Detail study of Arsha Haemorrhoids according to ayurveda

Detail study of Arsha means Haemorrhoids

1. ARSHA Detail study Vd.Vaibhavi Anupam Alman MS Shalyatantra

2. Definition Arsha is an abnormal fleshy growth in anorectal region. Arshas the fleshy projections that create obstruction in anal passage kills the life like enemy.

3. Nidan 1. Ahara- (Dietic factors): Dietic indulgence like excessive or less intake, irregular diet, incompatible diet etc. which will vitiate Dosha & will interfere with the digestive power leading to poor digestion & constipation.2.Vihara (Habits): Sexual indulgence, therapeutic excesses & abuses, suppression of natural urges, termination of pregnancy etc. will vitiate Vata. 3.Local irritation factors: Defective sitting, vehicle riding, local touching of anus with cold water or rough objects, injury to the part etc. may be responsible for production & aggravates already existed Arshas. 4.Mandagni as a prime factor: Arshas, Grahani & Atisara are causative factors for each other due to imbalance of Agni. 5.Genetic factors: Sahaja Arshas are caused by Beejotpata hetu, which may result from (i) Bad deeds of the past life. (ii) Defects in Beejabhaga & Beejabhaga-avayava of mother & father. Sushruta categorized such diseases under Adibala-pravritta vyadhi (Hereditary disease). 6.Other causes: General weakness & emaciation from prolonged illness like Udara roga, Pleehavriddhi (splenomegaly), Grahani etc.

4. Samprapti Acharya Sushrut describes samprapti of arsha as below4- In persons who are not self-controlled regarding ahar & vihara , who indulge in things which aggravates the doshas such as , use of incompatible foods, over eating , more of copulation, sitting on ones heels, riding on animals, suppression of urges of the body etc. especially , the doshas getting aggravated either individually or in combination of two or all three or together with blood, spread out & travelling through the main dhamani in the downward direction reach the guda & produce sprouts of muscle in gudavali especially in persons who have weakness of digestive power; these sprouts grow in size due to contact by grass, sticks, stone pebbles & lumps of cloth etc. or by touch of cold water; these sprouts are called Arshas (pile mass).

5. Types of Arsha=  According to origin- 1. Sahaja (congenital) 2. Kalaja / Doshaja (Acquired)-Vataja, Pittaja, Kaphaja, Dwidoshaja, Tridoshaja. According to character of bleeding- 1. Shushka Arsha (Dry type) - Vataja, Kaphaja. 2. Ardra Arshas (Wet type)- Pittaja, Raktaja. According to Site- 1. Bahya 2. Abhyantara According to Therapeutic groups- 1. Bheshaja sadhya 2. Kshara sadhya 3. Agni sadhya 4. Shastra sadhya

6. Sr. No. Arshas Sushruta 26 Charaka 27 AshtangaHrudaya 28 1 Vataja + + + 2 Pittaja + + + 3 Kaphaja + + + 4 Dwandaja - + + 5 Sannipataj + + + 6 Raktaja + - - 7 Sahaja + + + 8 Shushka - - + 9 Ardra - - + Table No. 02- Classification of Arshas in Ayurvedic Classics

7. Purvarupa of Arsha: Annasradha, Antrakoojanam, Kasa, Swasa, bhram, durbalatha, Udgarabahulyam, Amlika, daurbalya, udara, pandu, Paridaha, Vishthambha, Pipasa, Sakthisadanam, Atopa, Karshya.

8. Vataja Pittaja Kaphaja Raktaja Color Aruna Bluish tip Pandu (yellowish white) Same as Pittaja Chief character Parishushka Tanu, visarpini (movable) Broad based, fixed, round, smooth Gunja Shape, size, surface Kadamba flower, tundikeri Blood mixed, excessive burning sensation Seeds of jackfruit Same as Pittaja Character of stool Hard stool, painful Yellowish eyes, skin, nails, stool, urine Excessive mucous excessive bleeding while hard defecation Associated features Pain in the pelvic region, backache, Fever, faintness, thirst Whitish nails, skin, eyes Same as Pittaja Complications Gulma, vatodara - Shopha, aruchi, avipaka Excessive blood loss Table No. 03- Rupa of Arsha. Sannipataj Combination of all above features Table No. 04- Rupa of Sannipataj Arsha.

