E-ISSN:2456-3110

Review Article

haemorrhoids

Journal of Ayurveda and Integrated Medical Sciences

2024 Volume 9 Number 8 AUGUST
Publisherwww.maharshicharaka.in

A review article on the managements of Arshas (haemorrhoids)

Sai Shashank K1*, Parvathy S2, Shankar S3
DOI:10.21760/jaims.9.8.28

1* Sai Shashank K, Post Graduate Scholar, Department of Shalya Tantra, Sri Dharmasthala Manjunatheswara Institute of Ayurveda and Hospital, Bengaluru, Karnataka, India.

2 Parvathy S, Associate Professor, Department of Shalya Tantra, Sri Dharmasthala Manjunatheswara Institute of Ayurveda and Hospital, Bengaluru, Karnataka, India.

3 Shankar S, Professor and HOD, Department of Shalya Tantra, Sri Dharmasthala Manjunatheswara Institute of Ayurveda and Hospital, Bengaluru, Karnataka, India.

A haemorrhoid is the most common affecting up to one quarter of all adults according to some estimates. Numerous interventions exist for their management, ranging from topical and medical therapies to outpatient treatments and surgical interventions that aim to fix or excise. The word Arsha is self-explanatory, indicating that the disease troubles a person like an enemy. Arshas can be corelated to haemorrhoids in modern science. Arshas is clinically an engorged condition of haemorrhoidal venous plexus characterized by prolapsed mass per anum, bleeding per anum mainly. In contemporary science there are treatments for haemorrhoids like sclerotherapy, banding, laser ablation, lifestyle modifications, surgical procedures like haemorrhoidectomy and other invasive technique. In Ayurvedic tests Chaturvidha Chikitsa is said, such as Bheshaja (medicinal), Kshara Karma (caustic treatment), Agni Karma (thermal hear burn) and Shastra Karma (surgery). In this review article, treatments from modern as well as Ayurvedic texts are documented so that proctologists around the world get a better understanding about the disease and its exact treatment modalities in both the sciences.

Keywords: Arshas, Haemorrhoids, Kshara Karma, Agni Karma, Shastra Karma

Corresponding Author How to Cite this Article To Browse
Sai Shashank K, Post Graduate Scholar, Department of Shalya Tantra, Sri Dharmasthala Manjunatheswara Institute of Ayurveda and Hospital, Bengaluru, Karnataka, India.
Email: 		Sai Shashank K, Parvathy S, Shankar S, A review article on the managements of Arshas (haemorrhoids). J Ayu Int Med Sci. 2024;9(8):184-189.
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https://jaims.in/jaims/article/view/3739

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2024-07-14 2024-07-24 2024-08-04 2024-08-11 2024-08-19
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
None Nil Yes 12.32

© 2024by Sai Shashank K, Parvathy S, Shankar Sand 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].

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Introduction

In today’s world full of stress and unhealthy food habits along with unhealthy lifestyles make people prone to ano-rectal diseases such as fissure-in-ano, haemorrhoids, fistulas-in-ano. In Ayurveda Arsha is explained as Mahagada. Shalya Tantra has a wealth of information related to modern surgical theory. The father of surgery, Acharya Sushruta, thoroughly described the Arsharoga in his treatise, which was thought to be one of the Mahagada and was cured indefinitely. Arsha is a troublesome disease that can affect anyone, anywhere, at any time. Haemorrhoids are a common issue in the present world and almost everyone has experienced them at some point in their lives. Arsha is described as a fleshy growth that obstructs the anal canal and eliminates the existence like enemy.[1]

The primary causes of Arshas are binge eating and a sedentary lifestyle, which decreases the activity of digestive enzymes and causes constipation, itching, burning, and pain near the Guda, which eventually results in bleeding.[2] The estimated worldwide prevalence ranges from 2.9% to 27.9%, of which more than 4% are symptomatic.[3,4]

Age distribution demonstrates a Gaussian distribution with a peak incidence between 45 and 65 years with subsequent decline after 65 years.[5,6] Different treatment modalities have been said for Arshas in Ayurveda. In early stage with less signs - symptoms Arsha can be treated with Bheshaja (internal medicine), Ksharakarma (herbal caustic paste locally) or Agnikarma (thermal heat burn) and if not cured with all above treatment, it should be treated by Shastrakarma (Surgery).[7] These treatments are said in a particular order which suggests which should be prioritised first. In this article we will look into various Ayurvedic and modern measures in treatment of Arshas.

