CASE STUDY

Personal history

Name
: Ms. Sriya Kanthi
Age : 50 years
Sex
: Female
Address
: Ginigathhena
Civil status
: Unmarried
Occupation
: Sewing
Religion
: Buddhist

Present complaint &

duration
Main complaint & history

Small skin tag in anal orifice

Prolapse when defecation
Spontaneously reducing
No pain or bleeding
No constipation

Since 3 yrs
It is gradually occured

 No other complaints
Past medical history
Family history : no
Bowel habit : normal
Urination

: normal

: no

Dietary habits:
Rice and vegetables for all the three
meals
Rarely eat meat and fish
Has eaten lot of spicy food before getting
this illness
Less water intake

Sleeping pattern
No sleep disturbances

Constitution
Physically - Pitta-Vatha
Mentally

- Madya Sathwa

Examination of Arshas
General examination
Local examination
General - per rectal examination
Special instrumental proctoscope

Examination:

According to Trivida pariksha

Prasna (interrogation)
Darsana (inspection)
Skin tag can see
No any other abnormality
Digital examination
Normal sphincter tone
pile mass can be feel 11 & 7 o clock

Proctoscopy

Pile masses can be seen

7 o clock and 11 o clock position
No bleeding
No pus discharging
No other abnormalities in rectal wall

Special features in
examination
Degrees of
Internal Piles
1st-degree
Projects into anal lumen internally
2nd-degree
Protrusion outside anal canal at defecation
with spontaneous reduction
3rd-degree
Protrusion outside anal canal at defecation
straining and needs digital repositioning
Permanently prolapsed irreducible piles

Examination of srothas
Anna waha srothasaGuda-pile mass
Agni-abyavarana sakti
weak
Jarana
sakti-weak

Examination of sara:

Rasa-avara
Raktha-avara

Causes
Sitting long time duration when
sewing
It is nearly 8 hours through out 3
years
Not having regular diet.
No regular bowel habit
Not having a good sleep

Clinical features
Small mass comes out when
defaecation
No

 Dosha- vata and kapha

Dushya- rasa, rakta, mansa
Roga margaya(site of disease): External &
internal
Srothas- anna waha srothas, purisa waha
srothasa
Srotho dusti- sangha

Pathogenesis
Susruta has expressed arsas under raktaja and
mansaja disease
Pathological dosas
Rakta involvement
Travel through pradhana dhamani
Affection of mamsadhara kala of gudavali
Arsas (fleshy mass)

Investigation
Proctoscopy
full blood count
Differential diagnosis
Chronic fissure-due to skin tag
Kaphaja arsas

Prognosis

yapya
According to age
Constitution
dietary habits

Cikitsa sutra
chaturvido arsasa: sadhanopaya:
thadyatha bhesaja:ksaro agni sastaramiti
tatra achira kala jatanyalpadosa lingopadravani
bhesaja sadhyani mrdu prasutavagadanyuchchitani
ksarena karakasa stira prutukatinanyagnina
tanumulanyuchchitani kledavanticha sastrena
tatra bhesja sadhyanamaarsa samadrushhanatu
bhesaja bhavati
ksaragni sastra sadhinyatu vidhana mukhyamana
mupadharaya
(Su/ci/6/3)

Management
Curative

Medical
parasurgical
surgical
Systemic
local
ksara karma
chedana
Dipana
snehana
agni karma
agni karm
Pachana
svedana
raktamoksana
Anulomana
dhupana
Rogahara yoga avagahana

According to the Sushruta

Samhitha
Mode of treatment
1.Beshaja/medicines
Arshas
-Which are newly occurred
-Having less dosha-dushya
-Symptoms are not fully
developed
-Without complications
2. Kshara applications
Arshas
-Of soft consistency
-Which are widely spread
-Deeply situated
-Protruded out

3. Shashtra/surgery
Arshas
Which are thin rooted
Which mucous discharge
Projected out
4. Agni/thermal
cauterization
Arshas
Having rough surface
Having fixed base
Which are thickened
Which are harder in
consistency

Medicinal treatments for Arshas

This mode of treatment can cure first degree
hemorrhoids. In other degrees of piles it may be used
along with other procedures. This treatment is done after
assessing dosha predominance.

