Management of internal hemorrhoids by Kshara karma: An educational case report

Abstract

A 66-year-old male patient came to the anorectal clinic, Outpatient department, AVT Institute for Advanced Research, Coimbatore, Tamil Nadu, with complaints of prolapsing pile mass during defecation and bleeding while passing stool. The case was diagnosed as “Raktarsha” - 11 & 7 ‘o’ clock position II degree internal hemorrhoids, deeply situated, projecting one and caused by pitta and rakta; with bleeding tendency. Kshara karma (application of caustic alkaline paste) intervention was done in this case to internal hemorrhoids under local anesthesia. The pile mass and per rectal bleeding resolved in 8 days and the patient was relieved from all symptoms within 21 days. No complications were reported after the procedure. The patient was followed up regularly from 2004 onward till date and proctoscopic examination did not reveal any evidence of recurrence of the hemorrhoids.

INTRODUCTION

Kshara karma measures for hemorrhoids are mentioned in classical Ayurvedic texts, but it is not widely practiced in all over India. Search of bibliographic databases like Pubmed did not fetch any research papers dealing with clinical trials or case studies on this subject. Therefore, this paper is being written to document the typical features of and outcomes of Kshara karma in management of hemorrhoids.

The study design is retrospective but all relevant tests and observations were rigorously documented.

Hemorrhoids occur in everyone; gradually, they become large and cause problems in only 4% of the general population and their prevalence peaks in people over 50 years of age.[1] Hemorrhoids that cause problems are found in 2 : 1 ratio of men and women.[2]

Different treatment modalities are available like expectant medical therapy, injection treatment, rubber band ligation, manual dilatation, cryosurgery, infrared coagulation, and operative treatments like formal hemorrhoidectomy.[3] However, the risk of recurrence or of developing an infection of the wound after the operation is high.[4] Risk or complications of Milligan-Morgan hemorrhoidectomy are pain - varies virtually nil to very severe, retention of urine - 7% of patients required catheterization, secondary hemorrhage - 1.2% patients, development of abscess or fistula.[5] Also, the patient requires longer hospitalization in some of the procedures.

Kshara karma (application of Pratisaraneeya teekshna kshara): 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.[6] It is a type of chemical cauterization. The Kshara karma method of treating piles has been described in detail in the ancient text Sushruta Samhita. The details of preparation of the herbal combination are mentioned in Sushruta Samhita[7] and Ashtanga Hridaya.[8] And also, the superiority of kshara over sharp instruments (sastras) and accessory sharp instruments (anusastras) has been mentioned in Sushruta Samhita.[9]

The preparation of pratisaraniya kshara in Ashtanga Hridaya is simpler than Sushruta Samhita. We followed the method of Dr. Ravi Shankar Parvaje. He is the Managing Director of Sushruta Ayurveda Hospital, Puttur, Karnataka, and a renowned practitioner. His method of preparation of Pratisaraneeya teekshna kshara known as “Pervaje Technique of Ksharakarma,” is a modification of what is described in Ashtanga Hridaya. It contains only six ingredients in comparison with eleven mentioned in Ashtanga Hridaya. Achyranthes aspera (Apamarga) is an additional ingredient that is not mentioned in Ashtanga Hridaya in this recipe. Dr. Ravi Shankar Parvaje's method of Kshara preparation is described below.

10 Kg of Achyranthes aspera (Apamarga) is burnt to get 1 kg of ash. One Kg of ash is mixed with six times of water to form a solution, which is filtered using a sterile cloth. The filtrate was boiled slowly to reduce it to 2/3 of quantity, followed by addition of 100 g of Oyster or Pearl (shukthi) shell powder. The solution is again boiled slowly. To this solution, 10 g of powdered Plumbago zeylanica (Citraka), Gloriosa superba (Langali), Acorus calamus (Vacha), and Coral (Pravala) are added to get semisolid, brownish-colored paste; this is collected and stored in dry glass bottle.

Alkaline preparations should be externally used in such skin diseases like Psoriasis, Taeniasis, Vitiligo, Non-lepromatous lesion, Fistula in ano, Tumor, Non-healing ulcer, Sinus, Exfoliative dermatosis, Mole, Non-elevated mole, Localized hyper pigmentation of skin, Nevus, and Abscess and Hemorrhoid.[7] In cases of worms and poisoning as well as in the seven forms of diseases which affect the cavity of the mouth and in different types of Diphtheria, external applications of alkalis act like substitutive surgical instruments.[10]

CASE REPORT

A 66-year-old male patient came to the Ano rectal clinic, Outpatient department, AVT Institute for Advanced Research, Coimbatore, Tamil Nadu, on November 27, 2004, with complaints of prolapsed pile mass during defecation, but mass returns spontaneously to the anal canal and occasional bleeding during defecation since 3 years. Proctoscopic examination confirmed the diagnosis as a case of 11 & 7 ‘o’ clock position second-degree internal hemorrhoids.

The patient was under Homoeopathic treatment for the above complaints and did not try any other system of medications. After careful interrogation of the patient, the following causative factors were identified as mentioned in classical texts. i.e., daily two-wheeler riding (utkata, kathina visamasana), intake of more spicy (vidahi), sweet (madhura) and cold (sita) food, irregular food habits (ajirna bhojana), and straining to pass stool (pratata atipravanhana) habitually. This is a primary disease (Svatantra vyadhi), with impaired digestion (agnimandya) as the underlying pathogenesis.