Materials and Methods

All sorts of references have been collected from our ancient Ayurvedic texts viz., Sushruta Samhita, Charaka Samhita, Ashtanga Hridaya, Ashtanga Sangraha. Modern books like Bailey and Loves’s, Short Practice of Surgery, Surgery of the Anus Rectum and Colon, Atlas of General Surgery Jaypee Brothers medical publishers are used as literary source.

Aim and Objectives

To study in detail on Arshas in both Ayurvedic and modern texts, and collect information referred to Arshas and find the possible treatment of Arshas.

Nidana of Arshas:[8,9]

The Nidana of Arshas are mentioned by Acharya Charaka Sushrutha and Vagbhata.

  • Based on food habits, excessive intake of incompatible diets like Guru, Sheeta, Abhishyandi,
  • Based on Vihara: excessive sexual intercourse, excessive staining, supressing of natural urges.
  • Based on therapeutic abuses, excessive Snehana therapy, inappropriate Vastikarma administration, etc.
  • Based on other factors such as improper seating on hard surfaces for long time or harsh chairs, long rides on vehicles.
  • Some other factors can be pregnancy in females

Sahaja Arshas is accountable for the ancestral past actions and behaviour. Sushrutha Acharya also mentions the role of foolish Ahara and Vihara in the origin of Arshas.

Samprapti of Arshas

The pathogenesis of Arshas, according to Sushruta, is caused by Nidanas, which lead to the vitiation of Doshas in one, two, or more combinations, along with Rakta. Doshas then move downward through the Mahadhamani, affecting the Gudavalitraya and causing Arshas in people who have Mandagni and other local causes.[10]

According to Charaka, Arshoroga is created when all the Doshas get vitiated, followed by Bahya and Abhyantara rogamarga, and has an impact on Gudavalitraya.[11] Vagbhata asserts that vitiation of the Doshas results in the formation of Mandagni, vitiation of the Apanavayu causes the stagnation of Mala in Gudavali, and prolonged contact with Mala results in the emergence of Arshas.[12]

Classification of Arshas

There are different opinions of Acharya regarding the Arshas classification:

  • On the basis of the origin 1. Sahaja 2. Kalaja

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  • On the basis of the character of bleeding Ardra (Sravi) - Bleeding piles due to vitiation of Rakta and Pitta Dosha. Shushka - Non bleeding piles due to vitiation of Vata and Kapha Dosha.
  • On the basis of the predominance of Dosha:
  • Vataja 2. Pittaja 3. Kaphaja 4. Raktaj 5. Sannipataj 6. Sahaj.
  • On the basis of prognosis
  • 1. Sadhya (Curable)
  • Yapya (Palliative)
  • 3. Asadhya (Incurable)

Sadhya: If Arsha is of single Doshika involvement and not very chronic.

Yapya: Arsha caused by the simultaneous vitiation of any two Doshas and the location of Arsha in the second Vali, the chronicity of the disease is not more than one year.

Asadhya: Sahaja Arsha and if caused by the vitiation of three Doshas and if the Arsha is situated in the Pravahini Vali, then it is incurable. In addition to this if the patient develops oedema in hands, legs, face, umbilical region, anal region, testicles or if he suffers from pain in the cardiac region, it is also considered as incurable.

