Clinical Study on Haemorrhoids and Therapeutic Evaluation of Habb-e-Rasaut and Habb-e-Muqil in its Management

Hamdard Medicus 31 Clinical Study on Haemorrhoids and Therapeutic Evaluation of Habb-e-Rasaut and Habb-e-Muqil in its Management Zakir Habib Khan, Mohammed Shahnawaz Akhtar, Mohammed Wasi Akhtar and Shaista Parveen Post Graduate Department of Moalejat, Jamia Tibbiya Deoband, G.T. Road, Deoband, District-Saharanpur, 247554, Uttar Pradesh, India. Haemorrhoid (Bawaseer) is a common problem characterized by an abnormally distended sub-mucosal arterio-venous shunt, embedded in swollen and inflamed anal cushion. Caused by accumulation of blood that is mixed with excess of Sauda and Balgham (Black bile and Phlegm), predisposed by improper venous drainage exacerbated by injury and inflammation. This study was done on 30 patients of 1st and 2nd degree internal haemorrhoids of either sex belonging to age group 20 to 60 years. Habb-e-Rasaut and Habb-e-Muqil were used daily for 60 days and promising results were found. Bleeding Per rectum, peri-anal pain, peri-anal itching, constipation and haemorrhoidal mass was improved in 80%, 94.4%, 90%, 85.7% and 53.3% cases respectively, after 60 days of treatment. Keywords: Haemorrhoids, Piles, Bawaseer, Habb-e-Rasaut, Habb-e-Muqil. Introduction Haemorrhoids or Bawaseer can be defined as dilated plexus of superior rectal vein in relation to anal canal 1. Haemorrhoids are enlargements of the vascular cushions of anal canal 2. Word haemorrhoids is derived from the combination of two Greek words Haema and Rhoos standing for Blood and Flow respectively. Piles is a Latin synonym derived from Pila, standing for ball are referred to the dilated veins 3. Hippocrates (460 B.C.-375 B.C.), a famous Unani physician and

Hamdard Medicus 32 Father of Medicine defined piles as: Piles are vascular out-growth of inner phlegmatic membrane of rectum 4. Samarqandi (13th century A.D.) described Haemorrhoids as: It is a growth similar to muscle/cartilage; which is formed by viscous, melancholic blood due to its deposition at the end part of rectal veins 4. It is of two types, one which bleeds is known as Damia (bleeding piles) and other that does not bleed is known as Amia (non bleeding piles) 4, 5. Haemorrhoids generally present according to the main branches of superior haemorrhoidal vein. There are three main branches situated in the left lateral, right anterior and right posterior; when patient is in lithotomy position, these correspond to 3, 7 and 11 O clock positions respectively 1-3, 6-7. Production of large quantity of melancholic blood in the liver leads to formation of haemorrhoids 4, 8. Usually the matter of Haemorrhoids are melancholic blood mixed with abnormal Phlegm 9, forming viscous melancholic blood in the rectal vessels 10. Thus Haemorrhoids are formed by concentrated melancholic matter and sometimes mixed with bile 5. Gravity, longstanding, straining and irregular bowel habits are important factors that develop or exacerbate the haemorrhoids 1, 3, 4. Diarrhoea due enteritis, colitis or dysentery aggravates haemorrhoids 3, 4. In addition, some other factors which may contribute to the development of haemorrhoids include risk factors, these are hot climate, young adults and old age people, male sex, obesity, rectal surgery, low fibre diet and use of excessive spicy meals or excessive meat, weight lifting and heavy exercise and chronic cough etc. 4, 8, 11. Many pharmacopoeial and non-pharmacopoeial Unani formulations are being used for the treatment of haemorrhoids. Pharmacopoeial formulations include Habb-e-Bawaseer Damwi, Habb-e-Rasaut, Habb-e-Muqil, Habb-e-Usara, Qurs-e-Kahruba, Sharbat-e-Anjbaar, Sharbat Deenar, Sharbat Habb-ul-Aas, Itrifal Muqil, Itrifal Zamani, etc., whereas non-pharmacopoeial formulations may include Roghan Baid-e-Anjeer, Sang-e-Jarahat, Gil-e-Armani, Dam-ul-Akhwain etc. Habb-e-Rasaut and Habb-e-Muqil are being used since long successfully to alleviate the symptoms of haemorrhoids. Thus these drugs i.e. Habb-e-Rasaut and Habb-e-Muqil were selected in combination to achieve good result and to assess their therapeutic efficacy in the management of internal haemorrhoids. Material and Methods This study was carried out on 30 cases selected from the OPD and

