ARSHA (HAEMORRHOIDS / PILES)
INTRODUCTION
Arsha is defined that the mass which is formed in Guda by pathological involvement of Twak, Mamsa and Meda. Moreover it is also opined by Charaka that a projection which is produced in Guda is called Arsha, while in other places of body is known as Adhimansa.
Arsha (Haemorrhoids) has been primarily classified into two types like Shushka and Ardra, Sahaja (congenital) and Jatottara (originated later on due to its own causes). Considering Doshic dominance, it is again classified into four varieties i.e. Vataja, Pittaja, Kaphaja & Shonitaja. Two or three Doshas together can produce mixed types of Arsha. Four kinds of treatments have been mentioned for Arsha i.e. Shastrakarma (surgical treatment), Agnikarma (cauterization), Ksharkarma (cauterization with alkali) and Shaman Chikitsa (medicines).
Case Definition:
Feeling of external mass in anal region associated with or without bleeding and pain. It usually occur at the level of Ano-rectal ring and prolapsed through anus at 3, 7 and 11 o’clock positions.
Various Presentations:
According to the predominance of particular Dosha, following presentations of the disease may be found.
Table 13.1: Types of Arsha with their characteristics
Features | Vatika | Paittika | Kaphaja | Raktaja |
Morphology of Pile mass | Wrinkled, hard, rough, dry, dusky red coloured pile mass, Shape like Karpasa Phala or Kadamba Puspa | Soft, flabby and delicate, red yellow black or blue coloured pile mass, Shape like Jalauka or Yava | Large sized, protuberant, smooth, rigid and benumbed, pale or white coloured pile mass shape like Karira, Panasa Ashti, Gaustana | Shape like Vata, Gunja seed, Vidruma |
Discharge | Absent | Foul smelling thin yellowish red discharge | continuous and profound discharge of tawny, whitish or reddish and slimy fluid | – |
Bleeding | – | Present | – | Severe |
Vega | Retention of flatus, urine and feces | – | – | – |
Colour of Twak, Nakha, Mukha, Netra, Mala and Mutra | Blackish | Yellowish or greenish | Whitish | – |
On palpation | – | Tender | Painless | Hot |
Associated Features | Colicky, pricking pain, twitching, tingling | Burning sensation, itching, pricking pain and tendency to suppuration | Thick & long standing swelling, excessive itching | Loss of strength & valour, senses become weaker, Immunity decreases |
Differential Diagnosis:
Rectal prolapse (Gudabhramsa)
Fissure-in-ano (Parikartika)
Ulcerative colitis and Crohn’s disease
Condyloma Acuminata
Proctitis
Ano-rectal warts
Ano-rectal abscess
Rectal polyp
Malignant tumours (Arbuda
LEVEL 1: AT SOLO AYURVEDA PHYSICIAN’S CLINIC/PHC
Clinical Diagnosis: On the basis of history and clinical presentations, patient can be diagnosed provisionally as case of Arsha.
Investigations: At this level, no specific test is needed to be performed.
