gold plated surface and carried out
through a quartz glass light-guide to the sapphire contact tip. The temp at the tip reaches
100oc. The heat generated causes tissue-coagulation and the depth of the coagulation is
determined by the time of exposure. The automatic time range is from 0.5 to 3 seconds,
giving a coagulation depth range of 0.5 to 2.5 mm.
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Coagulation:
The instrument is switched on & the timer set at 1.0 – 1.5 seconds. With the haemorrhoid
clearly visualized through a proctoscpoe, the tip of the coagulator is placed in firm
contact with the base of the haemorrhoid using light pressure. The tip should not be
embedded in the tissue. The instrument is then fired to the end of each automatically time
setting. A circular whitish eschar will appear on the mucosa after each exposure. Three to
five exposures are made in a semicircle around the base of haemorrhoid, allowing a gap
of few millimeters between each .It is important to place the tip of the instrument
accurately to avoid misfiring, thereby causing pain.
Complications:
Though not common, bleeding and pain can occur within 24 hrs of infrared coagulation.
The bleeding is mild and stop spontaneously, while pain is easily controlled with simple
analgesics.
6. Laser Therapy:
By using the laser, haemorrhoids are treated. Hamorrhoidal tissue gets necrosed & the
principle is same as infrared photocoagulation.
7. Radiofrequency coagulation:
The electrode placed in closed contact with the haemorrhoidal mass which results in
release of energy and produces coagulation within the tissue. It occurs as a result of heat
produced by the tissue resistance to the passage of high frequency wave.
8. Ultroid:
The probe tip is placed at the apex of haemorrhoids above the dentate line. The voltage is
gradually increased to the tolerance of the patient. The probe is left in position for
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approximately ten minutes or until the popping sound ceases. Then the current is
decreased to zero gradually.
9. Bipolar diathermy:
This method consists of passing short current through tip of probe applied directly and
firmly over the haemorrhoidal mass.
10 DGHALMeans Doppler Guided Haemorrhoidal Artery Ligation.
Dr. K Morinaga, saga, Japan has invented this new technique of DGHAL in 1995.
Haemorrhoidal Artery Ligation- with the development of Doppler assisted modified
proctoscope The DGHAL has revolutionsed the approach and treatment of haemorrhoids.
This method has proven to be a simple, safe and highly effective method of treating
haemorrhoids.
All methods to treating haemorrhoids described earlier are directed to the haemorrhoidal
tissue itself.Thus by ligating arteries, DGHAL stops the blood flow to the haemorrhoids.
Surgical Management:
Indications:Third and fourth degree haemorrhoids, Fibrosed and thrombosed haemorrhoids,
Failure of non operative treatment of second degree haemorrhoids or Intero-external
haemorrhoids and Uncontrollable recurrent bleeding.
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Contra indications:Secondary haemorrhoids due to pregnancy, pelvic tumour and liver diseases with
portal,hypertension, First degree haemorrhoids, Septic haemorrhoids and Acutely
thrombosed haemorrhoids.
Parks (1965) described the aims of Haemorrhoids operation as follows.
Remove as much as of Haemorrhoid plexus as possible. Create adherence
between the upper anal mucosa and the underlying internal sphincter, so that functional
prolapse will be minimized. Deal with associated conditions such as fissure. Prevent the
formation of minor sources of annoyance. Leave the anal canal physiologically normal,
no incontinence, pain or stenosis.
Recent surgical books also advise the treatment of Haemorrhoids on similar lines.
Types of surgical techniques
3. Open Haemorrhoidectomy
•
Ligation and excision
•
Excision with suture
•
Excision with clamp and cautery
4. Closed Haemorrhoidectomy
5. Submucous Haemorrhoidectomy
6. Stapled Haemorrhoidectomy.
Both open and closed technique involve ligation and excision of the haemorrhoid,
but in the open technique the anal mucosa and skin are left open to heal by secondary
intention, and in the closed technique, the wound is sutured.
