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ORIGINAL ARTICLE
Year : 2022  |  Volume : 16  |  Issue : 4  |  Page : 274-279

A comparative clinical study of Vasa Paratisarneeya Teekshna Kshara and Apamarga Paratisarneeya Teekshna Kshara in the management of Abhyantara Arsha (Internal Piles)


1 Department of Shalya Tantra, Faculty of Indian Medical System, SGT University, Gurgaon, Haryana, India
2 Department of Shalya Tantra, National Institute of Ayurveda, Jaipur, Rajasthan, India

Date of Submission27-Aug-2020
Date of Decision04-Aug-2022
Date of Acceptance10-Aug-2022
Date of Web Publication17-Dec-2022

Correspondence Address:
Himadri Mudgal
Department of Shalya Tantra, Faculty of Indian Medical System, SGT University, Gurgaon Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joa.joa_22_20

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  Abstract 


Introduction: Ayurveda has become a cornerstone of our history and played a significant function in defining our environment. Aacharya Sushruta has described the concept of Ashta-Mahagada. Arsha. Aacharya Sushruta has described various types of treatment modalities for Arsha, which include Kshara Karma. The present study was planned and carried out to compare the efficacy of Vasa and Apamarga Paratisarneeya Teekshna Kshara (VPTK and APTK) in the management of Abhyantara Arsha. Methods: For current study total 30 patients were taken and allocated into 2 groups (Group A and Gtoup B). Time plan for the study was 1 month including follow-up. Follow-ups were done on 2nd, 3rd and 4th week. In 1st Group (A), 15 subjects having 1st, 2nd & 3rd degree internal pile were taken and it was kept as a control group. Here Apamarga Pratisaraneeya Teekshna Kshara was applied and in 2nd group (B) Vasa Pratisaraneeya Teekshna Kshara was used. The sign and symptoms were evaluated before and after accomplishment of treatment. Results: In reduction of bleeding, Group B (96.25 %) showed better result than Group A (91.90 %). For reducing size of pile mass, Group A (92.50%) was better than Group B (89.00%). But in post-operative pain, Group B caused less pain (100%) than Group A (75.18%).

Keywords: Arsha, Ashta-Mahagada, bleeding, Kshara Karma, pile mass, postoperative pain


How to cite this article:
Mudgal H, Kumar P H. A comparative clinical study of Vasa Paratisarneeya Teekshna Kshara and Apamarga Paratisarneeya Teekshna Kshara in the management of Abhyantara Arsha (Internal Piles). J Ayurveda 2022;16:274-9

How to cite this URL:
Mudgal H, Kumar P H. A comparative clinical study of Vasa Paratisarneeya Teekshna Kshara and Apamarga Paratisarneeya Teekshna Kshara in the management of Abhyantara Arsha (Internal Piles). J Ayurveda [serial online] 2022 [cited 2023 Feb 6];16:274-9. Available from: http://www.journayu.in/text.asp?2022/16/4/274/364044




  Introduction Top


The protection and promotion of well-being, as well as longevity, have been a problem in human history. Research to promote radiant health and the treatment of diseases began with the evolution of human life itself. Acharya Sushruta had mentioned theory of Ashta-Mahagada[1] i.e eight chronic diseases which have very poor prognosis Arsha is one such disease.

Because of following sedentary lifestyle, unhealthy eating patterns, excessive sitting or standing, prevalence of anorectal disorders are slowly increasing in population. These proctological conditions commonly gets associated with psychiatric symptoms because of their position in body and impaired suffering that impacts the quality of life. As per Ayurveda, anorectal diseases are usually caused by Mandagni, leading to Vibandha (Constipation). In constipation by straining there will be pressure on haemorrhoid veins situated in anal canal that induce its dilation is considered as piles. Perianal skin is one of the most pain-sensitive region of the body owing to the presence of rich nerve ends. Thus, only a moderate type of illness may bring a great deal of pain to the individual.