Hamdard Medicus 33 IPD of the Post Graduate Department of Moalejat, Jamia Tibbiya Deoband, Saharanpur, Utter Pradesh, India. All the 30 cases were selected randomly on the basis of inclusion and exclusion criteria. The study was started on 37 patients, but 7 patients were dropped out as they could not follow the protocol or left the study in the mean time before completing the course of study. Patients with clinical features of haemorrhoids of both sexes, age ranging from 20 to 60 years were taken up and only included in the study when 1st or 2nd degree internal haemorrhoids was confirmed after taking history and undertaking clinical examination especially proctoscopy. The selected patients were having recurrent bleeding per rectum for not more than one year and were clinically stable. Patients, who were severely anaemic or suffering from any bleeding disorder or have been operated for the same problem or suffering from any systemic disease and confirmation of external or 3rd and 4th degree internal haemorrhoids on examination, were excluded from the study. The patients were evaluated on the basis of history taking and examination, including general examination and per rectal examination. Per rectal examination was done with care and very gentleness as haemorrhoids may cause discomfort during per rectal examination 1, 3, 6. Proctoscopy was performed to detect disease of rectum/anus to rule out other causes of rectal bleeding and to inspect haemorrhoids. The degree and position of the haemorrhoids were also revealed by proctoscopy. All the selected patients were given Habb-e-Rasaut 2 tablets twice a day with plain water and Habb-e-Muqil 2 tablets at bed time with lukewarm water for 2 months and follow up was done at every 15 days for clinical features, but proctoscopy was repeated only at the end of the treatment. The study was open and observational, and the patients were informed about the expected outcome of the treatment. The treatment was started after taking written informed consent from the patients. The drugs were procured from the college pharmacy, which were prepared according to the formulation described in the pharmacopoeia Qarabadeen-e-Majeedi. HABB-E-RASAUT 12 1. Post Halila zard (Terminalia chebula Retz.) 42 gm. 2. Rasaut (Berberis aristata DC.) 42 gm. 3. Muqil (Commiphora mukul Hook. ex Stocks) 42 gm.

Hamdard Medicus 34 HABB-E-MUQIL 12 1. Turbud safaid (Ipomoea turpethum R.Br.) 84 gm. 2. Khardal (Brassica nigra [L.] Koch.) 10 gm. 3. Sakbeenaj (Ferula persica Willd.) 42 gm. 4. Muqil (Commiphora mukul Hook. Ex Stocks) 124 gm. 5. Halila siyah (Terminalia chebula Retz.) 124 gm. 6. Post Halila zard (Terminalia chebula Retz.) 124 gm. Observations and Results TABLE 1 Distribution of Patients According to Age Age groups No. of patients Percentage 20-30 12 40.00 31-40 08 26.70 41-50 10 33.30 51-60 00 00 Total 30 100.00 TABLE 2 Distribution of Patients According to the Sex Se x No. of patients Percentage Male 19 063.30 Female 11 036.70 Total 30 100.00 TABLE 3 Distribution of Patients According to the History of Weight Lifting History of No. of patient Percentage Weight lifting Present 09 030 Not present 21 070 Total 30 100

Hamdard Medicus 35 TABLE 4 Distribution of Patients According to Food Habits Food habits No. of patients Percentage Vegetarian 09 030 Non-vegetarian 21 070 Total 30 100 TABLE 5 Distribution of Patients According to Occupation Occupation Number of patients Percentage Labourer 09 30 Farmer 05 16.7 Shopkeeper 02 6.7 Teacher 03 10.0 Driver 03 10.0 Student 04 13.3 Housewife 04 13.3 Total 30 100.0 TABLE 6 Distribution of Patients According to Family History of Haemorrhoids Family history No. of patients Percentage of haemorrhoids Present 12 040 Not present 18 060 Total 30 100

Hamdard Medicus 36 TABLE 7 Effect of the Drugs on Clinical Features 0 15th 30th 45th 60th day day day day day S.No. Clinical No. of No. of No. of No. of No. of features cases cases cases cases cases 1. Bleeding per rectum 30 30 28 15 06 2. Peri-anal Pain 18 15 08 02 01 3. Peri-anal Itching 10 09 05 02 01 4. Constipation 28 28 24 10 04 5. Haemorrhoidal mass 30 14 In this study it was found that maximum number of patients belong to 21-30 age group (12 patients) and males predominated the incidence. Out of total 30 patients 21 were having negative history of weight lifting and same number of patients were non-vegetarian. All the patients were classified according to profession into Labourer, Farmer, Shopkeeper, Teacher, Driver, Student and Housewife according to their occupation, maximum number of patients belonging to the Labourer group (9 patients). Family history of haemorrhoids was found to be positive in 12 (40%) cases. Bleeding per rectum was present in all the 30 patients at the commencement of the treatment and was present in 28 patients at 30 th day, while it was present only in 6 patients at the 60th day of the treatment. Thus Bleeding per rectum was improved in 80% cases by the end of the study. Peri-anal pain was present in 18 patients at the commencement of the treatment and was present in 8 patients at 30th day, while it was present only in 1 patient at the 60 th day of the treatment. Thus peri-anal pain was improved in 94.4% cases at the end of the study. Peri-anal itching was present in 10 patients at the commencement of the treatment and was present in 5 patients at 30th day, while it was present only in 1 patient at the 60th day of the treatment. Thus peri-anal pain was improved in 90% cases at the end of the study. Constipation was present in 28 patients at the commencement of