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EXAMINATION OF RECTAL CASE77
I .HISTORY
The patient may present with the following symptoms.
1.BLEEDING
Amount of bleeding
Anal fissure – streaks of blood or drops of blood
Internal haemorrhoid – bright red blood spatters all over the pan.
Colour of blood lost
bright red – coming from the rectum or anal canal.
dark red – coming from ascending, transverse, descending or sigmoid colon.
Black – from the small intestine or higher
Relation to defaecation
Internal pile – bleeding at the time of passing stool and spatters all over the pan
Acute fissure – bleeding at the time of passing hard stool and amount is not much
Acute and chronic fissure in ano – streaks of blood at the side of stool
Rectal polyp – child with bleeding per anum
Prolapsed piles, polyps, unreduced prolapse of rectum, carcinoma,
diverticulosis, ulcerative colitis – bleeding at times other than defaecation.
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2. DISCHARGE OF PUS OR MUCOUS
Fistula-in-ano patients complains of soiling of clothes with purulent discharge coming
from a sinus
Ulcerative carcinoma patients often passes a considerable quantity of blood - stained,
purulent, offensive discharge at the time of defaecation.
Excess mucous - Colitis, crohn’s disease, colloid carcinoma of rectum
3. PAIN
All the pathological condition below the Hilton’s line are painful and those above the
line are painless. Inflammation or infiltration beyond the rectal wall is painful.
a. Nature of pain
Ano rectal abscess – throbbing pain
Anal fissure – sharp cutting pain
b.Relation with defaecation
Chronic fissure in ano – constant pain, which starts with defaecation.
Fistula in ano – intermittent pain
Uncomplicated pile, carcinoma of rectum, which is not spread into pelvic
cellular tissue or sacral plexus – painless.
4. ABNORMALITY OF BOWEL HABITS
The growth at the pelvi rectal junction or in sigmoid colon -increasing constipation
who had regular bowels.
Proliferative growth in ampulla – sensation of fullness in the rectum.
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Ulcerative growth – spurious morning diarrhoea.
Growth in the lower part of anal canal – alteration in the shape of the stool
(pipestem or tape like)
5. PROLAPSE
Protrution during defaecation – prolapse, polypus or long standing internal pile
Slight protrution.- Prolapse of mucous membrane and submucosa only
Protrusion more than 2 inch – Procidentia.
II. PAST HISTORY
Ano rectal abscess – Fistula – in – ano.
Fistula – in – ano – Tuberculosis, Crohn’s disease, Ulcerative colitis, Colloid
carcinoma of rectum.
Habitual constipation – Internal piles and fissure.
Dysentery or severe diarrhea in prolapse, anal tag or peri anal abscess- Crohn’s
disease
III. FAMILY HISTORY
Polyposis is a hereditary disease. A family history may be volunteered by the
patients suffering from piles, fissures, prolapsed and carcinoma of rectum.
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IV RECTAL EXAMINATION
Position of the patient
1. The left lateral position ( sim’s) – The patient lies on the left side with the hips
and knees well flexed which is suitable for the examination of peri anal region
and proctoscopy.
2. Dorsal position – Patient lies on his back with hip flexed, which is best for
bimanual examination. This is popular when the patient is too ill to alter his
position. More information regarding recto-uterine and recto- vesicle pouch can
be obtained in this position.
3. The Knee Elbow position – The patient standing on his flexed knees and elbows.
The thighs are bent right angles to the trunk. Best for feeling prostate and seminal
vesicles.
Right lateral position – Can be chosen in case of suspected carcinoma of
Pelvi rectal junction.
4. Lithotomy position - more information regarding pelvic viscera can be obtained
and examination can be conveniently performed.
Inspection
Presence of anal tags, sentinel pile, external opening of fistula – in – ano,
pilonidal sinus, condyloma, anal carcinoma, pruritis ani etc. should be looked
carefully.