According to Madhukosa, Arsha is considered a disease that tortures and destroys as an enemy.[2] Charaka states that Arsha is like an irregular muscular growth in Guda.[3] Vagbhata described Arsha as a muscular outgrowth in the anal region that obstructs the anal canal and is considered lethal and dangerous as an opponent.[4] According to origin Arsha is subdivided into Sahaja and Jatasya-uttarakalaja.[5],[6]

Acharya Charaka mentioned two types of Arsha based on association with bleeding as Ardra and Shushka.[7] Acharya Vagbhata divided it again into Vatanubandhi, Pittanubandhi, and Kaphanubandh.[8]

Acharya Sushruta has mentioned four different types of treatment for Arsha.[9]

  1. Bheshaja Karma (medication) - Achirakala, Arsha with Alpa Dosha, Alpa Lakshana, and Alpa Upadrava.
  2. Kshara Karma (caustic therapy) - Mridu, Prasrita, Avagada, and Uchchhrita Arsha
  3. Agni Karma (thermal cautery therapy) - Karkasha, Sthira, Prithuk, and Kathina Arsha
  4. Shastra Karma (surgery) - Tanumoola, Uchchhrita, and Kledayukta Arsha.


Kshara Karma is an important para surgical method practiced safely. Kshara Chikitsa is perfomed by two method.[10]

  1. Internal administration (Paneeya Kshara)
  2. External application (Pratisaraneeya Kshara).


Numerous research works were carried out on effectiveness of Apamarga, Chitraka, Aragvadha, Saptachhada, Arka, Palasha, Kadali, Patala, Nimba, and Snuhi Kshara in Arsha Roga at various canters in India. These Kshara preparations, while being effective, while being effective, sometimes may cause post-operative discomfort and pain. So, to solve this situation, Vasa Pratisaraneeya Teekshna Kshara was taken up for current study, as it has got Haemostatic (Raktastambhana), Analgesic (Vednasthapaka), Anti-inflammatory, Antimicrobial (Jantughna) etc activities. Pratisaraneeya Teekshna Kshara Karma provides a borderline risk of recurrence, it is very cost effective, causes very minimal pain and bleeding, reduces inflammation, doesn't cause anal incontinence and patient usually requires minimal hospital stay. So, keeping all these things in mind present study was planned.


  Materials and Methods Top


Total 30 patients were taken up for the study. Whole course of study was explained to patients and their signed, written informed consent was taken before starting of the trial. Institutional Ethics committee (IEC) approval was taken, via letter no. IEC/ACA/2018/47; dated 11/05/2018. This study was also registered in Clinical Trials Registry- India with registration number, CTRI/2019/07/020369.

Selection criteria

Inclusion criteria

  • Patients suffering from Arsha and aged between of 20yrs to 60yrs
  • Patients having Mridu, Prasrita, Avagada and Uchchhrita Arsha
  • Patients having Arsha (Pittaja and Raktaja)
  • Diagnosed case of Internal Piles of 1st, 2nd and 3rd degree.


Exclusive criteria

  • Patients, aged >20yrs and <60years.
  • Patients suffering from systemic illness like uncontrolled DM, Hypertension, Hep. B, TB and HIV.
  • 4th degree internal piles, external piles and other associated Ano-rectal diseases.
  • Thrombosed or Strangulated pile mass.
  • Pelvic pathology and Pregnancy.


Study type

Interventional.

Study design

  • Allocation: Randomized
  • Endpoint classification: Safety and efficacy study
  • Primary purpose: Treatment.


Preparation of Apamarga and Vasa Paratisarneeya Teekshna Kshara

Ingredients used in preparation of Apamarga Pratisaraneeya Teekshna Kshara[11]

  • Apamarga ash - .3kg
  • Shukti (Oyster shell) - .03kg
  • Chitrakamula Kalka - .003kg
  • Water 6parts of Ash of Apamarga.


Ingredients used for preparing of Vasa Pratisarneeya Teekshna Kshara

  • Vasa ash - .3kg
  • Shukti (Oyster shell) - .03kg
  • Chitrakamula Kalka - .003kg
  • Water 6parts of Ash of Vasa.


Apamarga/Vasa (15 kg) was collected, dried, and then combusted. After combustion, weight of the Apamarga ash attained was 1.4 kg and Vasa was 1.2 kg. The remaining method for the preparation of Kshara is the same. 300 g ash was blended with six times the amount of water and filtered 21 times. When the filtrate was as clean and clear as Gomutra Varna, it was held on a mild fire and reduced to 2/3rd. Then, Shukti, 1/10th part of the ash (30 g) by weight, was heated to hot red. It was mixed with filtrate solution and stirred well continuously until it was reduced to 1/3rd. This was further heated by adding 3 g of Chitraka Mool Kalka (weight 1/10th portion of Shukti). Thick solution was obtained and this is known as Apamarga Paratisarneeya Teekshna Kshara (APTK)/VPTK. It was collected and stored in an air tight container.

