Journal of Ayurveda and Integrated Medical Sciences

Drugs used in the preparation of Ksharsutra along with the mechanical pressure of tying the thread heal anorectal disorders gradually. In the presented study, Ksharsutra ligation was performed on a patient aged 23 years suffering from Arsha on 3’o clock position prolapsed without bleeding but with irritation, pruritis ani and mild mucous discharge. Ksharsutra has been found to be effective, economic, easy to prepare and use. Moreover the daily routine of the patient is not disturbed. As this study performed on a single patient, more such trials are required to reach concrete conclusions.

Clinical Presentation

The most common clinical presentations of symptomatic haemorrhoids include painless bleeding along with defecation. The patient complains that it splashes in the pan as the stool comes out (where streak of blood may be seen on the stool fissure-in-ano,). This may continue for months or even years. As the veins become larger and heavier, partial prolapse will occur with each bowel movement gradually stretching the mucosal suspensory ligament at the dentate line until the 3rd degree haemorrhoid results. Pruritus, soilage, perianal irritation by mucus discharge. Blood loss can be substantial which can lead to iron-deficient anaemia.^[4] A patient complaining of bleeding associated with pain should bring to mind an alternative explanation, such as acute or chronic anal fissure, abscess, Crohn’s disease, irritated external haemorrhoids or anal cancer. Thrombosed or engorged external haemorrhoids may present with pain without bleeding.

It is manifested due to improper diet, prolonged standing and faulty habits of defecation causing derangement of Tridosha, mainly Vata Dosha. Vitiated Dosha localizes in Guda Vali, Pradhana Dhamani and Mansdhara Kala and vitiates Twak, Mansa, Meda and Rakta, resulting in the Annavaha Sroto Dushti.^[5] Modern management of Arsha, mainly, a surgical approach, i.e., hemorrhoidectomy, wherein the result was found to be less satisfactory.

Anatomy of Guda

According to Acharya Sustrata, there are 107 Marma (vital parts) and out of these 19 are Sadyopranhara (immediate death)^[6] and Guda Marma is one of them. Guda, chief site of Apana Vayu, is a passage through which Mala (waste) and Vata (flatus) of our body are excreted. Length of Guda

Degree of haemorrhoids - mucosal haemorrhoid along with the prolonged dilatation of internal haemorrhoid may also cause 3rd degree or prolapsed haemorrhoids.^[4] e.g.

• First degree haemorrhoids - haemorrhoids does not come out of the anus.
• Second degree haemorrhoids - Haemorrhoids comes out only during defecation and is reduced spontaneously after defecation.
• Third degree haemorrhoids - comes out only during defecation and does not return by themselves but need to be replaced manually and then they stay reduced.
• Fourth degree haemorrhoids - are permanently prolapsed at this stage. There is feeling of heaviness in rectum.

Causes

The exact causes of symptomatic haemorrhoids are unknown. A number of factors are believed to play important role including; Irregular bowel habits (constipation or diarrhoea), lack of exercise, nutritional factor (a low-fibre diet), increased intra-abdominal pressure, prolonged straining, ascites, an intra-abdominal mass, or pregnancy, genetics, absence of valves within the haemorrhoidal veins, aging. Other factors that are believed to increase the risk include obesity, prolonged sitting, chronic cough, pelvic floor dysfunction. Evidence for these associations, however, is poor. During pregnancy, pressure from the foetus on the abdomen and hormonal changes cause the haemorrhoidal vessels to enlarge. Delivery also leads to increased intra-abdominal pressure. Surgical treatment is rarely needed in those who are pregnant, as symptoms usually resolve post delivery.

Causes of Haemorrhoids are also classified as

(i) Idiopathic causes.

(ii) Secondary causes

(i) Idiopathic causes

a) Hereditary : often seen in members of the same family.

b) Anatomical

1.Absence of valves in superior haemorrhoidal veins.
2. The veins pass through the rectal musculature,

Chest X-Ray

Preoperative Procedure

• Consent of patient was taken.
• Cleaning of bowel was done at prior night.
• Part preparation of the perianal area was done.
• Xylocaine sensitivity was done.
• T.T 0.5 ml was given by I.M. route.

Presentation of Case

On initial examination, there was Arsha on 3’o clock position (Figure 2) prolapsed without bleeding but with irritation, pruritis ani and mild mucous discharge,

Operative Procedure

Patient was kept in lithotomy position on the operation table. The part was cleaned with aseptic solutions and after then local anaesthesia was given with 2% xylocaine and adrenalin injection and draping was done. Position of pile mass was assessed. The pile mass was hold with the help of pile holding forceps. A semicircular groove was made. Pedicle of pile mass was crushed and pile mass was transfixed with the help of Ksharsutra and curved needle and was ligated. Its colour was changed quickly to Jambuphal Nibh (purple colour) (figure 3). Warm water irrigation was done followed by T bandaging with Yasthimadhu Ghrita.

Figure 2: Position of haemorrhoids

Paschata Karma
The patient was advised to take sitz bath twice a day and was asked to remain mobile as soon as possible. The patient was also advised to take easily digestible diet. Triphala Guggulu 2 tabs TDS along with Abhyarishta 30 ml BD and Avipatikara Churna 5gm HS.

Figure 5: After 21 days