Abstract
This is the era of fast foods. Irregularity in food timing, improper diet, and mental stress coupled with a sedentary life disturb the digestive system resulting in increased incidence of hemorrhoids. In the present report, we present two cases of intero-external hemorrhoids. Case 1: A 30-year old young male approached with intero-external hemorrhoid at 11 O’clock position as a primary. Case 2: A 41-year-old female visited with second degree intero-external hemorrhoid at 11 O’clock position. Hemorrhoids present in these patients can be considered as Kaphaja Arṣa. These cases were diagnosed by per rectal digital and proctoscopic examinations by ayurvedic proctologists. In both cases, application of Jīmūtaka Lepa was done under local anesthesia administered using lignocaine 2% with adrenaline. This was followed by manual anal dilatation. Jīmūtaka Lepa was applied to the internal hemorrhoids (Arṣa). Changes were observed in the form of edema, ulcer in 3-4 days and sloughing out of the pile mass up to 5-7 days. Subsequently fibrosis of hemorrhoidal masses started after 7 days. Jīmūtaka Lepa shows a significant effect in obliterating the hemorrhoidal mass within a month of application. The patients were followed-up regularly with proctoscopic examination in each visit and did not reveal any evidence of recurrence of the hemorrhoids.
KEY WORDS: Arṣa, hemorrhoids, Jīmūtaka, Lepa, Luffa echinata
INTRODUCTION
Hemorrhoids are dilated; tortuous or varicose veins occurring in the anus and originating in the epithelial plexus formed by radicals of the superior, middle and inferior rectal veins.[1] Hemorrhoids are an extremely common problem and have been documented since thousands of years. Hemorrhoids are unique to human beings. Nearly half of the population is bound to experience one hemorrhoidal episode at some point during their lives.
Suśruta mentions the types of Arṣa (hemorrhoids) and the management schematically as Bhaiṣaja (medicine), Kṣāra (alkali), Agni (cauterization), and Shastrakarma (surgical excision). Arṣa can be treated with conservative management unless it is very chronic.[2]
The application of Kṣāra, Agni, and Shastrakarma should be done with precaution or else, pain, edema, giddiness, flatulence, abdominal distension, and diarrhea may result. It may even lead to the death of the patient.[3]
Vāgbhaṭa is of the opinion that placing the varti (suppository) prepared out of Jīmūtaka (Luffa echinata Roxb.) in the anus will cure Arṣa.[4] Nighaṇṭu Ādarsha opines that fumigating the Arṣa by Jīmūtaka will lead to the contraction of Arṣa.[5] Jīmūtaka has laghu (light), rūkṣa (dry), tīkṣṇa (corrosive), properties; kaṭu (pungent), tikta (bitter) taste; uṣṇa vīrya (hot potency) and its therapeutic actions are: Kaphapittahara (quality of pacifying Kapha and Pitta), Tridoṣahara (quality of pacifying all three dosha).[6] It is used to cure anal diseases. The paste of the fruit is applied to the hemorrhoids. Luffa echinata Roxb. is also considered as a potential therapeutic in the treatment of human colon cancer.[7]
In various Ayurveda classics, the efficacy of Jīmūtaka in treating the Arṣa is highlighted.[8,9,10] The application of Jīmūtaka in different forms as Lepa (application of medicine), dhūpa (fumigation) and varti has been prescribed. Lepa is one of the classical methods of application in ṣaṣṭi upakrama.[11,12] Jīmūtaka Lepa is described as an ointment and suppository for Arṣa by Vāgbhaṭa in the context of Arṣa cikitsā. It contains the following ingredients: Powders of Jīmūtaka seeds, Jīmūtaka fruit fibers and Kanji (sour gruel).[13]
CASE REPORTS
Case 1
A 30-year-old male patient visited the outpatient Department of Shalyatantra, KLE's Ayurveda Hospital and Research Center, Belgaum, Karnataka on 13th September 2012. He had a chief complaint of mass/anus since 1 year associated with itching and discomfort. He also had a history of altered bowel habits since 18 months. The patient noticed that gradually the mass had increased in size at the anus. He had undergone medicinal management, but his condition was not alleviated. On examination, second-degree intero-external hemorrhoid at 11 O’clock position was seen [Figure 1].
Figure 1.
Case 1 - Intero-external Hemorrhoidal mass extending from 7 to 11 O’clock position, before treatment
Case 2
A 41-year-old female patient visited outpatient department of Shalya Tantra, KLE's Ayurveda Hospital and Research Centre, Belgaum, Karnataka on 13th December 2012. She had a complaint of mass/anus since 1 months associated with constipation. On examination second degree, intero-external hemorrhoidal mass at 11 O’clock position was seen [Figure 2].
Figure 2.
Case 2 - Intero-external hemorrhoid at 11 O’clock position. Before treatment
Hemorrhoids present in both patients were diagnosed as Kaphaja Arṣa. After detailed examination of the patients, the causative factors were identified as mentioned in the classical texts. These include: Constipation associated with flatulence (viṣṭambi), predominantly cold, junk foods, which are not easily digestible (guru annapāna), excessive intake of nonvegetarian food, sedentary life (avyāyāma), constipation (vibandha) were seen in case 1 and in case 2 it was observed that the patient was taking excessive cold, junk food, which are not easily digestible, sleeping in day time (divā svapna), sedentary life and constipation. Arṣa is a primary disease (Svatantra vyādhi) with impaired digestion (Agnimāndya).
By taking detailed history and conducting a thorough clinical examination, we decided that Jīmūtaka Lepa would be appropriate in these cases as a best interventional treatment modality rather than surgery. This is because Jīmūtaka is known for its corrosive action and its indication in the treatment of Kaphaja Arṣa in the Ayurveda classics. Surgical excision and other treatment modalities have been avoided in their early stages. Before performing the treatment, routine blood and urine analysis were carried out.
