E-ISSN:2456-3110

Case Report

Bleeding Hemorrhoid

Journal of Ayurveda and Integrated Medical Sciences

2023 Volume 8 Number 10 October
Publisherwww.maharshicharaka.in

Management of a Bleeding Hemorrhoid by FGHAL and RAR - A Case Report

Yakkundi R1*, Savitri2
DOI:10.21760/jaims.8.10.43

1* R C Yakkundi, Professor Hod, Dept Of Shalya Tantra, Sri Shivayogeshwara Rural Ayurvedic Medical College Inchal, Belagavi, Karnataka, India.

2 Savitri, Assistant Professor, Dept of Shareera Rachana, Sri Shivayogeshwara Rural Ayurvedic Medical College Inchal, Belagavi, Karnataka, India.

A 52 year old male patient came to our SSRAMC hospital OPD with complaints of bleeding per rectum and mass during defecation. The case was diagnosed as ‘Raktarsha’ (bleeding piles) at 3 o’ clock caused due to Pitta and Rakta vitiation. Due to bleeding per rectum his hemoglobin was reduced to just 4.5grams. Blood transfusion was done at our hospital to increase his hemoglobin. FGHAL was performed with RAR in this case under LA. The pile mass and per rectal bleeding reduced in 6 days. The patient was relieved from all the symptoms in 14 days. No major complains were received after the procedure. Proctoscopic examination was done every week for 4 weeks which did not reveal any complications.

Keywords: Arshas, Case Report, Bleeding Piles, FGHAL, RAR, Ayurveda

Corresponding Author How to Cite this Article To Browse
R C Yakkundi, Professor Hod, Dept Of Shalya Tantra, Sri Shivayogeshwara Rural Ayurvedic Medical College Inchal, Belagavi, Karnataka, India.
Email: 		Yakkundi R, Savitri, Management of a Bleeding Hemorrhoid by FGHAL and RAR - A Case Report. J Ayu Int Med Sci. 2023;8(10):272-274.
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https://jaims.in/jaims/article/view/2833

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2023-08-12 2023-08-18 2023-08-23 2023-08-28 2023-09-20
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
None declared Nil Yes 20.90%

© 2023by Yakkundi R, Savitriand Published by Maharshi Charaka Ayurveda Organization. This is an Open Access article licensed under a Creative Commons Attribution 4.0 International License https://creativecommons.org/licenses/by/4.0/ unported [CC BY 4.0].

J Ayu Int Med Sci 2023;8(10)272
R. C. Yakkundi et al. Management of a Bleeding Hemorrhoid by FGHAL and RAR

Introduction

Arshas can be correlated to Haemorrhoids according to signs and symptoms, which are described in modern medical field. Due to sedentary life style, constipation is very common these days. Haemorrhoids are developed due to any factors viz. sedentary life style, improper or irregular diet, fast food intake, prolonged standing or sitting, faulty habits of defecation, etc. which results in derangement of Jatharagni leading to vitiation of Tridoshas, mainly Vatadosha.[1] These vitiated Doshas get localized in Gudavali and Pradhanadhamani.[2] This further vitiates Twak, Mamsa, and Medha Dhatus due to Annavaha Srotodushti and it leads to development of Arshas.[3] The western culture of fast food and less zero fibre diet have worsened the condition.

Arshas is being described by all the ancient classics of Ayurveda. Acharya Sushruta placed this disease in Ashta Mahagada.[4]

Doppler Guided Haemorrhoidal Artery Ligation (DGHAL) was first published in 1995 by a Japanese surgeon Morinaga.[5] A simple ligation technique was however first reported by Blaisdellin 1958.[6] Later on 2006 Aigner postulated that there was three times increased blood flow in the posterior haemorhoidal vessels supplying the anal cushions and hence leading to engorgement. This subsequently leads to development of haemorrhoids.[7]

Based on these principles of Morinaga and Aigner, instead of using DGHAL probes which are available as single use and expensive, we tried to palpate the branches of SHA with index finger (FGHAL) at 2-3 cms above the dentate line (apex of pile mass) and ligate them all. It is followed by RAR (recto anal repair). This is done by a plication suture which is then tightened to reduce the prolapsed mucosa and sub mucosa into its original place, whilst the healing process is very quick.

Case Report

 A 52 year old male patient came to the OPD of Shri SSR Ayurvedic Medical College Hospital and Research Center, Inchal with complaints of bleeding per rectum and mass per rectum during defecation since 2 months. He also had severe weakness and loss of appetite. Proctoscopic examination

confirmed the diagnosis as a case of 3 o’ clock bleeding hemorrhoid. The patient had taken medical treatment from local practitioner for 15 days which did not alter the signs and symptoms.

