"THE ROLE OF PICHU (TAILA) APPLICATION THE MANAGEMENT OF ARSHA (HAEMORRHOIDS)" - A PILOT STUDY

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1 J.R.A.S. Vol. XXVII, No. 1-2, (2006) pp '. "THE ROLE OF PICHU (TAILA) APPLICATION THE MANAGEMENT OF ARSHA (HAEMORRHOIDS)" - A PILOT STUDY IN M.Mruthyumjaya Rao', B.Das 2, G.C.Nanda 2 and M.M.Padhi2 (Received on ), A pilot study was conducted to see the efficacy of "Pichu (Taila) application in the treatment Arsha (Haemorrhoids) at Ano-Rectal Clinic, Central Research l nst it ute (Ay.), Bh uban eswar. This observational (pilot) study was conducted Oil 25 patients of Arsha as per the Proforma designed by CCRAS. New Delhi. Out of25 cases who received the above regimen. 80 percent cases got complete relief. 12 percent got marked relief and 8...percent got moderate relief Analysis was made to assess the results in relation to various aspects including improvement in hemoglobin levels. After analyzing the results it is concluded that the above drug regimen is effective in Arsha management. Introduction Arsh a (Haemorrhoids) has been described in Ayurveda one among the Mahagadas and is generally translated as haemorrhoids in modern terms. The patients with piles may have one or more of a number of individual problems, that no single treatment method can be advised for all patients and that several different methods may achieve actually good result. The ill defined derangement of anal canal function may produce symptoms singly or in combination: pain, bleeding, prolapse, mucus discharge, peri-anal itching, constipation and incontinence to flatus and! or faeces. Regarding the treatment of piles the least invasive procedure / treatment is 1Asst.Director (Ay.) 2 Research Officer (Ay.) Central Research Institute( Ay.) Unit-I, Bhubaneswar 41

2 M.Mruthyumjaya Rao, et at. most desirable excepting few conditions to treat the haernorrhoids. Several surgical! conventional therapies are now in practice depending upon condition ofhaemorrhoids like sclerotherapy, rubber band ligation, anal dilatation, photo coagulation, cryosurgery, haemorr-hoidectomy etc. This Increasing number of therapies themselves proves that there is no universally acceptable technique in the management ofhaemorrhoids. Sushruta, recommended four different treatment modalities which are widely acceptable and practicable even today. They are 1. Aushadha Chikitsa (Employment of medicinal remedies) 2. Ksh ara Ch ik it sa- (Chemical Cauterization). 3. Agnikarma (Thermal cauterization) 4. Sashrakarma (Surgical management). Out of four therapeutic regimens, the Kshara & Agni Karmas are regarded as para-surgical procedures, which can be carried out without much preparation. In Sushrut Samhita, we can also see some external applications apart from some oral remedies. Keeping the treatment descriptions given by Sushruta in view, pichu application IS selected for the study as per the parameters set in the protocol. Materials and Methods A single blind pilot study was conducted at Ano-rectal clinic of C.R.I.(Ay.), Bhubaneswar devised protocol & proforma, using specially designed as per both Ayurvedic and modern parameters. Essentially the study aimed to evaluate the efficacy of the pichu application check the bleeding in terms of the days taken to as well as associated symptoms and to see the recurrence of bleeding & other symptoms after complete healing. A) Selection of cases: A total no. of 25 patients with complains of bleeding per rectum during andlor after the defecation with or without other symptoms like, itching, discharge, constipation, with lor without pain were examined per-rectally and confirmed by proctoscopic examination were admitted for the study. The cases of strangulated pile masses, and haemorrhoids associated with malignancy were excluded from the study. B) Preparation of Pichu: A plain rubber catheter gauze (sterile) No. 7 is wiped with the soaked till it comes to the size of little finger and is secured by sterile surgical thread. 1. Drugs used for pichu: Murivenna tail + Jatyadi tail + Kasheesadi tail The ingredient in kaseesadi taila is having the properties of Sodhana and Ksharana; Jatyadi taila is a good wound healer and Murivenna is being used by Kerala Physicians as an anti-septic and also having the soothing effect and hence the combination is selected 42