Vataja - sneha, sweda, vamana, virechana, asthapana

and anuwasana vasthi
Pittaja virechana
Rakthaja - sanshamana
Kaphaja - ardrak, kulathya
Thridoshaja - all doshaja cikithsa

systemic medicine
-

improve appetite
correct bowel habbits
astringent action on blood vessels
jataragni to be kept in normal status

Local measures
help in reducing pain and inflammation
- Svedana
- Avagaha
- Abyanga
- Dhupana
- pralepa
- rakta srava

Para surgical measures

should care of
pre operative measures
- operative measures
- post pperative measures
Ksara karma
Agni karma
Rakta moksana

Kshara karma forArshas

It is a non-surgical procedure of Ayurveda indicated
for the management of hemorrhoids.
A medicine (alkaline in nature) derived from a
combination of various herbs is applied to the pile
mass with the help of a special slit proctoscope.
It is a type of chemical cauterization.
The Kshara karma method of treating piles has
been described in detail in the Ayurvedic classical
text Sushruta Samhitha.
The details of preparation of the herbal
combination are mentioned in Sushruta Samhitha.
Application of kshara is considered superior over
other procedures used for the treatment of
hemorrhoids or piles.

Ksara
Pratisaraniya ksara is used
used in soft
- extensive
- deeply situated
- projectile piles
Pittaja and raktaja arsa treated by
mrdu ksara

Purva karma

Sneha, sweda and one day prior mrdu virechana was given.
Pradana karma
This is indicated for II Grade internal piles. The patient is in
lithotomy position and kshar is applied to the dilated pile pedicles
with the help of Jambaushatha shalaka under the guidence of
proctoscope (Arsho darshan yantra) having slit on its side.
When the colour of arshas aree appeared like a colour of pakwajambu, kshara is washed out by amla dravya.
Kshara application is repeated till the pakwa-jambu colour is not
appear.
Each pile pedicle is treated differently at the interval of one week.
This may cause fibrosis of the tissues which prevents the pile
pedicle from protrusion.

Paschat karma
The paste of yashtimadhu and ghruta is applied to the arshas.

APPLICATION OF KSHARASUTRA THERAPY

In this process hemorrhoids are tied off at its
base (pedicle) by Kshara-sutra or specially
processed thread with medicines.
By the principle of pressure necrosis, it
prevents blood supply to the respective pile
mass immediately.
Eventually hemorrhoids shrink, shrivel up, die
and ultimately fall off within 10 days, leaving
some scar tissue which supports the
corresponding veins in that area, preventing
them to distend or bulge further.

Agni karma
Modified way is - electric heat cautery
- freezing
Superior treatment
It can destroy diseased tissues completely
Indicated in rough
- broad
- hard
- fixed masses
- vataja and kapaja
- prolapsed and 3rd degree piles

Agni karma for Arshas

Agni karma in the form of thermal
cautery is a suitable procedure in the
excision of sentinel piles and anal
warts falling in Vatha Kaphaja type of
Arsha.
The hot shalaka is applied at arshas.
Procedure is same as kshara
application. Even after the excision of
arshas, agni karma is recommended.

Rakta moksana
Susruta enumerated arsas as a contra indication
for rakta moksana.
Caraka advised local blood letting in presence of
vitiated blood with the help of jalauka.
Finally sastra karma is indicated in pedunculated
big
discharging arsas of good risk
to do using surgical procedures.

Shastra karma for Arshas

After preparing the patient, the arshas
is excised in lithotomy position. All the
bleeding points are cauterized.
Raktha mokshana for Arshas
It is done with the help of jalauka,
suchi, shashtra etc.