Treatment: In the initial stage, when the patient is having mild features of Arsha, along with diet restriction, two or more of following drugs may be given:
Table 13.2: Medicines at level 1 for Arsha
Drugs | Dosage form | Dose | Time of administration | Duration | Anupana |
Haritaki Churna1 | Churna | 2-4 gm | Empty stomach / bed time or early morning | 2-3 weeks | Luke warm water |
Triphala Churna2 | Churna | 2-4 gm | Empty stomach / bed time or early morning | 1-2 weeks | Luke warm water |
Draksha3 | Dried fruit | 10-20 gm | Empty stomach / bed time or early morning | 1-2 weeks | Luke warm water |
Aragvadha4 | Churna | 2-4 gm | Empty stomach / bed time or early morning | 1-2 weeks | Luke warm water |
Castor oil5 | Oil | 10-20 ml | Empty stomach / bed time or early morning | 1-2 weeks | Luke warm water |
Avipattikara Churna6 | Churna | 5-10 gm | Empty stomach / bed time or early morning | 2-5 days | Water |
Piplayadi Ghrita7 | Ghrita | 5 gm | Twice daily before meals | 1-2 weeks | Luke warm water |
Takrarishta8 | Arishta | 10 -20 ml | Twice daily after meals | 1-2 weeks | Equal quantity of water |
Abhayarishta9 | Arishta | 10 -20 ml | Twice daily after meals | 1-2 weeks | Equal quantity of water |
Surana Vataka10 | Vataka | 500 mg | Twice daily after meals | 1-2 weeks | Luke warm water |
Eranda Bhristha Haritaki | Churna | 3-5 gm | Empty stomach / bed time or early morning | 2-5 days | Luke warm water |
Local Application:
Parishek: Arka11, Eranda12, Bilvapatra Kwatha13
Avagaha: Triphala Kvatha14, Panchavalkala Kwatha
Dhoopana: Arkamoola15 and Shamipatra16
Abhyanga: Jatyadi Taila17, Murivenna
Matra Basti: Jatyadi Taila Pippalyadi Taila
Patha-Apathya (Diet and life style):
Do’s –
Ahara: Green gram, fruits like Draksha, orange juice, sweet lemon juice, musk melon, salads prepared from cabbage, cucumber, carrot,
spinach and vegetables prepared from green leafy vegetables, Surana, Patola, gourd, intake of sufficient quantity of warm water.
Vihara: Regular exercises like walking, jogging, outdoor games, following daily & seasonal regimen properly.
Don’ts –
Ahara: Heavy food articles and preparation, green peas, black eyed beans, yellow gram, raw vegetables and salads, refined foods such as white flour, cabbage, cauliflower, brinjal, peas, potato.
Vihara: Jobs involving sedentary activities, continuous standing,
sitting for long durations on hard seats, continuous cycling or bike riding etc.
Referral criteria:
Cases not responding to the therapy
All case of moderate to severe bleeding per rectum
Cases with complications
LEVEL 2: CHC’S OR SMALL HOSPITALS WITH BASIC FACILITIES
Clinical diagnosis: The diagnosis is made on the basis of criteria mentioned in level-1 for fresh cases. The case referred from level-1 or
fresh case must be evaluated thoroughly for any complication.
Examination:
Per rectal examination
Proctoscopic examination
Investigations:
CBC
Special investigations like ECG, Chest X-Ray may also be required for surgical fitness of patients who requires operation.
Treatment: Treatment given in level-1 may be continued. Following medicines may be added; patient may be kept under observation while prescribing these kinds of medicines.
Table 13.3: Medicines at level 2 for Arsha
Drugs | Dosage form | Dose | Time of administration | Duration | Anupana |
Arogyvardhini Vati18 | Vati | 1-2 Vati | At bed time or early morning empty stomach | 1-2 weeks | Luke warm water |
Arshakuthara Rasa19 | Vati | 1-2 Vati | At bed time or early morning empty stomach | 1-2 weeks | Luke warm water |
Kankayana Vati20 | Vati | 1-2 Vati | At bed time or early morning empty stomach | 1-2 weeks | Luke warm water |
Phalatrikadi Kwatha21 | Kwatha | 20-40 ml | Empty stomach / twice a day | 1-2 weeks | – |
Erandamula Kwatha22 | Kwatha | 20-40 ml | Empty stomach / twice a day | 1-2 weeks | – |
Pathya – Apathya (Diet and life style education): Same as level 1
Referral criteria:
Patients with severe bleeding per rectum.
Patients having severe anaemia, who needs blood transfusion.
Piles cases associated with other disorders like heart disease, uncontrolled BP, DM, HIV positive, HbsAg positive, VDRL positive, malignancy etc.
LEVEL 3: AYURVEDA HOSPITALS AT INSTITUTIONAL LEVEL OR DISTRICT
HOSPITAL / INTEGRATED AYURVEDIC HOSPITALS
Clinical Diagnosis: Same as level 1: For a fresh case reporting directly
Investigations: Same as level 2
Treatment: At this level, in addition to treatment options of level 1 and 2, the following treatment options should also be tried.
Kshara Karma (potential cauterization)
Kshara Pratisarana
Kshara Sutra ligation
Agni Karma (direct cauterization)
Shastra Karma (surgical management)
Classical Virechana Karma
Pathya – Apathya (Diet and life style education): Same as level 1
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