Intervention

Total numbers of subjects taken up for study was 30, which were later allocated into two groups (A & B) with 15 patients in each [Table 1]. Duration of the study was 1 month including follow-up. Follow up was done on 2nd, 3rd, and 4th week.
Table 1: Intervention

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Treatment

Application of Pratisaraneeya Kshara procedure

Poorva karma

Subjects selected for the study were kept nil orally for at least 4 hours before to the surgery. Consent was taken. Part preparation was done in perianal region. Then after administration of Proctoclysis enema, Pre medications were given as per requirement. Later plain 2% xylocaine sensitivity test was done.

Pradhana karma

Patient was made to lie down in lithotomy position on table. Perianal region was cleaned with antiseptic solution and draping was done. Local anaesthesia (2% xylocaine with adrenaline) was infiltrated in operative site. Then proctoscope was lubricated and introduced in anal canal, position of pile mass was checked. Later Slit proctoscope was used and skin around pile mass was pulled laterally with forceps (Allis tissue holding) to view pile mass. Later healthy anal mucosa was covered with wet cotton to prevent dripping of Kshara. Apamarga [Figure 1] /Vasa Pratisaraneeya Teekshna Kshara [Figure 2] was applied on pile mass and proctoscope was shut for Shatamatrakala (~ 2 minutes) with the palm. Later pile mass was cleaned with Nimbu Swarasa. It was observed that whether the pinkish pile mass was turned to Pakva Jambu Phala Sankash Varna (blackish). If not, Kshara was applied once again till the pile mass turned to Pakva Jambu Phala Varna. This was repetitively done on all the pile masses. At the end the anal canal was packed with gauze piece drenched in Yastimadhu Taila for preventing burning sensation and local oedema. It was packed with Dry dressing and the patient was shifted to ward.
Figure 1: Application of Apamarga Paratisarneeya Teekshna Kshara

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Figure 2: Application of Vasa Paratisarneeya Teekshna Kshara

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Paschat karma (postoperative treatment)

Patients were advised to not to take orally anything after 6 hours of procedure. Dressing was taken off after 6 hours and administration of 20 ml of Yasthimadhu Taila was done. From day 1 onwards, patients were asked to take sitz bath with Sphatika Bhasma after eliminating motion for 10-15 minutes, 2 times a day and Yasthimadhu taila was administered rectally after performing sitz bath for 7 days and following medicines were prescribed:

  1. Laxative- Powder of Haritaki -5 gms at bed time.
  2. Triphala Guggulu – 2 tablets, 2 times a day daily for 7 days


Patients were educated to follow Pathya Ahara and Vihara.

Assessment criteria

Subjective parameters

  1. Pain
  2. Raktasrava (BPR – Bleeding per rectum)


Objective parameters

  1. Pile mass size.
  2. Pile mass colour.
  3. Anal sphincter tone.


Statistical analysis:

Average (mean) of obtained values of individual variable at 4 times i.e. BT (Before Treatment- 0 day), 1st week, 2nd week, 3rd week and 4th week of treatment (AT) of 15 patients in each group was calculated. This obtained average data was analysed by “Wilcoxon rank sum test” (two tailed) for assessing the significant difference between BT & 1st week, BT & 2nd week, BT & 3rd week, BT & 4th week of treatment (AT). Collected mean data of individual variables and individual subjects of each group in Before Treatment and After Treatment (IV week) period, their Mean Difference (M.D = B.T-A.T) was calculated. With this Mean difference (M.D), percentage of change in each variable and each subject after treatment was obtained. Later percentage of change in individual variable after treatment of Group-A, and Group-B was compared.

Criteria for total assessment of procedure

  • Cured: 80%-100 % improvement of signs and symptoms.
  • Marked relief: 65%-79% improvement of signs and symptoms.
  • Moderate relief: 40% - 64% improvement.
  • Mild relief: 25% to 39% improvement.
  • Unchanged: <25% or no change in signs and symptoms of the disease.



