Clinical presentation of  Hemorrhoids and its

                         Management by Ksharsutra
Hemorrhoids popularly known as “piles” is the most common surgical condition of the ano-rectal region. This condition arises when the veins in the rectum and anal canal swells due to increased pressure because of the factors like straining, during defecation, pregnancy, any growth, obesity etc. which plays a major role as the causative factors for piles.

If network of the swollen veins were inside the rectum, it is called as internal hemorrhoids. These swollen veins comes out per anus during defecation as prolapsed masses which either get reduced spontaneously after the act of defecation or has to be reduced digitally and then it remains inside. In later cases these swollen veins always remain outside the anal canal as prolapsed pile masses. Based on this prolapsed, piles are categorized under four degrees like 1^st, 2^nd, 3^rd, and 4^th. Internal hemorrhoid can also lead to painless bleeding. Prolapsed piles are particularly itchy type. Those afflicted with this type usually worsen the condition when they wipe it often due to its itchiness.

If the swollen veins develop under the skin around the anus, it is called as external hemorrhoids. And one can feel and even see them. People with Piles usually complaint the following symptoms :

Ø  Swelling in the anal area. One can also palpate the swollen veins in case of external piles and 4^th degree prolapsed internal piles

Ø  Painless bleeding during defecation which usually comes in the form of splash of blood

Ø  Something coming out per anus during defecation which either gets reduced or has to be reduced

Ø  Itching in the anal region

Ø  Constipation

The ideal thing to do if any person is having the above mentioned complaint is to consult a medical professional and have a thorough check up.

                                                  

Most common factors that worsen the symptoms are:

Ø  Constant diarrhea or constipation

Ø  Extended period of time for the act of defecation

Ø  Difficulty in giving birth to a child

Ø  Obesity

Ø  Lifting of heavy weight

75% of the population have piles at one point of their lives. But only a small percentage of these patients consult medical professional and even much smaller percentage has surgical intervention among them. The rest resorts to conservative management which include lifestyle modifications and symptom management.

In lifestyle management, there are three areas to consider:

Ø  Diet

Ø  Exercise

Ø  Habits

Dietary Modifications

Constipation is a major problem in these patients. It is oftentimes is the result of lack of fiber and fluids in the diet. Living a sedentary lifestyle and having other medical conditions can also cause constipation.

One is constipated when he/she has two or less bowel movements in a week, one strains during defecation, has hard stool to pass or incomplete evacuation of feces. These in turn causes the hemorrhoids to develop or if already afflicted, become worse. The things that you can do to remedy your constipation are:

Ø  Eat a well balanced diet. Add plenty of fiber rich food like fruits, vegetables, whole grain cereals and legumes.

Ø  Drink more than 8 glasses of water per day

Ø  Avoid caffeinated and alcoholic beverages, as these are diuretics and can cause effects of dehydration

Ø  Observe healthy bowel habits for which you should do the following things-

¨      Have your meals at the same time as much as possible to train your bowel

¨      Avoid straining

¨      Do not stay in the bathroom longer than necessary

¨      Be careful on using laxatives to relieve you of constipation

¨      Avoid hot and spicy foods. Remember the saying“ what burns coming in, would burn bring out”.

¨      Refrain from eating processed foods

Ø  Be active in your daily life. Lack of activity leads to increased weight, weaker muscles, and immune system.

Triphala- combination of three herbs equal is one of the excellent regulator of the bowel to manage the constipation. A teaspoon of aloevera after  meal is said to be effective in relieving hemorrhoids. Hemorrhoids can be prevented or cured when you have the right diet to prevent constipation.

Lifestyle modifications would also be the answer to the elimination of hemorrhoids in your life.

Ø  Cease Smoking : As nicotine affects bowel function

Ø  Limit alcohol consumption

For the symptoms associated with hemorrhoids, some of the things a patient can do to get relief.

Ø  Warm sitz bath for 15 min., 3- 4 times a day also preferably after a bowel movement

Ø  Never scratch the hemorrhoid

Ø  Keep the anal area clean and dry all the time

Ø  Frequently applying aloevera on the areas promotes comfort

However, in the event that the hemorrhoids become extremely painful and bothersome like in case of thrombosis, strangulation, a patient to have surgical intervention like banding, sclerotherapy, cauterization, hemorrhoidectomy etc.

Hemorrhoids are dealt rationally under the concept of arsha. And mandagni is said to be the  main reason in its pathogenesis. In modern busy day to day life , people neglects proper diet and lifestyle habits. It ends in reducing digestive fire (agni) and making it manda. Mandagni means patient is not able to digest food material at properly. It results in accumulation of half digested food material (Aam) in the form of toxins inside or throwing it out before time in watery or semisolid form which disturbs doshas in ano-rectal region. Acharya Sushruta has mentioned it in the Ashta Mahagada, showing the gravity of the disease.

In Sushruta samhita, its whole treatment is covered under four categories i.e. Bheshaja, Kshara Karma, Agni karma, Shastra Karma. Under Kshar karma, kshar sutra treatment is done as parasurgical procedure for the hemorrhoids which needs surgical intervention. It is a medicated thread which is prepared according to set protocol according to the standard guidelines. In the operative procedure this medicated thread is ligated at the root of the pile masses under full aseptic conditions.

Effects of kshar sutra ligation on clinical features of arsha is very significant. Kshara sutra has surgical actions like incision, excision, debridement, scrapping and medical actions like haemostatic, antiseptic, healing etc., which acts simultaneously to cure the arsha (piles). The kshara used in the medicated thread cauterize the tissue of the ligated masses indirectly by its kshara guna (corrosive properties). The action of turmeric powder  provides the effect of bactericidal action with healing properties.

The mode of action of  kshara sutra starts immediately after contact with the tissue. Kshara invades into the cells of the lesion till the destruction of the engorged tissue of the mass occurs or up to the removal of the pile masses. During the cutting effect, there may be oozing of blood, which is ceased by the sclerosing effect of the kshara. Hence, there is minimal chance of bleeding. The chance of infection is also less because of turmeric and kshara. The pressure exerted by ksharasutra ligation creates mechanical strangulation of blood vessels and tissue, which causes the local necrosis of pile masses, forces falling out of the pile mass during defecation.

The beauty of kshara sutra ligation lies in the fact that it can be conducted at OPD level. It is an ambulatory procedure; patient can perform his/ her daily routine work from the next day of surgery. It requires less duration for the completion of treatment. There is minimal need of anti-biotic and anti- inflammatory drugs. After separation of the mass, wound heals quickly. Hospitalization period is less. There is least possibility of recurrences. It is much cheaper than the surgical modalities available in modern system of medicine. There are minimal adverse  affects during the post operative period like anal-stenosis, incontinence, bowel irregularities . Many studies and experience of kshar sutra practitioners revealed that kshara sutra ligation is a standard surgical treatment in the 2^nd, 3^rd and 4^th degree of arsha (piles) and also an affordable treatment for all the classes of people in society.