3 THE ROLE OF PICHU (TAILA) Application of Pichu: After keeping -- the patient in lithotomy position the proctoscope is placed per rectally. After the picliu is inserted in to the anal canal through the lumen, the proctoscope is taken out immediately and the Pichu is kept for one hour. Thispichu is applied once in two days and 10 applications of such are done in the period of 21 days. 3. Follow-up: After application of the pichu for 10 times all cases were followed, up to 6 weeks to see the recurrence if any. C) Diet: To be taken: Ghee, milk, rice and plenty of liquids. To avoid: Non-veg. and spicy foods. D) Criteria adopted for assessment of the response of therapy: Since the bleeding is the main symptom in the bleeding haemorrhoids, the days taken to arrest the bleeding is noted along with alleviation of other associated.. symptoms like Prolapse of pile mass, Itching / pruritis, discomfort, pain, discharge & anaemia (as shown in Table: III) and the result was assessed in the following manner. 1. Complete relief: When the bleeding is checked completely within 7 days of therapy and complete disappearance of associated symptoms if any and no recurrence up to 6 weeks of the follow-up.. 2. Marked relief: When the bleeding is checked after 7 days but Before 14 days of therapy and complete disappearance of associated symptoms if any and no recurrence up to 6 weeks of the follow-up. 3. Moderate relief: Arrest of bleeding after 14 days but before 21 days of the therapy and complete disappearance of associated symptoms if any and no recurrence up to 6 weeks of follow-up. 4.Mild relief: Arrest of bleeding after 21 days but before 30 days and complete disappearance of associated symptoms if any and no recurrence follow-up. up to 6 weeks of 5. No relief: No checking of blood before 30 days or checked After 30 days and/or recurrence even after complete recovery from the symptoms. 6. Drop out/lama: 1. Discontinuation of the treatment during the trial. 2. Development of any serious complications. 3. Aggravation of the disease. Results and Conclusions a. Condition of patients on admission: (Summarized in table -I) Out of 25 patients admitted for study, 28 percent were males while 72 percent were females. Maximum of 44 percent of cases fall under the age group of

4 M.Mruthyumjaya Rao, et al. yrs while minimum of 4 percent under the group of 51 & above. Among them about 72 percent were of pitta prakriti while minimum 12 percent were of Vataprakriti, maximum no. of patients (88%) had constipated bowel habits and almost all patients were nonvegetarians. Table I. Condition of patients on admission: SJ. Condition No. of patients (%) A Age group(in yrs.) Male Female Upto 20 2(8.0) 0(0.0) (16.0) 7(28.0) (4.0) 6(24.0) (0.0) 4( 16.0) 51 & above 0(0.0) 1(4.0) Total 7(28.0) 18(72.0) B Prakriti of patient No. of patients (%) ficlfa 3(12.0) Pitta 18(72.0) Kapha 4(16.0) c Bowel habits No. of patients (%) Regular 3(12.0) Constipated 22(88.0) Alternate bowel habits 0(0.0) D Dietary habit No. of patients (%) Vegetarian 01(4.0) Non-vegetarian 24(96.0) 44

5 THE ROLE OF PICHU (TAILA)... b. The characteristic of Arsh a I haemorrhoids on admission: (Summarized in table- II) About 48 percent of patients had the disease for at least one year and about 12 percent of patients had previous anal surgery. The type of Arsha was interoexternal in about 52 percent of patients; haemorrhoids were positioned at 3 clock in all cases. A maximum no. of 52 percent of Arsha was found to be of pittaja type followed by Raktaja and Sannipataja with the incidence of about 16 percent each. Table II Characteristics of Arslta / Haemorrhoids on admission Incidence/ Characteristics Percentage of Patients (n = 25) a) Duration of No. of disease (yr.) patients (%) < >3 12 (48.0) 8(32.0) 3(12.0) 2(8.0) b) H/O previous No.of treatment Pts. (%) Medical 15(60.0) Surgical 3(12.0) FreshfNone 7(28.0) c) Type of No.of Haemorrhoids Pts. (OAI) External 3(12.0) Internal 9(36.0) Intero external 13(52.0) e) Type ofarsha No.of Pts. CYlI) Vataja 1(4.0) Pittaja 13(52.0) Kaphaja 2(8.0) Sannipataja 4(16.0) Raktaja 4(16.0) Sahaja 1(4.0) f) Position of No.of Haemorrhoids Pts. ('Yo) (0' clock) (n=573) 3 clock 25( 100.0) 5 clock 21(84.0) 7 clock 23(92.0) 11 clock 24(96.0) c. Clinical findings noticed on admission (Summarized in table No.III) All patients had bleeding per rectum and prolapse in 84 percent, 28 percent had pruritis, 72 percent had discomfort at peri anal region, 56 percent had pain during/ after defaecation, 76 percent had mucus discharge. About 12 percent had the mean hemoglobin of 6.3 gm, about 72 percent had the mean Hb% of 7.3 gm% while remaining patients (16%) had either mild anaemia or normal level of haemoglobin with mean of 10.5 gm%. About 60 percent had moderate bleeding, about 8 percent and 32 percent had mild and profuse bleedmg per rectum respectively. 45