General examination

  • General condition - average
  • B.P - 140/90mm of Hg.
  • Pulse - 88/min
  • Height - 160 cm
  • Weight - 72 kg
  • Temp - 98.6°F
  • Resp rate - 18/min
  • Tongue - coated
  • Pallor - present

Ashtavidha Pareeksha

  • Nadi - 88/min
  • Mala - 1 time/day
  • Mootra - 4-5 times /day
  • Jihva - Malavrit
  • Shabda - Samanya
  • Sparsha - Anushna
  • Drika - Samanya
  • Akriti - Madhyama

During the careful interrogation with the patient, the following causative factors were identified as mentioned in classical texts.[7]

  • Daily 2 wheeler riding (Utkatasana)
  • Consumption of sweets (Madhuraahara)
  • Straining to pass stool (Atipravahana)
  • Impaired digestion (Agnikarma)

As the underlying causes. The patient was also a chronic alcoholic (since 20 years) which was a contributing factor for increased bleeding.

During the routine investigations it was found that the hemoglobin of the patient was only 4.5 grams. Under the physicians guidance blood transfusion was done at our hospital. 4 points of blood was transfused till the hemoglobin reached 10grams. Till then stool softners, and Raktasthambaka drugs were given to the patient.


J Ayu Int Med Sci 2023;8(10)273
R. C. Yakkundi et al. Management of a Bleeding Hemorrhoid by FGHAL and RAR

The patient was not willing to undergo any invasive surgery and hence the FGHAL with RAR was offered. This particular case was treated with FGHAL and RAR because arresting the bleeding was the major attention.

The procedure was done under local anaesthesia with all aseptic precautions. With the help of fiber beak proctoscope hemorrhoidal artery was palpated with index finger and was ligated above the dentate line by using 2-0 vicryl and surgical knot was applied. It was repeated 1 centimeter above the first suture. Recto anal repair was also done by plicating the haemorrhoidal mass and high ligation. The bleeding was arrested due to FGHAL and the prolapse was reduced due to RAR.

The proctoscope was then removed and the anal canal was irrigated with antiseptic solution. Anal packing was done and the patient was kept under observation for 6 hours in the post operative ward. He was discharged after 7 days.

Observation

1)  Pain

VAS score for post operative pain

1.6 hours3
2.12 hours2.2
3.24 hours1.4
4.48 hours1.1
5.72 hours1

2)  Bleeding
Jaims_2833_01.jpg

Results

The study included a patient of 52years presenting bleeding per rectum, mass per rectum. On examination he had grade 2 bleeding haemorrhoid. After the procedure spontaneous bleeding was stopped. But there was minimal post defecatory bleeding which eventually stopped

after 5 days. There was minimal post operative pain (as shown in table) which did not need much pain killers. Patient was discharged after 7 days when all the signs and symptoms were relieved. Follow up was done weekly once for 4 weeks and no complications were seen.

Conclusion

FGHAL is a cost effective alternative to DGHAL. FGHAL followed by RAR provides a very low pain and discomfort with minimal need for analgesics and wound care. So, it can be concluded that DGHAL with RAR causes lower post operative pain, arrests bleeding, and achieves immediate and long term results without any complications compared to many other invasive procedures of haemorrhoids.

References

1. Chaturvedi GN, Shastri K. Charak Samhita (Chikitsasthan). Varanasi: Chaukhambha Academy; 2011;419.

2. Shastri KA. Sushruta Samhita (Nidanasthana). Varanasi: Chaukhambha Sanskrit Sansthan; 2010;306.

3. Chaturvedi GN, Shastri K. Charak Samhita (Chikitsasthana). Varanasi: Chaukhambha Bharati Academy; 2011;417.

4. Shastri KA. Sushruta Samhita (Sutrasthana). Varanasi: Chaukhambha Sanskrit Sansthan; 2010;163.

5. Morinaga K, Hasuda K, Ikeda T. A novel therapy for internal hemorrhoids: ligation of the hemorrhoidal artery with a newly devised instrument in conjunction with a Doppler flowmeter. Am J Gastroenterol. 1995;90:610-613.

6. Office ligation of internal hemorrhoids. Am J Surg. 1958 Sep;96(3):401-4.

7. Aigner F, Bodner G, Gruber H, Conrad F, Fritsch H, Margreiter R, Bonatti H. The vascular nature of hemorrhoids. J Gastrointest Surg. 2006;10:1044-1050.


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