9. VYADHI VINISHCHAY- According to nidana panchaka & trividha pariksha vyadhivinishchay of arsha is done. Local examination is done with the help of an instrument called Arsha Yantra (Proctoscope).

10. Management of Arsha: Acharya Sushrut has enumerated four curative measures in the treatment of Arshas. They are Bheshaja, Kshara karma, Agnikarma, Shastra karma. Bheshaja Chikitsa- Arsha which are alpakala, alpadosha, alpalinga, & without updravas are fit for bheshaja karma. It includes abhyanga, swedan, vasti, dhoopana, avagahana, pralepa, parisheka, oral medicine preparations churnas, vati / modaka, arishtas, ghritas, guggulu, asavas, tailas, rasa oushadas, lehyas. Kshara Karma – Kshara karma is useful as the substitute of shastra karma, because kshara can be used safely on the patients who are afraid of surgery.

11. Agnikarma – Agnikarma is indicated in rough, fixed, broad & hard type of piles masses. It is also advised in Vataja & Kaphaja arshas & those which are prolapsed & Doshapurna (thrombosed or infected external piles). Shastra Karma – The surgical intervention i.e. Chedana (excision) is indicated only in well pedunculated big & bleeding type of Arshas in strong patient. Raktamokshana – Acharya Sushrut enumerated Arshas as one of the diseases contraindicated for bloodletting. But in the management of Arshas, he advised bloodletting under certain conditions like protruding out with full clinical picture of Arshas

12. Anatomy of Anal canal Figure -The anal sphincter in schematic coronal section. In figure, No 3, given numbers describes as bellow,
1. Rectum
2. Side wall of pelvis
3. Pelvic floor (levator ani)
4. Ischiorectal fossa
5. Level of anorectal junction
6. Internal anal sphincter
7. External anal sphincter
External anal sphincters are under voluntary nerve control. It is made up of striated muscle and is supplied by inferior rectal and perineal branch of fourth sacra.

13. Blood supply – Inferior rectal artery. Venous drainage – Internal rectal venous plexus lies in the submucosa of anal canal. It drains mainly into the superior rectal vein but communicates freely with external plexus. It is an important site of portasystemic communication. They are situated in anal column at 3,7,11 o’clock. Their saccular dilatation forms ‘primary internal piles’.

14. HAEMORRHOIDS These are dilated veins within anal canal in sub epithelial region formed by radicles of superior, middle, inferior rectal veins. Haemorrhoids are clearly divided into two categories, internal & external haemorrhoids. Internal haemorrhoids means it is within anal canal & internal to the anal orifice. It is covered with mucus membrane & it is bright red & purple colour. It is usually commencing at the anorectal ring & ends at dentate line. The external haemorrhoid is situated outside the anal orifice & is covered by skin. The two varieties may coexist & the condition called intero-external haemorrhoids. There are two peculiar conditions which are associated with external haemorrhoid, i)Dilatation of the veins at the anal verge ii)Perianal haematoma or thrombosed external haemorrhoid.

15. AETIOLOGY OF INTERNAL HAEMORRHOIDS. AETIOLOGY OF INTERNAL HAEMORRHOIDS. 1.Hereditary- It is often seen in members of same family. 2.Anatomical- It has long been suggested that internal pile is natural consequence of adaption of erect posture by mankind, a) absence of valves in superior haemorrhoidal veins. (b) The veins pass through the rectal musculature 10cm above the anus will cause occlusion of veins & congestion during defecation. (c) The radicles of superior rectal vein lie unsupported in loose sub mucous connective tissue of rectum. 3. Exciting causes- Parks suggested straining to expel constipated stool caused dilatation of venous plexus. Once dilatation of venous plexus as well as partial prolapse would occur with each bowel movement it would stretch the mucosal suspensory ligament. Over purgation & diarrhoea of colitis, dysentery, enteritis etc. aggravated latent haemorrhoids .