  • According to contemporary medicine based on the position
  • Internal
  • External

Internal haemorrhoids

Internal haemorrhoids are those which occur inside the rectum. These are the varicosities of the veins in the rectal region. As this area does not have pain receptors, internal haemorrhoids are usually not painful and most people do not know they have them. These may bleed when irritated mostly due to constipation.

External haemorrhoids

External haemorrhoids are those which occur outside the anal verge. They are varicosities of the inferior rectal arteries which are branches of the pudendal arteries. They are painful sometimes, and can be accompanied by irritation and swelling. They are prone to thrombosis, if the vein ruptures and a blood clot develops, then it becomes a thrombosed haemorrhoid.

  • On the basis of symptoms
  • Grade I: No Prolapses. Just prominent blood vessels.
  • Grade II: Prolapses upon bearing down but spontaneously reduce.
  • Grade III: Prolapses upon bearing down and require manual reduction.
  • Grade IV: Prolapsed and cannot be manually reduced.

Chikitsa

In Ayurveda the fundamental rule to cure a disease is to eliminate the root cause of the disease and prevent the contributing etiological factors. Four therapeutic modalities for Arsha have been documented by Acharya Sushrutha,[13] and these treatments are to be used based on the degree of dosha involvement in Arshas.

  • Bheshaja Karma (medical treatment)
  • Shastra Karma (surgical management)
  • Kshara Karma (chemical cauterization)
  • Agni Karma (cauterization)

Bheshaja Chikitsa

Bheshaja Chikitsa (Medical management) is described as very first line of treatment of Arsha. It is statistically good effective in 1st to 2nd degree of Ushna disease prognosis.[14] The ingredients having Veerya, Katu Vipaka, Deepana, Pachana, Vatanulomaka, Srotosodhana, Sronitsanghata Bhinnakara Guna are capable to Samprapti Vighatana and cure the disease[15] and based on that various preparations are mentioned for management of Arsha. Arshas which are newly arisen, with Alpa Doshas Linga and Upadrava can be treated with Bheshaja.

Local measures - There are many preparations which can be applied locally. These preparations are helpful in eliminating the painful manifestation of Arshas.

Shastra Karma

When conservative measures prove ineffective, Arsha is managed surgically using a variety of procedures. Haemorrhoidectomy is one of these that is typically advised in patients with prolapsed heamorrhoids, internal heamorrhoids, and significant degrees of disease presentation.


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Shastra Karmas can occasionally be linked to complications such as bleeding, infection, incontinence, anal strictures, and urine retention. When comparing haemorrhoidectomy to other anorectal operations, problems related to bleeding are more frequent. Those Arshas which are Tanumoola, Uchritani and Kledavanta are to be treated with Shastra.

Kshara Karma

Kshara is a caustic, alkaline substance that is manufactured from the ashes of therapeutic herbs. It is a less intrusive treatment than Agni karma and Shastra Karma. It is known as one of the Anu Shastras or Upayantras.

It is the best among sharp and secondary instruments since it performs Tridoshahara property along with Chedana, Bhedana, and Lekhana Karma. Because Kshara Karma can be used to treat places that are difficult to reach with traditional procedures, it is versatile.

Beyond this, Ksharakarma is more effective than other forms of treatment because it may be used externally as well as inside. Kshara Karmas can be applied to patients who are afraid of surgery, making them useful substitutes for surgical instruments.

Piles caused by Vata and Kapha should be treated with cauterization and application of Kshara. Those caused by Pitta and Rakta should be treated with use of Mrudu Kshara. Those Arshas which are Mriudu, Prasrutha, Avagadha and Uchritha are treated by using Kshara.

Agni Karma

Agni Karma is an important para surgical procedure. Agni Karma can help treat illnesses that are incurable even with the use of pharmaceuticals, medical devices, and Kshara.

It is greater than Kshara Karma because ailments do not recur. It is often modified for use in surgical techniques like freezing and electric heat cautery. Those Arshas which are Karkasha, Sthira, Pruthu and Katina are treated using Agnikarma.

