Raktashrsha A Case presentation

SDMCAH,HASSAN

1. Case presentation 01/06/2017
Raktarsha
Presented by:-
Dr.Mahendra Prasad Yadav.
First Year PG Scholar
Dravyaguna Department.
SDM College of Ayurveda &
Hospital,Hassan.
Guided by:-
Dr.Prakash L Hegde
Professor ,Dravyaguna
Department.
SDM College of Ayurveda &
Hospital,Hassan.

2. Identification Detail
•Name of the patient: x
•Age: 23 yrs
•Sex: M
•Address: Tumkur
•Date of admission: 14.03.017
•Date of discharge: 03.04.017
•IPD No. 20059
•Ward No. General Male Surgery Ward
•Bed No. 6

3. Chief complains
•Bleeding per rectum – since 2 years
•General body weakness- 6 months
Associated complaints
–Hard stool and bleeding during defecation

4. Vedana Vruttanta (History of present illness)
Patient was apparently healthy 2 year back,
then gradually he developed Bleeding per
rectum with general body weakness. He
does not take any medication at all. Last
yesterday he is suffering from severe P/R
bleeding and comes to SDM hospital Hassan
and admited in shalya general ward.

5. Poorva Vyadhi Vruttanta
(History of past illness and treatment)
No known case of DM and HTN
No history of major surgery
Kula Vruttanta (Family History)
No any specific diseases.

6. Vayaktika Vruttanta
•Functional history
–Sleep: – Has sound sleep
–Appetite: – reduced
–Bowel :– 2/3 times per day with blood
–Urine: – clear / normal frequency, 6 times /day

7. Contd…
•Personal History
–Diet – veg
•Daily dietary routine
- 7am- Coffee
–9:30am Breakfast Chapati,Uppitu.Chitrana.
–2:00 pm - Lunch - Rice, Ragi mudde
–8:00 pm – Dinner – Mude,Rice.
–9.30-10.00- sleep
– Addiction: – he is not addicted to alcohol, nicotine
and other addictive substance.
–Occupation:- Salesman,Tyre Showroom.
–Socio-economic history:- Middle class

8. Treatment History
•None

9. Astha-vidha Pariksha
1. Nadi Pitta++
2. Mala Hard with bleeding sometimes.Frequency per day – Twice /three
Ama -Saam
Gandha - N
Rupa - grathit
3. Mutra Frequency per day - N
Gandha - N
Rupa - N
4. Jihwa coated
Normal texture and color
5. Drik Intact
6. Shabda NAD
8. Sparsa No any enlargement in P/A and P/R mass
7. Aakriti Average

10. Dashavidha Parikshya
1. Prakriti Kapha++Pitta+
2. Vikriti vata
3. Sattwa Madhyama sattwa
4. Satmya Madhyama satmya
5. Ahara shakti Madhyama
6. Vyayama shakti Avara
7. Sara Ashthi sara
8. Samhanana Madhyama
9. Agni Madhyama
10. Vaya Madhya vastha

11. General examination
•G.C. – Anaemic look
•B.P. – 110/70 mmHg
•Pulse – 80/min, with regular rhythm and normal
volume
•Temp. – Normal
•Respiration – 20/min
•J
0
A
+++
C
0
C
0
O
0
D
0
•Weight = 45 kg-Previous wt =52kg
•Height = 5.6 ft

12. Systemic examination
•Chest – Clinically NAD
•VS – S
1
+
S
2
+
S
m
0
•P/A – NAD
•P/R- at 3 O’clock,7O’clock and 11 O’clock
haemorrhoidal mass found.

13. Investigations and findings
–USG abdomen pelvis–done SDMCAH 15-03-017
Normal study
–Stool Examination Report-16-03-017
–Occult blood –Negative, ova and cyst-not seen

14. Laboratory investigation –at 14-03-017
Test Result
Haemoglobin 5.2gm%
Total WBC count 6200 cells/cmm
ESR (Wister gren’s
method)
04mm/hr
Differential count Neutrophils 65%
Lymphocytes 30%
Monocytes 01%
Eosinophils 04%

15. Test Result
Platelets 3.77 lakh/cmm
RBC Count 3.10million/cmm
Haemogram reportPCV 18.%
MCV 58.1 fL
MCH 15.2 Pg
MCHC 26.1%
RDW 40.4 fL
Bio-chemistry
report
RBS 92.9 mg/dl
Blood Urea15.4mg/dl
Serum
Creatinine
0.8mg/dl

16. Test Result
Urine
analysis
Albumin Absent
Pus cells 1-2
Epithelial cells1-2/HPF
Serology HIV Negative
HBsAg Negative
HBA1C 6.60%
Mean blood
glucose
133.3mg%

17. HAEMATOLOGY REPORT
Blood Grouping

O
R-h Positive
Bleeding Time 2’30”
Clotting Time 4’30”