16. 4.Physiological cause- Corpus cavernosum with direct communication arteriovenous communication. Hyperplasia of the corpus cavernosum rectum may result from failure of mechanism controlling the arteriovenous shunts producing superior haemorrhoidal veins varicosity & haemorrhoids. 5.Diet- Low roughage ‘western’ diet may excite haemorrhoid formation. Whereas adding bulk or bulk forming compounds can prevent haemorrhoid formation.

17. SECONDARY HAEMORRHOIDS Haemorrhoids may be secondary to few conditions, which must be excluded before one treats a case of haemorrhoid. These are- 1.Carcinoma of the rectum- compresses on the superior rectal veins & gives rise to haemorrhoid. 2.Pregnancy- compresses superior rectal vein as also cause’s secondary laxity to smooth muscle of the veins. Uterine tumours may similarly compress the superior rectal vein. 3.Chronic constipation- & its cause should be excluded, otherwise condition will reoccurs. 4.Difficulty in micturition- stricture of urethra or enlarged prostate will cause increased intra-abdominal pressure in the superior haemorrhoidal veins to cause haemorrhoids. 5.Portal hypertension has hardly ever caused haemorrhoid, through it is the junction of portal & systemic veins.

18. Clinical Features= 1.Bleeding Bleeding is bright red painless occurs along with defecation. The patient complains that it splashes in the pan as the stool comes out (c/f. fissure-in-ano, where streak of blood may be seen on the stool). 2.Prolapse Prolapse is a later symptom. In the beginning prolapse is minimal. According to prolapse, haemorrhoids can be divided into four degrees. First degree- Haemorrhoid does not come out of the anus. Second degree- Haemorrhoids come out only during defecation & are reduced spontaneously after defecation. Third degree- Haemorrhoids comes out only during defecation & do not return by them, but need to be replaced manually & then they stay reduced. Fourth degree- The haemorrhoids that are permanently prolapse. At this stage great discomfort is complained of with a feeling of heaviness in the rectum.

19. 3.Pain Pain is not characteristic of haemorrhoid unless there is associated thrombosis or there is associated fissure-in-ano. 4.Mucous discharge Mucous discharge is a particular symptom of prolapsed haemorrhoids. 5.Anaemia- Is often seen in long standing cases of haemorrhoids due to persistent & profuse bleeding

20. Management: Before treatment of haemorrhoid is undertaken the surgeon must exclude any serious disease in the rectum or colon. Therefore, any haemorrhoid treatment must be preceded by sigmoidoscopy & barium enema. Occult blood test of the stool is necessary. Bowel Regulation- Many haemorrhoidal symptoms can be relieved by avoiding excessive defecation straining. This can be done by advising high residue diet & mild laxatives. Topical ointments for local applications may do well by reducing oedema. Injection therapy- Sclerosant injection has been the method of treatment of small vascular haemorrhoids & indeed is used to control all cases of first-degree haemorrhoids . Rubber band ligation- Rubber banding is ideal method of treatment of treating large first degree & second-degree internal haemorrhoid in absence of associated tags or external haemorrhoidal component

21. Cryosurgery- The new form of cryotherapy involves freezing the tissues of the haemorrhoid for a sufficient time to cause necrosis. Haemorrhoidectomy- Indication- For large third-degree haemorrhoids particularly with associated tags & an external haemorrhoidal plexus 1.Ligature & excision method- 2.Sub mucous Haemorrhoidectomy (PARK’S) 3.Circular stapled haemorrhoidectomy 4.Endostapling Technique-

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