Haemorrhoids -Hemorrhoids are swollen, enlarged veins or veinous plexus, inside and outside of anus and rectum.

Hemorrhoids are swollen, enlarged veins that form inside and outside of your anus and rectum. Type, line of treatment, Ayurvedic views all are brief here.

1. 1

Hemorrhoids-
Dilated or enlarged veins in the lower portion of the rectum or anus or Symptomatic anal cushions.
Hemorrhoidal venous cushions are normal structures of anorectum and universally present in all
persons unless previous intervention has taken place. It is a common anal pathology but many
patients are embarrassed to seek medical attention.

Cause-
➢ Straining and constipation.
➢ Pregnancy.
➢ Obesity.
➢ Prolonged sitting.
➢ Weight lifting
➢ Portal hypertension and anorectal varices.
➢ Chronic diarrhea.
➢ Familial
➢ Colon malignancy.
➢ Loss of rectal muscle tone.
➢ Spinal cord injury.
➢ Rectal surgery.
➢ High socioeconomic status.
➢ Episiotomy.
➢ Anal intercourse.
➢ IBD

# STRAINING AND CONSTIPATION - is due to Low fiber diet resulting in Less bulky stools
formation. It causes straining at defecation and Increased intra anal pressure, Decreased venous
return. Ultimately enlarged hemorrhoidal venous cushions. They are clusters of vascular tissue,
smooth muscle and connective tissue lined by normal epithelium of anal canal. They are
commonly seen in the left lateral, right anterior and right posterior (3,7,11’o o'clock) position with
patients in lithotomy position.

# Internal Hemorrhoids Disease Manifested by two main symptoms - Painless Bleeding, Protrusion
(Pain is rare as they originate above the dentate line) Most popular etiologic theory states that
Hemorrhoids result from chronic straining at defecation. Continued straining causes engorgement
and bleeding, as well as hemorrhoidal prolapse


Types- Depending on anal origin within anal canal and relation to dentate line hemorrhoids
divided in to
1. Internal hemorrhoids.

2. 2

2. External hemorrhoids.
3. Mixed hemorrhoids.
✓ Internal- Lie above the dentate line. Develops from embryonic endoderm. Covered by
columnar epithelium of anal canal. Not supplied by somatic sensory nerves.so cannot
cause pain.
✓ External - Lie below the dentate line. Develops from embryonic ectoderm. Covered by
squamous epithelium. Innervated by cutaneous nerves that supply perianal area.
Other classification-
➢ GRADE I- painless bleeding, no prolapse.
➢ GRADE II -prolapse on defecation that reduces spontaneously.
➢ GRADE III -prolapse that has to be reduced manually.
➢ GRADE IV permanent prolapse.

Clinical Presentation-
1. Painless bleeding- Fresh bleeding, after defecation. Bright red blood in stool, Dripping in
the toilet, On wiping after defecation
2. Perianal pruritus and irritation.
3. Lower Abdominal and perineal discomfort.
4. Acute pain when piles mass is strangulated.
5. Thrombosed external hemorrhoids may present with acutely painful mass at rectum.
occasionally signs of systemic illness in case of strangulation
6. Pain during bowel movements
7. Rectal Prolapse (while walking, lifting weights)

On examination- Skin tags. Fissure, discharge, may be present.
P/R-done in Sim’s position.
Anoscopy.
Proctosigmoidoscopy.
Flexible sigmoidoscopy.
Colonoscopy.
CBP.
Proctoscopy.
Coagulation profile.
# Patients should be examined in the left lateral decubitus position (while asking the patient to
bear down) to look for any rashes, mass, tag, condylomas or eczematous lesions, external sphincter
function, Any abscesses, fissures or fistulae.

# Lubricated finger should be gently inserted into the anal canal , the resting tone of the anal canal
should be ascertained as well as the voluntary contraction of the puborectalis and external anal
sphincter. masses should be noted as well as any areas of tenderness.

3. 3


# Seek emergency care if - large amounts of rectal bleeding, Lightheadedness, Weakness, Rapid
HR < 100 BPM, low BP, anemia, weight loss.
The blood in the enlarged veins may form clots and the tissue surrounding the hemorrhoids can
die (Necrosis). This causes painful lumps in the anal area. Severe bleeding can occur causing iron
deficiency anemia.