18. Panchalakshana Nidana
Nidana Ahara –
Guru,Madhura,sheeta,Abhishyandi,Vdahi,Virudh.
Vihara – Vegavarodha (Mala, Mutra),
Utkatasana,Vishama prasuti
Poorvaroopa/
Roopa
•Vistambha
•Daurbalya
•Kukshi aatopa
•Karshya
•Bahula udgara
•Sakti sada
•Alpa vit kata
•Grahani
•Pandu
•Udara shanka

19. ( Cha.Chi.14/23-25)
Samprapti

20. samprapti

21. Samprapti Ghataka
•Dosha : Tridosha
•Dushya : Twak raktha mamsa meda
•Agni : Jataragni
•Ama : Jataragni janya
•Udhbhavasthana: Amashaya,pakvashaya
•Sanchara : Adhogamani dhamani
•Adhishtana : Twak mamsa meda
•Vyaktha : Guda valitraya
•Marga : Abhyantara,bahya marga
•Srotas : Rakta,mamsa.medavaha,rasavaha
•Srotodushti : Sanga

23. |
||||
|
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Arsha chikitsa sutra

24. EKAL DRAVYA
i.Bilwa (Aegele marmelos)
ii.Chithraka (Plumbago zeylanica)
iii.Nagara (Zingiber officinale)
iv.Ativisha (Aconitum heterophyllum)
v.Abhaya (Terminalia chebula)
vi.Dhanvayasaka (Fagonia critica)
vii.Daruharidra (Berberis aristata)
viii.Vaca (Acorus calamus)
ix.Cavya (Piper chaba)
x.Kutaja (Holarrhena antidysentrica)

25. Chikitsa
S
N
Karma Kalpana Kala
1.Blood transfussion 4 times
2.Hemorrhoidectom
y

3Dressing P/R Yashtimadhu
Ghrita
2 Time/day
4Sitzbath 2 time/day
Karma (Therapeutic Procedures)

26. Kalpana (Oral medications) S.N. Kalpana Matra Anupana/Sahap
ana
1.Tab.Bolbadharasa 2-2-2
2.Syp.Abhayarista 15 ml. bid
3.Cap.Haem up 0--0-1
4.Tab.Pulmocef -500mg 1-0-1
5.Tab.Zefi -200 mg 1-0-1
6.Tab. Anuloma DS 0-0-2
7.Dadimadighrita 10 ml .bid
8. Tab. Aciloc 150 mg 1 tab. bid
9.Inj.Taxim-1gm bid

27. Cont…….
10 Inj.Metronidazole
11. Inj.Aciloc

28. Anuloma DS
•Ajmoda- Ptychotis ajowan
•Jeeraka – Cuminum cyminum
•Balharada- Terminalia chebula
•Yastimadhu- Glycyrrhiza glabra
•Shunthi – Zingiber officinale
•Saindhava lavana
•Swarnaksheeri- Cassia lanceolata

29. Dadimadi Ghrita
•Dadima - Punica granatum -Dried Seed- 192
g
•Dhanya (Dhanyaka) - Coriandrum sativam-
Fruit -96 g
•Citraka -Plumbago zeylanica -Root- 48 g
•Shringavera (Shunthi) - Zingiber officinale-
Rhizome -48 g
•Pippali - Piper nigrum -Fruit -24 g
•Ghrita (Goghrita) -960 g
•Jala -Water -3.072 litres

30. Daily Progress Report
Date Kalpana(Medicine)Matra(Doeses) Anupan/Sahapan
14.03.017
Tuesday
1.Bolbadha Rasa
2.Pushyanuga Choorna
2-2-2
1tsf .BID
Water
,,
15.03.017
Wednesday
Same med +Blood
transfusion+
1.Cap.Haem up
2.Dadimadi ghrita

0-1-1
10 ml .BID with L.W.W
16.03.017
Thrusday
Same treatment
17.03.017
Friday
Same t/t
Stop Pushyanug
choorna
+ Tab.Dolo -50 mg 1tab .Sos

31. 17.03.017
Friday
1.Tab.cremalax
2.Colocrep
3.Tab.Zefi -200mg
3.Plenty of water 5-
6lts with
electrolyte 2 pouch

2-2-2
2 bottles in2lts of
water
1tab .BID
b/w 5pm
18.03.017
Saturday
1.Bolbadha rasa
2.Haemup
3.Dadimadi ghrita
4.Tab.zefi-200 mg

2-2-2
0-1-0
10ml .BID
1 tab .BID
19.03.017
Sunday
Same treatment +
Blood transfusion
Inj. Lasix 20mg
Inj.Avil 1amp.
Inj.Hydrocortisone
State after BT
state before BT
,,
20.03.017
Monday