6 MMruthyumjaya Rao, et el, Table III Clinical features (signs & symptoms) noticed on Admission ( n=25) SI. Symptom No. of pts.( 0/0) A. Bleeding (25=100%) Profuse/severe Moderate mild 8(32.0) 15(60.0) 2(8.0) B. Prolapse of pile masses 21 (84.0) C. Itching! Pruritis 7(28.0) d) The speed of recovery from bleeding and other associated symptoms (Summarized in Tables from IV to IX) : i) Healing took place 111 all 25 patients with varying degree of d urat io n starting from one week to four weeks. Out of 25 cases about 80 percent patients had healing (complete relief) by 1st week, 12 percent had (marked relief) by two weeks and 8 percent had (moderate relief) by three weeks (Table IV). D Discomfort 18(72.0) E. Pain 14(56.0) ii) Analysis was made about the response in reference to the duration of the F. DIscharge (mucoid) 19(76.0) G. Anaemia Severe 3( 12.0) (Hb(~;;,<7grn. %) (mean Hb%) =6.3 Moderate 18(72.9) (b%7-iogm) (mean Hb) =7.3 Mild/normalcy 4(16.0) (Hb%> 10gm%) (rneanl-lb'z.) =10.5 disease and it shows 40 percent of cases who had complete reliefhad the duration of illness less than one year and about 8 percent of cases who had marked reliefhad illness less than one year (Table V). iii) A maximum no. of 52 percent of Intero-external haernorrhoid cases had complete relief and about 28 percent of cases of internal haemorrhoids had complete rei ief (Table VI). 46

7 THE ROLE OF P/CHU (TA/LA)... Table IV Speed of Recovery from bleeding and other associated symptoms Resu It / Recovery No. of patients Percentage Complete reliefby 1 week Marked reliefby 2 weeks Moderate relief by 3 weeks Mild reliefby 4 weeks No relief after 4 weeks 010P out / Recurrence o o o Total Duration of illness Table V Speed of recovery according to the duration of the illness (n=25) Results of tbe treatment No. of patients (Percentage) (in yrs.) CR MR MDR MLR NR DO Total Up to I 10(40.0) 2(8.0) 0(0.0) 0(0.0) 0(0.0) 0(0.0) 12(48.0) (20.0) 1(4.0) 2(8.0) 0(0.0) 0(0.0) 0(0.0) 8(32.0) (12.0) 0(0.0) 0(0.0) 0(0.0) 0(0.0) 0(0.0) 03(12.0) 3&above 02(8.0) 0(0.0) 0(0.0) 0(0.0) 0(0.0) 0(0.0) 02(8.0) Total 20(80.0) 03(12.0) 02(8.0) 0(0.00) 0(0.00) 0(0.0) 25 (100.00) Type of haemorrboid Table VI Speed of recovery according to the type of baemorrboids (n=25) Results of the treatment No. of patients (Percentage) CR MR MDR MLR NR DO Total Extemal 0(0.00) 01(4.0) 2(8.0) 0(0.00) 0(0.00) 0(0.00) 03(12.0) Intemal 07(28.0) 02(8.0) 0(0.0) 0(0.0) 0(0.0) 0(0.0) 09(36.0) Intero-ext. 13(52.0) 0(0.0) 0(0.0) 0(0.0) 0(0.0) 0(0.0) 13(52.0) Total 20(80.0) 03(12.0) 02(8.0) 0(0.00) 0(0.00) 0(0.0) 25 (100.0) Abbreviations CR = Complete Relief MLD = Mild Relief MR = Marked Relief NR = No Relief MDR = Moderate DO = Drop out Relief 47