Management of Haemorrhoids

Haemorrhoidal treatment varies from therapeutic treatment, lifestyle modifications to surgeries depending on degree and severity of disease.

Non-Operative Treatment

Rubber band ligation

Rubber band ligation is a fast simple and effective measure in treating first and second degree haemorrhoids and few cases of third degree prolapse to some extent can also be treated. The ligation of haemorrhoidal tissue with the help rubber band causes ischemic necrosis and scarring, leading to fixation of the connective tissue to the rectal wall.

Sclerotherapy

This is currently recommended as a treatment option for first- and second-degree haemorrhoids. The rationale of injecting chemical agents is to create a fixation of mucosa to the underlying muscle by fibrosis. The solutions used are 5% phenol in oil, vegetable oil, quinine, and urea hydrochloride or hypertonic salt solution.

Infrared coagulation

The infrared coagulator produces infrared radiation which coagulates tissue and vaporizes water in the cell, causing shrinkage of the haemorrhoid mass.

Cryotherapy

Cryotherapy ablates the hemorrhoidal tissue with a freezing cryoprobe. It has been claimed to cause less pain because sensory nerve endings are destroyed at very low temperature.

Laser ablation

Laser ablation also known as laser haemorrhoidectomy or laser haemorrhoidoplasty, is a minimally invasive surgical procedure used to treat haemorrhoids. In this procedure a specialized laser is used to precisely target and shrink the haemorrhoidal tissue. The laser energy is delivered to the haemorrhoid, causing it to shrink and eventually scar. This reduces the blood flow to the haemorrhoid/ leading to its gradual resolution Operative treatment- operation is preferred when all the non-operative measures have failed to show result in treating the haemorrhoids, also when haemorrhoids are of third, fourth degree where surgery is the only option left.

Haemorrhoidectomy

Excisional haemorrhoidectomy is the most effective treatment for haemorrhoids with the lowest rate of recurrence compared to other modalities.


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It can be performed using scissors, diathermy, or vascular sealing device such as Ligature and Harmonic scalpel. Excisional haemorrhoidectomy can be performed safely under perianal anaesthetic infiltration as an ambulatory surgery. Indications for haemorrhoidectomy include failure of non-operative management, acute complicated haemorrhoids such as strangulation or thrombosis, patient preference, and concomitant anorectal conditions such as anal fissure or fistula-in-ano which require surgery. In clinical practice, third-degree or fourth-degree internal haemorrhoids are main indication for haemorrhoidectomy.[14] Major drawback of haemorrhoidectomy is postoperative pain. There has been evidence that Ligasure haemorrhoidectomy results in less postoperative pain, shorter hospitalization, faster wound healing and convalescence compared to scissors or diathermy haemorrhoidectomy.

Apathya in Arshas

Fried food, maida rich foods, non-veg, chilies, constipating foods, ideal sitting without any work to body, excessive pressure while defecation, food which are deep fried. These foods can cause Arshas.

Pathya in Arshas

Cow milk, buttermilk, pure ghee, wheat, rice, green gram, fibre rich foods, boiled vegetables, sufficient sleep, exercise regularly, good and regular diet habits, Vega Dharana should be avoided specially the urge to pass stools.

Discussion

This article provides a detailed exploration of treatments from both Ayurvedic and modern medical perspectives. It aims to bridge gap between traditional wisdom and contemporary scientific practices in addressing common ailment of haemorrhoids, known as Arshas in Ayurveda.

Conclusion

Arsha is a condition associated with age, occupation, way of life, and food. Ayurvedic classics describe an ideal pattern of living that one can follow to live a long and healthy life. Some significant factors mentioned in Ayurvedic classics for the manifestation of Arsha (piles) include eating low-fiber food, bad eating habits, abnormal body posture, complicated delivery, repeated abortion,

psychological imbalances, and physical harm to anal region. Nidana Parivarjana plays an important role in prevention of Arshas. As a result, Ayurveda has a great deal of potential to successfully and trouble-free handle all stages of Arsha.

References

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