Haemorrhoids are the pathological enlargement of the vascular cushions present in submucosal layer of anal canal which otherwise act as a hermetic seal in maintaining the continence. Ayurveda aim at to treat the hemorrhoids at the basic pathological level and offers a wide range of treatment options ranging from medical management to the use of parasurgical as well as surgical measures.
Haemorrhoids and its Management: How can Ayurveda have the upper hand...
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Haemorrhoids
& its Management
How can Ayurveda have the Upper Hand…
Dr. Ashish Sharma
Medical Officer (IM), Sir Sunder Lal Hospital &
Research Scholar, Department of Shalya Tantra
Faculty of Ayurveda, IMS, BHU, Varanasi
3. Haemorrhoids
haema blood and rhoos flowing
haemorrhides (Greek) means blood flowing
Piles
pila (Latin) which means ball or mass
4. Vascular Cushions
(Thomson, 1975)
Corpus cavernosi recti
Muscularis submucosae ani
Functions:
Venous drainage
Maintenance of continence and protection of sphincter
mechanism through filling of cushions
Augmentation of anal closure mechanism by hermetic seal
Microscopically, hemorrhoids are sinusoids (vascular structures
without muscular walls). Bleeding from hemorrhoids is arterial,
arising from the pre-sinusoidal arterial plexus, as evidenced by the
bright red color and having an arterial pH.
5. Theories of Haemorrhoidal Development
Congestion and Hypertrophy of Anal cushions due to
obstruction
Conditions like Chronic constipation, pregnancy, ascites, pelvic
tumor
Cirrhosis with raised portal pressure cause increased
incidence of rectal varices.
Loose attachment of vascular cushions and the muscularis
submucosae Prolapse of vascular cushions
Conditions like increasing age, constipation, over purgation or
recurrent diarrhoea, colitis and prolonged straining
6.
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Magnitude of the Problem
Most common anorectal problem reported in anorectal clinics.
At least 50% of the people above 50 years of age have some
degree of haemorrhoid formation.
Men > Women (approx 2:1)
30-40% prevalence rate in USA*
40 million in India, out of 1.065 billion population estimated**
*Ohning GV, Machicado GA, Jensen DM. Definitive therapy for internal hemorrhoids: new opportunities and
options. Rev Gastroenterol Disord 2009;9:16–26.
**Extrapolated prevalence, US Census Bureau, International Data Base, 2004, www.rightdiagnosis.com
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Management
1. Advice on diet and defecation habits
2. Medical Management
Bulking agents, Vasotopic agents and Topical applicants
3. Invasive Therapy
Mucosal fixation
Sclerotherapy, RBL, Cryosurgery, IRC, Ultroid, Bipolar,
Radiofrequency Coagulation
Prevention of Venous Return Impedance
Sphincterotomy, Lord’s dilatation
Surgical Intervention
Haemorrhoidectomy, Haemorrhoidopexy, DGHAL
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Advice on Diet & Defecation
Habits
• यच्चान्यदपि स्निग्धमस्ग्िदीििमर्शोघ्िं
सृष्टमूत्रिुरीषं च तदुिसेवेत्॥
(Su. Chi. 2/8)
• Stop Straining during defecation
• Stop sitting in toilet for long
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Commonly Available Treatments
Complications or Limitations
Sclerotherapy
Rubber Band Ligation
Pain & Bleeding (Wechter & Luna, 1987)
Slippage of band
Not suitable for broad base piles
Pain, Haemorrhage, Local sepsis
(Murray Lyon & Kirkham, 2001; Guy & Seow-Cheon,
2003)
Lower Urinary tract sepsis (Bullock, 1997)
Bacteremia (Adami et al, 1981)
Fistula, Fibrotic bands, Stricture etc.
Cryosurgery
Extensive post op. discharge & Pain
(Berry & D’costa, 1978)
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Commonly Available Treatments
Complications or Limitations
Haemorrhoidectomy
Pain, Haemorrhage, Fissure, Skin Tags,
Incontinence & Stenosis
Stapled haemorrhoidopexy
Stricture and Pelvic sepsis (Molloy and Kingsmore, 2000)
Internal Sphincter damage & InContinence
(George et al, 2002 & Brusciano et al 2004)
DGHAL
Expensive and at specialized centers only
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क्षार : “क्षर् + सञ्चलने, क्षरतीतत”,
which means to move or remove.
(Shabdakalpadrum)
Kshara : Ksharana ({kj.k )or Kshanana ({k.kUk )
To remove, erode or debride the unhealthy
tissue
• Kshara is a caustic material obtained from the ash of medicinal
plants, minerals, shells and other herbs either individually or in a
combination of two or more using a special technique of
preparation.
13. Properties-
Alkaline in nature : pH 12 – 13.5
Brownish Viscous material
After local application, it remains
on the area of contact without
spreading to surrounding
Penetrate effectively into the
deeper layer of tissue within short
times.
‘यद्येरण्डजनालमेष दहतत क्षारो वरो वाक्शतात्’ (Haranchandra)
1 min.
14. Preparation of patient
Office procedure
Only local rectal cleaning is needed, not of
whole gut.
Local anaesthesia
Packing of healthy mucosal are by
normal saline soaked gauze piece.
Measurement by using special rings
Skin or external component of
pile pile mass is retracted
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• Kshara is basically having corrosive/lytic property due to
its alkaline caustic nature.
• Depending upon the period of contact and concentration,
Kshara (caustic material) causes
• Direct cell death by destroying the cell membrane
via saponification of lipids and alkaline proteinate
formation
• As a noxious chemical stress to cells initiating the
inflammatory response
20. Source plant
Dried in shade
Burning in Open Furnace
Ash
Ashing
Temp – 800oC
Washed inTap water
21. Dissolutions in 6 times of water
Filtration
Boiling over mild heat (120-1400 c)
Evaporation of filtrate
Evaporation of Filtrate
Kshara
Ash
22. Evaporation of Filtrate
Addition of conch shell, oyster and
lime stone
Boiling over Mild heat (120-
140o C)
Addition of Paste of Chitraka, Danti, Langli etc.
Pratisaraniya Kshara
#Preparation, Standardization and Clinical Application of Pratisaraniya
Kshara in the Management of Haemorrhoids (Gudarsha).
M Sahu, Ashish Sharma, Mohan Kumar, S J Gupta, A K Dwivedi; 2014
23. Avoidance of Causative Factors
(Nidana Parivarjana)
Correction in Lifestyle
Dietary and Defecation Habits
Medical Management
•Correction of Digestive function
•Correction of Constipation & Bowel
Habits
•Stabilization of Anal epithelium
Eradication of Local Pathology
•Surgical Excision (Shastra Karma)
•Thermal Cauterization (Agni Karma)
•Chemical Cauterization (Kshar Karma)
Management of Haemorrhoids
A Holistic Approach
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• Treat Haemorrhoids only when
Symptomatic
• Treat only when patient has deferred the
habit of straining
• Minimum required intervention should be
performed
25. Kshara is a potent caustic drug.
Over enthusiasm may lead to
complications.
When ashing was done in Muffle furnace the yield of Kshara varies with temp. & max. yield was found at 8000 C
The amount is more when plant is burnt in open furnace