The patient was not willing to undergo modern surgery and requested Ayurvedic treatment. Hence, Kshara karma procedure was offered. This particular case was treated by Kshara karma because it was having symptoms of ‘Raktarsha’ (bleeding piles) with soft-elevated, well-defined mass. The bleeding was also noted during proctoscopic examination. The Kshara karma application in treating “Raktarsha” has been indicated in the ancient text Ashtanga hridaya.[8]

Before planning treatment, Complete blood count and other tests were done to rule out conditions like Anemia, Clotting disorder, other infective disorder, Human immunodeficiency virus, Diabetes Mellitus, and Hepatitis.

The Kshara karma (Application of caustic alkaline paste) was performed with the help of slit-type proctoscope under local anesthesia. The caustic alkaline paste was applied on 11 and 7 ‘O’ clock position internal hemorrhoids one after the other. After application on each hemorrhoid, the applied Kshara was cleansed with lemon juice after one minute. It was observed that the pile mass has reduced in size and its color has turned to blackish brown (pakva jambu phalavarna in shatamatrakala).[7] Then, the proctoscope was removed and the anal canal was finally irrigated with medicated oil, anal pack was done. The patient was discharged on the same day after 3 hours of observation, as there was no postoperative bleeding.

Patient was asked to attend surgical clinic for anal examination once a week for 4 weeks. Diet and lifestyle guidelines and corrections were suggested to the patient and patient was expected to follow these guidelines for at least one year. For this one-month period, following medications were prescribed to reduce pain and inflammation and promote healing. Orally: Chiruvilwadi Kashayam (15 ml with 40 ml of lukewarm water, twice in a day empty stomach), Tablet Gandhaka Rasayana (250 mg twice a day after food), Tablet Maha Sankha Vati (250 mg twice a day before food), Tablet Triphala Guggulu (250 mg twice a day before food); Per rectum: Narayana Taila (5 ml twice a day). Lukewarm sitz bath was advised after each defecation. After this one month treatment, following medications were prescribed to cure digestive impairment (agnimandya) for 3 months. Orally: Sukumaram Kashayam (15 ml with 40 ml lukewarm water, twice in a day, empty stomach), Takrarishta (30 ml twice in a day after meals)..

During each follow-up visit, signs and symptoms were assessed. There was moderate to mild pain, tenderness, inflammation, and brownish black discharge on first visit and second visit. During the third and fourth visit, there was no pain, tenderness, discharge, or anal stricture and the internal hemorrhoids had completely resolved [Table 1].

Table 1.

Follow-up observation form

To assess pain in this particular case, following criteria were adopted:

Severe - To relieve from pain, analgesic injections are required/Pain or discomfort dose not reduce after oral analgesics.

Moderate - To relieve from pain, oral analgesics are required.

Mild - Feeling discomfort within tolerable limit, no requirement of analgesic either orally or in other route.

Nil - No discomfort in any manner in the site, no analgesics.

Discharge –

Severe - Changing sanitary pads or cotton pads minimum 2 times a day

Moderate - Changing of pads once a day only

Mild - No requirement of pads

Nil - Area is completely dry

Tenderness standard assessment

Severe - Patient feeling pain by touching perianal area. Not possible to perform P/R examination.

Moderate - Little finger P/R can be done, patient feeling very much tolerable pain

Mild - Index finger P/R done with very much tolerable pain

Nil - Index finger insertion to anal canal without any pain or discomfort

The subject was followed up annually for a period of 8 years. There was no evidence of recurrence of hemorrhoids on proctoscopic examination.

DISCUSSION

Pratisaraneeya teekshna kshara was applied to the internal hemorrhoids. It was observed that the Pile mass became black in 35 seconds as described in the Sushruta Samhita. Lemon juice (citric acid) was used to neutralize the kshara after proper burning of pile mass.

Pratisaraneeya teekshna kshara causes coagulation of Hemorrhoid plexus (cauterization of pile mass), necrosis of tissue followed by fibrosis of plexus, adhesion of mucosal, submucosal coat helps in prevention of further dilatation of veins and prevents prolapse of regional mucosa of anus. This makes permanent radical obliteration of Hemorrhoids.

Detailed action of Pratisaraneeya teekshna kshara from the time of application up to 21 days are shown in Table 2. The whole treatment that was given to the patient is presented below as a flow chart.

Table 2.

Action of Pratisaraneeya teekshna kshara

In present day practice, application of Kshara is found to be a safe, efficacious, and cost-effective method for management of internal hemorrhoids. Compilation of case reports and clinical studies are needed to standardize the treatment protocol and define outcome measures. In this way, comprehensive treatment guidelines can be formulated.

CONCLUSION

Pratisaraneeya teekshna kshara was found effective in obliterating the hemorrhoid mass within 21 days of application. The patient was followed up regularly from 2004 onward till date by doing proctoscopic examination in each visit and proctoscopic examination did not reveal any evidence of recurrence of the hemorrhoids. This case is being reported after a follow up of eight years non-recurrence of hemorrhoids. The patient was on active treatment for only a period of three months. Diet restrictions were followed for another year. This case study shows that a combination of kshara karma, conservative treatment (samana aushadhis), diet restrictions, and life style modifications administered over a period of one year is effective in obliterating the pile mass as well as preventing recurrence on a long-term basis.