8 MMruthyumjaya Rao, et al. iv) It has also been observed from the study that there is a signi ficant improvement in hemoglobin levels after 45 days of the therapy (Table VB). Table VII Improvement in the Hemoglobin level (n=25) Level of Hb% Hemoglobin on admission After 30 days Hboil. After 45 days. Hb'V.. <7gm.% 03( 12) (mean=6.3gm. %) 0(0.0) 0(0.0) 7-10gm.% 18(72.0) 0(0.0) 0(0.0) (mean=7.3.%) >10 gm.% 04 (16.0) 25 (100.0) 25( 100.0) (mean=10.5) (mean= 10.8) (mean=12.5) Table VIII Improvement in different signs & symptoms (Parameters) at the end of the study SI. Parameters No. of relieved subjects at the No. end of the study No.(%) 01. Bleeding (n=25) 25( 100.0) 02. Prolapse of pile masses (n=21) 17(80.95) 03. Itching/ Pruritis (n=7) 7(100.0) 04. Discomfort (n=18) 17(94.44) 05. Pain (n=14) 14(100.00) 06. Discharge (n= 19) 18(94.73) * Total mean percentage of cure at the end of the study is

9 ... THE ROLE OF P/CHU (TA/LA)... Discussions The Haemorrhoids are regarded as a surgical disease and there are many operative and para-surgi~al techniques are in practice, and most of oper a ti ve procedures involve risk factors and hence have their limitations. In view of above to find out a non-invasive, conservative Ayurvedic drug regimen In the management of Arsha and owing to the properties of drugs, taila pic/ill has been selected and kept for study. Usually taila will help in producing a soothing effect and will help easy descent of the faecal column. The main ingredient of Kasheesadi taila is Kaseesa (Co S04) and the effect of Kaseesa is known as Sodhana and Ksharana which helps in healing of the eroded portion of the haemorrhoidal vessels and facilitates & promotes quick healing. The Physicians of Kerala are using' Murivenna tai/a' successfully for quick healing of internal traumas (bonelmusclelligament etc.) and also it is soothing in nature. It helps in easy passage of bowels without damaging further the lumen of the rectum. It also been used as anti-septic, anti-infllammatory and hence helps in reducing the size of the pile mass, reducing the vascosity & thrombosis ofhaemorrhoidal vassels, Jatyadi taila has a potent wound healing properties and helps in repair of eroded surfaces of the hemorrhoidal vessels and mucosal lining of the ano-rectal canal. Secondly, the pressure exerted by the pichu helps in mild dilation of the anal canal as well as the sphincter which helps in reduction in the size of the prolapsed pile mass, as well as proper penetration and absorption of the oils. Since the earlier studies revealed the refined foods, fast foods and non veg. diet rises the incidence of hemorrhoidal bleeding, the patients were kept on Milk, rice diet and plenty of liquids which also helps in the prevention of the recurrence. On the basis of the results of this single blind pilot study, it is concluded that the earlier the chronicity of the disease, the quicker the healing and also minimum or negligible chances of recurrence. After analyzing the results, it is concluded that the pichu application is encouraging in the management of Arsha. Since it is a pilot study involving only 25 patients, to see its role in more scientific way, more number of cases is required to draw a final conclusion. Acknowledgment: The authors are highly indebted to the director, CCRAS, New Delhi. We are also thankful to the patients who gave their consent to carry out the study. 49

10 MMruthyumjaya Rao, et et. REFERENCES H.G.Anderson 1909 The after results of the operative treatment of haernorrhoids pre.medj.2: Burkitt 1972 Varicose vein, Deep Vein thrombosis and Haemorrhoids (Epidemiology and Suggested Etiology,) Br.M.l.2,556 L.P.Fielding et al. Management of patients with symptomatic haemorrhoids an introduction - (page ) S.K.Sharma et al Kshara sutra therapy in Fistula-in-ano and other Ano rectal diseases Rastreeya Ayurveda Vidyapeeth publication, New Delhi B.N.Sharma 1999 Ayurvedic management of Ars h a (Heamorrhoids)-CCRAS publication Rob & Smith Operative edition. surgery Lippin cott company-4th M.Stanely.Goldburg et al Annals of Ano - Rectal Surgery, 1.P. publication Susruta, Susruta Santhita Chawkamba Sanskrit Series Office, Varanasi. (commentary by Ambika dutta Sastri), 1.M.Watts, et al A controlled study of pain after di fferent forms of Haemorrhoidectomy, Surg,gynoec, obstet.120:

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