  Observation and Results Top


Age

Among total of 30 patients,10 patients (33.33%) were from age group of 21-30 years, 6 patients (20%) were from age group of 31-40 years and 7 patients (23.33 %) from 41 – 50 years age and 7 (23.33 %) patients belonged to age group 51-60.

Gender

Out of 30, 28 patients (93.33%) were male and remaining 2 patients (6.66%) were female.

Occupation

In this study, 5 (16.67%) patients were service holder, 5 (16.67%) patients were student, 9 (30%) were businessman, 6 (20%) were farmer, 2 (6.67%) were labor, and 3 (10%) were housewife.

Degree of hemorrhoids

In the study, 10 (33.33%) patients had second degree, 17 (56.67%) had third degree, and 3 (10%) had first-degree hemorrhoids.

Prolapse of pile mass

In the study, 27 (90%) patients had prolapsed mass and 3 (10%) had no prolapse of mass.

Position of pile mass

In this study, In 17 (56.67%) patients pile masses were at 3, 7 & 11 o'clock position, 4 (13.33%) had pile masses 3 & 11, In 4 (13.33%) patients pile masses were at 7 & 11 o' clock position, While in 2 (6.67%) pile masses were at 11 o' clock position and In 3 (10%) patients pile mass were at 3 o' clock position.

Bowel habit

In this study, 27 (90%) patients had constipated bowel and 3 (10%) had normal bowel habit.

Comparison between Group, A & Group B by using Mann-Whitney U test

Significant variation was seen in both groups [Table 2] after treatment for the parameter bleeding and pile mass colour. Group B had significant decrease in the bleeding as compared to group A and group A showed significant result in colour of pile mass than group B. While in group A patients had not significant (p=0.588) result in reducing pile mass size, anal sphincter tonicity and in reduction of pain. Group B has shown slight difference on pain than group A and group A showed slight difference in anal sphincter tone as compared to group B. But the difference was not statically significant.
Table 2: Comparison of after treatment-before treatment

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In parameter, bleeding Apamarga Pratisaraneeya Kshara [Table 3] showed 91.90% relief, while Vasa Pratisaraneeya Kshara showed 96.25% relief for same parameter. In parameter pile mass size showed 92.50% relief by Apamarga Pratisaraneeya Kshara and 89.00 % relief by Vasa Pratisaraneeya Kshara. Percentage of pain relief in group A was 75.18% and in group B, it was 100% [Table 4].
Table 3: Percentage difference in individual variable of Group A and Group B

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Table 4: Total effect of therapy in 30 patients

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[Graph 1] depicts total effect of therapy in 30 subjects also shows group wise relief of signs and symptoms. In group A 14 (93.33%) subjects got cured, 1 (06.67%) patient got mild improvement. In group B 86.67% subjects i.e. 13 subjects got cured, 1 (06.67%) patient had noticeable improvement and 1 (06.67%) subject had moderate improvement. Out of 30 subjects, 27 (90.00%) got cured, 1 (03.33%) had noticeable improvement, 1 (03.33%) got moderate improvement and 1(03.33%) got mild improvement.




  Discussion Top


Nowadays, people's habits have changed, erratic and insufficient diets, suppression of natural urges and psychological disorders, such as anxiety and depression, etc. Advanced technologies have altered normal lifestyles, contributing to a rapid rise in ano-rectal diseases. Arsha is described by all the classics of Ayurveda that show the significance of this disease. As described in classical texts, these are muscular over growth and causing obstruction of the anus, while bleeding per anum and prolapse of mass per anus are two main features of the disease. Previous studies conducted on Apamarga Pratisaraneeya Teekshna Kshara (APTK) indicate positive results with limited recurrence and complications. No work has been done on the efficacy of VPTK. So attempt was therefore made to determine its effectiveness to manage Abhyantara Arsha.

In current study, 10 (33.33%) subjects had 2nd degree, 17 (56.67%) had 3rd degree and 3 (10%) had 1st degree haemorrhoids.

In this study, 27 (90%) patients had constipated bowel and 3 (10%) had normal bowel habit. This indicates that constipation is the main cause of Arsha.