Same treatment
21.03.017
Tuesday

same treatment+
Blood transfusion

sameprocedure
22.03.017
Wednesday

same treatment.
Preparation for colonoscopy

32. Preparation for colonoscopy
23.03.017
Thrusday
Same treatment
24.03.017
Friday
Same as date 17.04
25.03.017
Saturday

Blood transfusion
same procedure
26.03.017
Sunday
1.Bolbadharasa
2.Cap.Haem up
3.Dadimadighrita
2-2-2
0-1-0
10 ml. Bid L.W.W
27.03.017
Monday
Time
10:30AM
S.A.3,7&11 o’clock Internal
piles mass-
Haemorrhoidectomy is done
Post op order
1.I.V.F -2DNS /1 RL
2.inj.Taxim 1gm
3.Inj.Metronidazole 500mg
4Inj.Aciloc 50 mg
5.Inj.Divon AQ in 100ml NS
5.Abhayarista
6.Tab.Anuloma DS
7.Tab.Inlam
8.Dressing with Y.M.Tail 20ml
P/R
9.Sitz bath
I.V . BID
I.V. TID
I.V. BID
BID
3 tsf . BID
2 tab . HS
SOS
BID
BID

33. PROGRESS REPORT DAY-1
28.03.017
Tuesday
1.I.V.F -2DNS /1 RL
2.inj.Taxim 1gm
3.Inj.Metronidazole
500mg
4.Inj.Aciloc 50 mg
5.Inj.Divon AQ in
100ml NS
5.Abhayarista
6.Tab.Anuloma DS
7.Tab.Inflam
8.Dressing with
Y.M.Tail 20ml P/R
9.Sitz bath
BID
TID
BID
SOS
3tsf .BID
2tab .HS
BID
BID
29.03.017
Wednesday
Post op day-2
Same treatment +
Cap.Haem up

0-1-0
30.03.017
Thrusday
Post op day-3
Same treatment & stop
Inj.Metronidazole

34. Planned for blood transfusion
31.03.017
Friday
Time
2:45pm
Same procedure for BT
01.04.017
Saturday

Post op day-4
same treatment
02.04.017
Sunday
1.Tab.Pulmocef-500mg
2.Tab.Aciloc-150 mg
3.Tab.Tolpa-D
4.Tab.Anuloma –DS
5.Cap.Haem up
6.Syp.Abhayarista
7. Y.M.Ghrita P/R dressing
8.Sitz Bath
1 tab .bid
1 tab .bid
1 tab. Bid
2 tab .Hs
0-1-0
3tsf .bid
bid
bid
03.04.017
Monday
Discharge with following
medicine
Dated 02.04.017 & follow up
after
5 days

35. Haemorrhoids ?
Engorgement of the haemorrhoidal venous
plexuses with redundancy of their coverings.

36. Haemorrhoids
haemorrhoides
haema=blood rhoos=flowing
bleeding

37. in anal canal
which may or may not bleed
Piles
pila (a ball)
swelling

38. External hemorrhoidInternal hemorrhoid
Below dentate line Above dentate line
Varicosities of veins
draining
inferior rectal artery
Varicosities of veins
draining
superior rectal artery
Lined by
squamous epithelium
Lined by
columnar epithelium
Painful Pain insensitive
Prone to thrombosis if
vein ruptures
(Thrombosed pile)
May prolapse outside
anal canal
(prolapsed hemorrhoid)

39. Aetiology
Straining
Constipation
Prolonged lavatory sitting
Trauma
Ageing
Diarrhoea
Lack of fibre rich diet
hereditary

40. Secondary causes
Local
Abdominal
Pelvic
Neurological
Pregnancy
Portal hypertension
anorectal deformity,
hypotonic sphincter
ascites
gravid uterus,
uterine neoplasm,
ovarian neoplasm,
paraplegia,
multiple sclerosis

41. Pathogenesis
•Various theories are :
1. Portal hypertension and varicose veins
2. Upright posture of human beings
3. Hyperplasia of corpus cavernosum recti
4. Erosion and weakening of wall of veins due
to infection secondary to trauma
5. Hard faecal matter obstructing venous return
6. Raised anal canal resting pressure

42. CURRENT VIEW
•Shearing forces acting on anus
•Caudal displacement of anal cushions and
mucosal trauma
•Fragmentation of supporting structures
•Loss of elasticity of anal cushions
•Loss of retraction of cushions

43. 11 o’clock
7 o’clock
3 o’clock

44. Incidence
•Difficult to evaluate.
•Prevalence ~ 5%.
•Peak of prevalence is between 45 and 65.
•unusual before the age of 20.
•Caucasians > Afro-Caribbeans.