Management
1. Treat according to dosha
2. Use four method of treatmentbhesaja, ksara, sastra, agni
3. Use of preventive methods
4. Rath pith treatment for sravi arsas

Preventive

1. avoid etiological factors

2. dosas to be kept in equilibrium
3. to bring agni in normal

Pathya
Drink Plenty of fluids
Do take adequate fibers in the diet
Exercise regularly.
Train yourself for regular meals
Lose weight, if you are overweight
Chew your food for proper digestion
Keep the anal area clean
Take warm baths
The hot poultice of dry radish is very good in nonbleeding piles
Have enough sleep

Apathya
Dont sit too much on a hard surface
Dont sit in the toilet for long periods.
Dont drink coffee or alcohol
Hurry, worry and curry is absolutely not good
Dont lift heavy objects.
Dont use laxatives regularly
Dont consume any medication directly; this
can be harmful for your stomach as well as
diseases

General description of guda according

to ayurveda
One among with fifteen kostanga(hollow
vicera)
One among the pranayatana
It is a sadyo pranahara marma
It is included as bahya srotas
Two parts-uttara guda and adara guda
Uttara guda-extend upto pelvic colon
Adara guda forms the part of anorectum
Functions of guda is governed by apana
vayu
Excrete waste products from the body

Arsa
Arsha Ru(root) + Asun
away

get the life

Abnormal fleshy growths in ano rectal

region like haemorrhoids, polyps, warts,
sentinel tags, and neoplasia either or
malignant or other fleshy growths of
different regions are included under
nomenclature of arsas while all arsas
are not haemorrhoids

Synonyms
Payu roga- disease of anus
Durnama- bad
Guda kila- peduncle
Gudankura- swelling in anus
Anamaka- gives pain to life
Gudaja- arrising from guda

Classification
1.Etiological
According to Susruta
Vataja
Pittaja
Kapaja
Raktaja
Sannipataja
Sahaja
2. According to site
Internal
External
Interno external

3. Clinical
classification
Suska
Sravi
4.According to therapy
Bhesaja sadhya
Ksara sadhya
Agni sadhya
Sastra sadhya
5. According to prognosis
Sadhya curable
Kasta sadhya difficult to cure
Yapya may be treatable if all
sources available
Asadhya - incurable

Etiology according to ayurveda

1. Dietic factors-incompatible diet, excessive
and less intake, irregular intake
2. Habits-sexual indulge, natural urge (vega
darana), pregnancy
3. Irritation in anal canal-deffective sitting,
vehicle riding, local touching with hard and
rough objects
4. General weakness and suffering from
prolonged illnesses
5. Mandagni
6. Genetic

Purva rupa of Arshas

Anna vishtambha
Daurbalya
Atopa
Ksrusha
Udgara bahulya
Pada apranikatha
Alpa mala/constipation
Grahani
Pandu
Udara

Roopa of Arshas

Subjective General symptoms

Agni mandya
Asya vairasya
Arochak
asthiparva shoola
vankshana shoola
hridaya shoola
nabhi shoola
payu shoola
Angamarda
Klama
Jwara
Swasa
kasa etc.

Objective General symptoms

Acharya charak has described
different sizes and shapes of arshas.
Eg: sarshapa, masur, masha, yawa,
tinduka, kareera, udumbara etc.

Complications of Arshas

Baddagudodara
Udawartha
Vamana
Aruchi
Vibanda
Athisara
Shawasa
Jwara
Shosha
Moha
pada shotha
guda, nabhi and medra shotha

Haemorrhoids
Haima=blood
rhoos=flowing
Pile ball
Definition(modern)
dialated veins within the anal canal in the
subepithelial region formed by radicles of
the superior, middle,and inferior rectal veins

Classification
1. Primary/Idiopathic Hemorrhoids

Causes
Standing position of human
being
Anatomical factors
Familial or genetic
Constipation causes
excessive straining

2. Secondary Haemorrhoids
Causes
Carcinoma of rectum
Portal hypertension
Pregnancy

3. Depending upon the

location of Haemorrhoids

Internal haemorrhoids
above the dentate line,
covered with mucous
membrane.
External haemorrhoids
at anal verge, covered with
skin
Interno-external
both varieties together

Location
Classically situated in the 3, 7, 11 0
clock positions.
Superior haemorrhoidal vein gives two
branches on right side (right anterior
and right posterior) and one branch on
left side. (left lateral)
Hence, piles are 2 on right side and
one on left side.
Accessory - At every oclock position

Symptoms according to
prolapse
1st degree no prolapse
- bleeding occurs
2nd degree prolapse occurs with
bowel movements but reduce
spontaneously
- prolapse
- bleeding
- discomfort

 3rd degree prolapse occurs daily with

defaecation and exertion.
requires manual reduction.
- prolapse
- bleeding
- soiling
- pruritis and discharge
4th degree persistent prolapse
reduction not possible
- symptoms as the above
- pain
- thrombosis

Etiology according to modern science

1.
2.
3.
4.
5.
6.