Maximum of in 17 (56.67%) subjects pile masses were situated at 3, 7 & 11 O'clock, In 4 (13.33%) subjects pile masses were positioned at 3 &11, while in 4(13.33%) subjects pile masses were at 7 &11 O'clock position, and in 2 (6.67%) subjects pile mass was situated at 11 O'clock position and in 3 (10%) subjects pile mass were at 3 O'clock position. This positioning of pile masses traits of the ending of superior rectal artery and its division into right and left two main branches. Its left branch remains as a single vessel and ends at 3 o'clock, But right one further split into 2 branches- anterior branch ends at 11 o'clock and posterior branch ends at 7 o'clock. Which proves that primary pile masses are usually positioned at 3, 7 &11 o'clock.

In this study, 27 (90%) patients had constipated bowel and 3 (10%) had normal bowel habit. This indicates that constipation is the main cause of Arsha.

While talking about each parameter, in reducing bleeding, VPTK (96.25 %) was better than APTK (91.90 %). Similarly, for reducing size of pile mass, APTK (92.50%) was better than VPTK (89.00%). But in case of post-operative pain, In VPTK subjects had less pain than APTK. In APTK 1st week after Kshara Karma procedure, subjects complaint of burning type of pain wherein VPTK, pain and discomfort was comparatively less to APTK.

In both A & B groups, as subjects suffered from burning pain in 1st week after procedure to deal with it Matra Basti with Yasthimadhu Tail was given.

Out of 15 subjects in group A and B, none of the patient developed recurrence. In both the groups patients who were Both APTK and VPTK act on pile mass in 2 ways – Firstly by virtue of Corrosive nature (Ksharana) it cauterizes the pile mass and secondly it acts by coagulating protein in haemorrhoidal plexus. This coagulation leads to the breakdown of Hb into haem and globin. So together it leads in reduction of size of pile. There will be necrosis of tissue. This necrosed tissue shed out in form of dark (blackish brown) discharge for period of 3 to 7 days. The haem part in the slough is responsible for its colour in discharge. Local tissue becomes fibrous and there will be development of scars. When haemorrhoid vein gets completely annihilated and there is no recurrence of disease.


  Conclusion Top


From this study, it can be stated that VPTK (Vasa Pratisaraneeya Teekshna Kshara Karma) showed almost similar efficacy as APTK (Apamarga Pratisaraneeya Teekshna Kshara) to manage Abhyantara Arsha. The current had a smaller sample size. Further similar study can be taken up with larger sample size for a more dependable and comprehensive assessment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.





 
  References Top

1.
Samhita S, Sthana S, Adhyaya A. Ch. 33/4. Available from: http://niimh.nic.in/ebooks/esushruta. [Last accessed on 2021 Nov 26].  Back to cited text no. 1
    
2.
Nidana M, Adhyaya A. Ch. 05/1. Available from: http://niimh.nic.in/ebooks/emadhavanidana. [Last accessed on 2021 Nov 26].  Back to cited text no. 2
    
3.
Samhita C, Sthana C, Adhyaya AC. Ch. 14/1. Available from: http://niimh.nic.in/ebooks/echaraka. [Last accessed on 2021 Nov 26].  Back to cited text no. 3
    
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Hridaya A, Sthana N, Adhyaya AN. Ch. 07/01. Available from: http://niimh.nic.in/ebooks/eastangahridaya. [Last accessed on 2021 Nov 26].  Back to cited text no. 4
    
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Samhita C, Sthana C, Adhyaya AC. Ch. 14/38. Available from: http://niimh.nic.in/ebooks/echaraka. [Last accessed on 2021 Nov 26].  Back to cited text no. 7
    
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Hridaya A, Sthana N, Adhyaya AN. Ch. 07/28-41. Available from: http://niimh.nic.in/ebooks/eastangahridaya. [Last accessed on 2021 Nov 26].  Back to cited text no. 8
    
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Samhita S, Sthana C, Adhyaya AC. Ch. 06/3. Available from: http://niimh.nic.in/ebooks/esushruta. [Last accessed on 2021 Nov 26].  Back to cited text no. 9
    
10.
Samhita S, Sthana S, Adhyaya KV. Ch. 11/7-8. Available from: http://niimh.nic.in/ebooks/esushruta. [Last accessed on 2021 Nov 26].  Back to cited text no. 10
    
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Hemantha Kumar P. Recent Advances in the Management of Arshas (Haemorrhoids). 1st ed. New Delhi: Chaukhamba Publications; 2004. p. 33.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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