METHODOLOGY
Preparation of Jīmūtaka Lepa
About 5 g powder of Jīmūtaka seeds and Jīmūtaka fruit pulp fiber were taken in a mortar and pestle. It is well triturated along with 5 ml of Kanji drava, till it attained semisolid consistency like an ointment without any particles [Figures 3-5].
Figure 3.
Dried form of Jimutaka fruits, seeds, and pulp (fibers)
Figure 5.
Prepared Jīmūtaka Lepa
Figure 4.
Materials required for Jimutaka Lepa application
Application of Jīmūtaka Lepa
Under local anesthesia,/rectal manual anal dilatation was done to admit four fingers easily. Lubricated normal proctoscope was introduced in the anus. Position of the pile mass was distinguished and proctoscope removed. Then, Sim's/slit proctoscope was introduced, and skin around the pile mass was pulled laterally with Alley's forceps to get a better view of hemorrhoids. After this, Jīmūtaka Lepa was applied over pile mass and the Lepa was left over for its sealing effect. The Lepa was not washed and left as long as the patient defecates [Figures 6 and 7]. To prevent pain, oral analgesic was given soon after the application of Lepa.
Figure 6.
Case 1 - Jīmūtaka Lepa applied over the hemorrhoidal mass
Figure 7.
Case 2 - Application of Jīmūtaka Lepa
OBSERVATIONS
Follow-up of the patient was done on postoperative 2nd day, after 7th day, 14th day and 21st day. Diet and lifestyle regimen were suggested to the patient and patient was expected to follow these guidelines for at least 6 months. For the period of 3 weeks, following medications were prescribed to reduce pain and promote healing.
Orally:
Tablet - Gandhaka Rasāyana (250 mg twice a day after food). This was prescribed with a view to treat the itching (pruritis) as this was one of the symptoms in both the cases[14]
Tablet - Triphalā Guggulu (250 mg twice a day before food) prescribed as an anti-inflammatory and laxative[15]
Cūrna - Anuloma (1/2 teaspoon at bed time) prescribed as a laxative to relieve flatulence, constipation.[16]
Lukewarm water sitz bath was advised after defecation.
After the scheduled 3 weeks of treatment, following medications were prescribed to cure the digestive impairments for 3 months.
Orally:
Abhayāriṣṭa (3 teaspoon with equal quantity of water, thrice a day, before food), prescribed as a carminative[17]
Takrāriṣṭa (3 teaspoon with equal quantity of water, twice a day, after food) prescribed as a carminative, laxative.[18]
During each follow-up, signs and symptoms were assessed. In both cases, there was mild to moderate pain, inflammation, tenderness, itching, and sero-sanguineous discharge on first visit. On the second visit, there was mild pain, itching, and discharge. During third visit, there was no pain, itching, and discharge, however, tenderness was observed. Hemorrhoids and associated symptoms had resolved [Tables 1 and 2].
Table 1.
Follow-up and observation of case 1
Table 2.
Follow-up and observation of case 2
Assessment criterion
For assessment following criteria was adopted.
Subjective
Pain: VAS scale
No pain - 0
Mild pain - 1-4
Moderate pain - 5-7
Severe pain - 8-10.
Itching:
No itching
Mild
Moderate
Severe.
Objective
Tenderness:
No tenderness - Per rectal examination can be done with index finger without pain
Mild tenderness - Per rectal examination can be done with index finger with mild pain
Moderate tenderness - Per rectal examination can be done with little finger with tolerable pain
Severe tenderness - Per rectal examination not possible due to severe pain at anal region.
Discharge:
No discharge - area is completely dry
Mild - no requirements of sanitary pads/cotton pads
Moderate - changing of pads once daily
Severe - changing pads the minimum twice daily.
DISCUSSION
Jīmūtaka Lepa was applied to the internal hemorrhoids. Changes were observed in the form of edema, ulcer in 3-4 days and sloughing out of the pile mass up to 5-7 days [Figures 8 and 9]. Subsequently, fibrosis of the hemorrhoidal masses started after 7 days. Hemorrhoids and associated symptoms of kapha pradhāna (kapha predominant) doṣa are significantly resolved after 14 days [Figures 10 and 11] [Table 3]. Jīmūtaka has Kaphahara properties and shows significant effects on Kaphaja Arṣa. Using the method shown in this study, Arṣa can be controlled by treating the disease in the initial stages. Jīmūtaka plays a significant role in treating the hemorrhoids in their I0 and II0. There is a need for clinical studies and documentation according to the protocol to confirm the results presented in this study.
Figure 8.
Case 1 - Sloughing of hemorrhoidal mass starts after 2 days of Jīmūtaka Lepa application
Figure 9.
Case 1 - Mucosal ulcer formation on third day of Jīmūtaka Lepa application
Figure 10.
Case 1 - Resolved hemorrhoidal mass, on 21st day
Figure 11.
Case 2 - Resolved hemorrhoidal mass, on 18th day
Table 3.
Action of Jīmūtaka
CONCLUSION
Jīmūtaka Lepa shows significant effect in curing hemorrhoidal mass within a month of application. The patients were followed-up regularly and proctoscopic examinations in each visit for a period of 6 months did not reveal any evidence of recurrence of hemorrhoids.
ACKNOWLEDGMENTS
The authors are grateful to Dr. Bhupesh R. Patel, Assistant Professor, I.P.G.T and R.A. at Gujarat Ayurveda University, Jamnagar, India for supporting to collect the study drug and we are also thankful with our deepest core of heart to Dr. Ashok Wali for his valuable guidance.
Footnotes
Source of Support: Nil.
Conflict of Interest: None declared.
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