Management- Treat only symptomatic hemorrhoids
I. Conservative
II. Nonsurgical
III. surgical
T.O.C in grade I- internal and non-thrombosed, external hemorrhoids.
Warm baths (sitz bath)-twice daily or thrice daily.
High fiber diet.
Adequate fluid intake.
Stool softeners.
Topical analgesics.
Proper anal hygiene.
To destroy internal hemorrhoids-
Rubber band ligation.
Sclerotherapy.
Coagulation.
Electrocautery,
electrotherapy.
Cryotherapy.
Laser therapy and radio wave ablation. etc.

GRADE I, II hemorrhoids- not improved by conservative procedures. Patient kept in the left
lateral position. 5ml of sclerosant is injected submucosally into the apex of the pile pedicle. 5%
phenol in arachis oil/almond oil. Patient is reassessed after 8weeks.
Complications-Too deep injection has disastrous consequences like pelvic sepsis, prostatitis,
impotence, and rectovaginal fistula.
Barron's bander is used to slip tight elastic bands onto the base of the pedicle of each hemorrhoid.
Bands cause ischemic necrosis of piles mass, which slough off in 10days.
Side effect is -bleeding.

Grade III, IV hemorrhoids with severe symptoms- Conservative or nonsurgical treatment fails.
Patient preference and Presence of anorectal conditions requiring surgery. (fistula, fissure, large
skin tags). Like- Fibrosed hemorrhoids, intero-external hemorrhoids when external hemorrhoids
are well defined.

4. 4

Procedure of hemorrhoidectomy- Open and closed techniques.
Open technique also called Milligan- morgan operation. Both involve ligation and excision of
the hemorrhoid but in open technique the anal mucosa and skin are left open to heal by secondary
intention, and in closed technique the wound is sutured. Stapled haemorrhoidopexy.
Complications-
▪ Early - Pain.
▪ Acute retention of urine.
▪ Reactionary hemorrhage.
▪ Late - Secondary hemorrhage.
▪ Anal fissure.
▪ Anal stricture.
▪ Incontinence.

Thrombosed External Hemorrhoids-
Safely excited when patients present within 48 to 72 hours of symptoms onset. If present after 72
hours from symptom onset, conservative therapy is preferred. Skin Tags excision when hygiene
problem exists
Strangulation and thrombosis of piles may present with Ulceration. Gangrene. Portal pyemia.
Fibrosis.
Diet and Regime-
✓ Eat high fiber diet,
✓ Drink Plenty of Liquids,
✓ Fiber Supplements
✓ Exercise
✓ Avoid long periods of standing or sitting Don’t Strain, go as soon as you feel the urge

AYURVEDIC MANAGEMENT OF ARSHA -
Arsha is a Mansa pradoshaja vikara. Hence Chikitsa Siddhanta is Samsuddhi (panchakarma),
Shastra, Kshara, Agni karma. Dushya of Arsha is – Twaka, Rakta, Mansa.

Treatment for shuska Arsha (non-bleeding piles) are-
• Orally- Arsha kuthar rasa
• Arshagni voti.
• Suran viti.
• Abhayaristha
• Takraristha.
• Gandharva hastadi kashaya.
• Haritaki with takra /guda
• Triphala powder etc.

5. 5


For itching and irritation- Chandroprobha voti,/ Arogyobordhani voti.

For raktarsha (bleeding piles)- any one
• Kutaja ghana voti
• Rakta sthambhana voti.
• Nagkeshar churna.
• Ayapana voti
If anal fissure and piles are co-exist – chitrakadi voti, /agnitundi voti are good choice. But first
make sure Arsha is vata- kaphaja. In pittaja arsha symptoms may agggravate.

If there is wet feeling/ or exudation/ stickiness/ staining in cloth-(ie, gudasrava)-
Nagkeshar churna/ pushyanug churna is usefull.

For sitz bath- Haldi- triphala kwashaya.
Neemba patra-haldi kashaya.
Sphatika kashaya.etc.

For local application-
Kashisadya taila.
Jatyadi taila.etc.


THANKS!