Palpation
The attempt to insinuate the finger between protruded mass and anal margin is
possible in intussusception but not in procidentia
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Indurated tender swelling with brawny oedema on one side of the anus –
ischiorectal abscess. Careful palpation of external opening of fistula – in –ano
indicates the track.
Digital examination
The patient is instructed to breath in and out deeply. The gloved finger should
be lubricated and pulp of the index finger is laid flat on the lubricated anal verge. Gentle
pressure is exerted and push the finger into the anal canal through rotator movements.
Note the tone of the sphincter, pain or tenderness and thickening of the wall.
Information received in rectal examination can be divided into :
With in the lumen
Apex of intussusception can be felt.
In intestinal obstruction, the finger fails to touch its wall.
In the wall
•
Chronically inflamed and thrombosed pile can be felt.
•
Internal opening of fistula – in – ano can be felt as a small dimple in the centre of
an indurated area.
•
Absence of smoothness of rectal mucosa in ulcer.
•
Induration and eversion is felt in malignant ulcer.
•
Soft round growth about the size of a small grape slipping under the finger in
polypus.
•
A benign structure feel like a diaphragm with a clean cut hole in the center.
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•
Malignant structure feel hard, irregular and ulcerated.
•
Carcinoma of rectum may bleed during examination.
Outside the wall
The structure around the rectum.
Anteriorly
o The anatomical structures involved are prostate, seminal vescicles, base of
bladder and recto – vescical pouch in case of males.
o The uterus, cervix, vagina and recto – uterine pouch in females.
o Normal prostate – firm, rubbery and bilobed.
o Disappearance of median sulcus of prostate – senile enlargement.
o Loss of lateral sulci – carcinoma of prostate.
o Stony hard irregular and immobile prostate with rectal mucosa fixed to it
carcinoma.
o Hot, tender and uniformly enlarged gland – acute prostatitis.
o The seminal vesicles can only be palpated in tuberculous disease as
irregular, hard and granular feel.
o The base of bladder can only be felt in malignancy.
o Tenderness in recto – vescical pouch - pelvic peritonitis.
Laterally
o Tender and tense swelling in ischio – rectal fossa indicate abscess.
o Tenderness high up on right side suggest appendicitis.
o Bilateral tenderness is present in salpingitis.
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o Central fracture, dislocation of hip joint, fracture of pelvic girdle,
aneurysm of the internal iliac artery, and stone in the lower part of rectum
may be felt per rectum.
Posteriorly
The hollow of sacrum and coccyx are easily felt.
Ano coccygeal teratoma and post – anal dermoid can also be felt.
Bimanual examination
The contents of the pelvis can be examined during rectal examination by placing
another hand on the abdomen. This gives better idea of size, shape and nature of pelvic
mass. At the rectal examination looks at the examining finger for presence of faeces,
blood, pus or mucus.
Abdominal examination
This is necessary in carcinoma arising from upper part of rectum. Examine the liver
for secondary metastasis.
Lymph nodes
Carcinoma arising from the hind gut metastasise to iliac group and those arising from
lower part of anal canal spreads to the inguinal group.
Special investigation
Proctoscopy – The lubricated proctoscope is introduced into the rectum in the
direction of anal canal- ie, upwards and forwards towards the patients umbilicus. Then it
is directed posteriorly to enter into the rectum. Then the obturator is withdrawn and
interior can be visualized. The internal piles, fissures, ulcer, growth and internal opening
of fistula can be seen.
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Arso yanthra – is an instrument specially designed for the examination and para surgical
procedure. Instrument is made up of metal or ivory or horn or wood in the shape of
gosthana. It should have a length of 4 angulas and diameter of 5 angulas in males and 6
angulas in females. For examination Dvichidra yanthra should be used and for doing
procedures Ekachidra is used. The measurement of hole is 3 angulas long and with
circumference equal to the middle of angula.
Sigmoidoscopy – by the instrument whole part of rectum and large part of sigmoid
colon can be examined.
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Alvas Ayurveda Medical College, Moodbidri