45. Symptoms
Prolaps
Pain
Discharge
& Pruritus
Bleeding
HaemorrhoidsProlaps
Pain
Discharge
& Pruritus
Bleeding
H’oids
Earliest symptom
{ A splash in the pan }
( If complication )

46. Physical Examination
•Left lateral decubitus position
•Any rashes, condylomata, or eczema
•Any abscesses, fissures or fistulae

47. Digital Rectal Examination
•The resting tone of the anal canal
•voluntary contraction of the puborectalis and
external anal sphincter.
•mass / any area of tenderness.
•Int. hemorrhoids are generally not palpable
•Appear as bulging mucosa on Anoscopy

48. Gr I Gr II Gr III Gr IV
not prolapse returns spontaneously manually returned remains prolapsed
Grading of hemorrhoids (on history)

49. Complications of hemorrhoids
Portal pyaemia
Suppuration
Fibrosis
Ulceration
Gangrene
Thrombosis
Strangulation
Gripped by Ext. sphincter
Impeded venous return
prolapse

50. Thrombosed
External haemorrhoids

51. Prolapsed
Internal haemorhoids

52. TREATMENT
•Conservative Dietary and lifestyle modification.
•Non operative/office procedures.
•Operative hemorrhoidectomy
•Minimal invasive procedures

53. Dietary & Lifestyle modifications
Minimize straining at stool.
and
Prevention of constipation

54. Dietary & Lifestyle modifications
•Drinking Fluids
•High-fiber diet
•Use of Fiber
supplements
•Stool softeners
•Exercise
•Local hygiene

55. Dietary & Lifestyle modifications
“you don't defecate in the library
so
you shouldn't read in the bathroom”

56. Dietary & Lifestyle modifications
•If prolapses,
gently push back
into anal canal
•Use moist towelettes or wet toilet paper
instead of dry toilet paper.

57. Topical Treatment
•Include:
– Pads,
– Ointments,
– Creams,
– Gels,
– Lotions
– Suppositories.

58. •Used now a days includes

–Calcium dobesilate .25%
–Anhydrous lignocaine 3%
–Hydrocortisone acetate .25%
–Zinc 5%

59. Sitz bath
•Sitz mean to sit
•Used in treatment of
Gr. IV hemorrhoids
•Duration:15-20 minutes
•Cold water is used
–Draw heat out of sore piles
–Reduce blood flow in them
–Reduce pressure inside
swollen piles

60. Sitz bath
•Post operative
•Warm water is used
–Dialatation of blood vessels
–Allow blood to pass through
swollen piles more quickly
–Relaxes muscles so ease anal
sphincter tone

61. Oral Medications
•Oral vasotopic drugs.
•Most common - purified flavonoid fraction.
•Actions:
–Increases vascular tone
–Increases lymphatic drainage
–Anti-inflammatory effects.
–Several recent studies have shown it to be
effective.

62. Topical medications
Commonaly used is
Combination of
Calcium dobesilate & docusate sodium

63. •Calcium dobesilate:
•Decrease capillary permeablity,
•Decrease platelet aggregation
•Stops bleeding
•Reduce thrombus formation
•Improves mucosal inflammation

64. EKMOOLIKA PRAYOG IN
RAKTARSHA

65. KUTAJA
L. N-Holarrhena antidysenterica Wall
Family - Apocynaceae
English name- Kurchi
Hindi – Karchi
Kannada name – Kodasige
Kula – Kutaja
RASA PANCHAKA
-Rasa- Tikta,Kasaya(twak),
Katu,Tikta(seed)
-Guna- Laghu,Ruksha
-Vipaka –Katu
-Veerya – Sheeta
-Doshkarma- Pittakaphasamaka
Chemical constituents-
conessine(kurchicine)
Holarrhimine,Holarrhidine
Used part- Stem bark & Seed
Dose- Twak kwatha 30-50ml,
Bija churna 0.5-1.5 gm

66. A Clinical Study of Kutaja
(Holarrhena antidysenterica Wall)
on Shonitarsha
ATANU PAL * P. P. SHARMA ** P.
K. MUKHERJEE ***
Institute of Post Graduate
Ayurvedic Education & Research, S.
V. S. P. Hospital, Kolkata.
AYU VOL. 30, NO. 4 (OCTOBER-DECEMBER) 2009, pp. 369-372

67. METHOD
Total 20 patients were registered for the clinical
trial and were treated with Kutaja tvak churna in a dose
of 4 gms twice a day.
Thetreatmentschedulewas
continued for two weeks.
Any unwanted effect of the drug during the total
period of treatment schedule was noted. Laboratory
investigation of routine blood, stool and urine were carried
out before commencement and after completion of the
treatment schedule.

68. RESULT
Analysis of the data of the present study revealed
Kutaja (Holarrhena antidysenterica Wall) tvak churna
has highly significant role in stopping the bleeding in the
disease Shonitarsha (Bleeding piles).

70. Questions?
•.