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.

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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

2. GREETINGS FROM 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

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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

15. Kshara
application
using scoop
Wait for
100
seconds
Neutralize with
dilute vinegar or
lemon juice
Colour change like
a Ripened
Blackberry
Application on Haemorrhoids

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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

18. Changes after local application on Gut mucosa of
Albino rats

19. Microscopic Picture
KOH 10% P.K.
P.K. P.K.

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.

26. We make
a BAD ASSHOLE
a GOOD ASSHOLE

27. THANK YOU