Hereditary
Anatomical
Existing cause
Physiological cause
Diet
Secondary to diseases
Chronic constipation
Difficult micturition
Portal hypertension
7. Pregnancy

Predominal symptoms

Abdominal flatulence
Weakness
Constipation
weakness of legs etc..

Pathology
(according to modern science)
Deficiency of fibre diet, irregular diet,
constipation, irregular bowel habits,
pregnancy,sedentary activities
Congestion, engorgement of vessels with
blood in haemorrhoidal plexes
Laxity of anal cushions
Haemorrhoids

Clinical features
Bleeding
-bright red
- painless, and occurs along defaecation
-Splashes in the pan as the stool comes
out
Prolapse
Pain-is not characteristic
Mucous discharge

Prognosis
Sadhya single dosha
bahya vali
duration

- <1yr

Kasta sadhya combination of two

doshas
- madyama vali
- >1 yr duration

 Asadhya Tridosha
- sahaja
- antar vali
- complicated
Yapya tridosaja with minimal
features

Complication
Bleeding commonly can see in first degree and early stage
of second degree
long standing cases present anaemia
usually occurs externally
can bleed internally into rectum
Thrombosis
external thrombosis are common
occurs as acute swelling in the anal verge and
extremely painful
occurs due to high venous pressure

 Strangulation
second degree piles are commonly
affected
when the internal haemorrhoid prolapses
and is gripped by external sphincter,further
congestion occurs as the venous return
becomes impeded and strangulation occurs
associated with considerable pain
called as acute attack of piles
Gangrene
occassionally occurs due to anaerobic

 Fibrosis
more common in external haemorrhoids
Suppuration
very rare
occurs as a result of thrombose pile
throbbing pain with peri anal swelling
Pyelophlebitis
rare
usually follows infection and suppuration
of the haemorrhoids

Investigations
Per rectal examination
Proctoscopy
Sigmoidoscopy

Methods of treatment
Medical treatment
Fixation treatment
Sphincteric pressure reduction
Excision of haemorrhoids
(haemorrhoidectomy)

Prevention
bowel regulation
avoid excessive straining while
defaecation
high residue diet
mild laxative
topical ointment for local application
to reduce swelling and pruritis

Medical treatment
raw and unprocessed bran
natural food fibre
tropical with hydrocortisone for itching
ointment and suppositories containing
astringent and emollients for discomfort
and pruritis

Treatments of piles
Lords dilatation
Under general anesthesia, the internal sphincter it widely
stretched which is supposed to relieve the venous
congestion and improve the piles.
This is indicated in grade 1 piles.
Injection of sclerosant
5% of phenol in almond oil is injected into sub mucosa
above the dentate line. Hence it is painless. It produces
aseptic thrombosis of pile mass and is indicated in
grade 1
Barrons band application
It is indicated in grade 1 and 2 haemorrhoids, where in
bands are applied at the neck of the haemorrhoids.

Haemorrhoidectomy
- Excision of the pile masses up to
base is indicated in grade 2 and 3
haemorrhoids.
Cryosurgery
- Liquid nitrogen at -1960C is applied
to pile masses which coagulate
tissues.

Post-operative complications

Retention of urine
Secondary haemorrhage
Anal stenosis
Wound infection

More about ksara

Definition

tatra karat kaandv kra
(Su. Sam.Su. 11/4).

ksara
Ksara is defined so because it destroys and
removes the unhealthy, vitiated tissues
(Ksarana)
Ksharana : This means that the kshaara mobilises, peels
off, burns away or cuts off the vitiated
Kshanana : This means Himsana (Twangmaamsaadi
himsanaath).

Importance of Ksara
treated as sastra and anusastra due to
its function;
excision removal
cutting deviding
scraping
mitigates all tridosas
Ksara act in both cutting and healing
process simultaneously

Properties of Kshara
Kshara pacifies of all three doshas because it is prepared
by many source plants.
Ushna veerya - it has cauterization & disruption
ability (although it is Soumya, but it also contains source
plants of Ushna veerya.)
Katu rasa, Ushna veerya and Teekshna guna facilitates
transformation, purification, absorption, healing,
scraping and coagulation effects.
Due to these properties it is beneficial in worm
infestation, kaphadusti, skin diseases, toxic formation,
obesity etc.

Chemical nature of Kshara

Ksharas are derived from the ashes of different plant roots and
plants

Alkali in nature (but Tankana considered as a kshara, where as

its chemical nature is acidic)

Allalkalishave apHgreaterthan7and makehydroxide

ionsinwater.

All alkalis will make litmus paper turn from red to blue.

Allalkalisreactwithacidsto form asaltandwater.

Indigestionmay be caused by too muchhydrochloric acidin

thestomach.

Alkalis can used internally to, neutralizetheacid.

Benefits of ksara

Non invasive surgery

No wound
Scars disappears within 2-3 weeks
Low cost
No need to admit
No need of anaesthetic drugs
Minimal discomfort to patients
Excellent results
Amazing benefits

Uses of Para surgical treatments

Patients who are fear of under going
surgery.
Could use various diseases
internal diseases patients.

and

The people of delicate temperament

and age.
Patient are not fit to undergo on
surgical operation, can use these

Properties of Kshara
10 Properties

Rasa
- Katu
Veerya - Ushna
Guna Agneya
Teekshna

&

When used in excess Can produce loss of libido

Tridoshagna
Shodana
Soumya
Ropana
Dahana
Soshana
Paachana
Stambana
Vilayana
Lekhana

Types
According to use Paniya- internal
Pratisaraniya external
According to potency

Mild mrdu
Moderate madhya
Strong - tikshna

Mode of Action

It has healing and cleansing effects.

It allows the proper drainage of pus from the fistula
The cutting effect of thread incises the skin
gradually without a surgical incision.
Less infection than the conventional seton therapy.
It is having the action of Excision, Scrapping,
Draining, Penetrating, Debridement, Sclerosing
and Healing.
Paniya ksara act through changing internal
environment of body (prakit vighata concept of
ayurveda).
It digests Ama

Mode of Action of Pratisaraniya Ksara in Internal piles

(1) It cauterizes the pile mass directly because of its corrosive

nature.
(2) It coagulates protein in haemorrhoidal plexus.
(3) The coagulation of protein leads to disintegration of
haemoglobin into haem and globin.
(4) Synergy of these actions results in decreasing the size of the pile
mass.
(5) Further, necrosis of the tissue in the haemorrhoidal vein will
occur.
(6) This necrosed tissue slough out as blackish brown discharge for
3 to 7 days.
(7) The haem present in the slough gives the discharge its colour.
(8) The tissue becomes fibrosed and scar formation seen.
(9) The haemorrhoidal vein obliterates permanently and there is no
recurrence of haemorrhoids.

Method of preparation of
ksara
On an auspicious day, during sarat rtu,
from an auspicious place
Select disease free tree
Chop into small pieces
Dry completely
Made into a heap along with sudha
sarkara
Use tila plant to burn
Collect ash after burning completely

Cont..
Six parts of water added and stir well
Filter through cloth
Reduce water content by boiling
Heat until precipitate the clear white
powder
If you need to get more potent ksara
can be added prativapa

Good qualities of ksara

Not very strong

Not very mild
White in colour
Smooth
Slimy
Not spreading
Neither too thick nor too watery
Acts rapidly

The Herbs suitable for Ksara

Kutaja
Palasha
Asvakarna
Tilvaka
Snuhi
Patala
Vrsa
Citraka
Indravrksa
Agnimantha
Asvamaraka
Paribadraka
Their root, stem, branches, leaves and fruits may
be burnt and ash collected.

Palasa

Is the main herb in this research

Palasa - Sanskrit name for Kela
Botanical name Butea monosperma Linn. (Fabaceae)
Synonyms - Brahmavruksa, Raktapuspaka, Ksarashresta,
Kimsukaare

Properties
Rasa - tikta,katu and kasaya
Guna - sara, laghu and snigdha
Vipaka katu
Veerya ushna
Action of bark kaphavatashamaka
Flowers are kaphapitttaghna.
It is used in externally for arsas and wounds.

THANK YOU