Hamdard Medicus 37 the treatment and was present in 24 patients at 30th day, while it was present only in 4 patients at the 60th day of the treatment. Thus peri-anal pain was improved in 85.7% cases at the end of the study. Haemorrhoidal mass (1st or 2nd degree internal haemorrhoids) was present in all the 30 patients at the commencement of the treatment, and it was lessened in 16 patients at the end of the study leaving only 14 patients with mass, but to a lesser extent. Thus haemorrhoidal mass was lessened in 53.3% cases. Discussion and Conclusion Most of the cases belong to male of age group 21-30 years, these people are supposed to do maximum physical work and face exertion. Weight lifting is one of the important factors to predispose haemorrhoids, as the history of weight lifting was found to be positive in a substantial number. In this study most of the patients were having non-vegetarian diet, it is too in accordance with the factors to predispose haemorrhoids, as it is responsible for constipation and hard stool. Among different occupations, labourers were the main sufferers; it may be due to the reason that they do strenuous work, weight lifting etc. 3-4, 7-9, 10-11. As many as 40% cases have positive family history, which suggests that there is genetic predisposition in the development of haemorrhoids 7, 11. All these observations about the haemorrhoids in the study are found to be in accordance with the descriptions present in the classical Unani literature and moderns medical texts. As the main cause of bleeding haemorrhoids is regular pressure exerted by constipation on venous anal cushions, that leads to improper venous return, engorgement of venous plexus and formation of haemorrhoidal mass; thus the aim of management is to check active bleeding, reduce injury and inflammation and to relieve constipation. When the drugs Habb-e-Rasaut and Habb-e-Muqil were given to the patients of 1st and 2nd degree internal haemorrhoids, we got promising results exclusively in the clinical features. Bleeding per rectum, peri-anal pain, peri-anal itching and constipation was improved in 80%, 94.4%, 90% and in 85.7% cases respectively, after 60 days of treatment. As far as the haemorrhoidal mass is concerned the result was not too encouraging, it was completely resolved (disappeared) only in 53.3% cases even after 60 days of continuous treatment; in remaining patients the haemorrhoidal mass was reduced but to a lesser extent. The overall benefit in the clinical features of internal haemorrhoids and haemorrhoidal mass may be due to Haemostatic, Anti-inflammatory, Analgesic, Soothing, Laxative, Mushil-e-Balghan wa Mushil-e-Sauda effects of Habb-e-Rasaut and Habb-e-Muqil.

Hamdard Medicus 38 The possible medicinal action of drug components of Habb-e-Rasaut and Habb-e-Muqil which lead to such promising result in the clinical features may be as follows: Relief in peri-anal pain may be attributed to the anti-inflammatory, analgesic and soothing effects of Sakbeenaj and Rasaut 13-16. Bleeding per rectum may be relieved due to haemostatic effect of Muqil and Rasaut 13-14, 16. Relief in peri-anal itching can be attributed to the astringent and anti-inflammatory effect of Rasaut, Post Halila Zard, Muqil, Khardal and Sakbeenaj 13-16. The constipation may have been relieved due to the laxative effect of Muqil, Sakbeenaj, Halila and Turbud Safaid whereas raised motility of the gut was induced by Turbud Safaid and Khardal with added bowel clearance 13-16. Thus soft stool plus raised gut motility decreased pressure and friction of stool to the haemorrhoidal mass and congested venous plexus. Reduction in haemorrhoidal mass or its size is supposed to be due to the astringent, anti-inflammatory and laxative effects of various constituents used in Habb-e-Rasaut and Habb-e-Muqil 13-15. On the other hand it has been described in classical Unani literature that, the pathological changes in humours (Akhlat) play an important role in the development of haemorrhoids. Few drugs of our formulations i.e. Turbud, Sakbeenaj, Halila Zard and Halila Siyah are mushil-esauda, mushil-e-safra, mushil-e-balgham and blood purifier 13-16. Hence Habb-e-Rasaut and Habb-e-Muqil may excrete the bad humours (Akhlat-e-Raddiya) from the body and correct the congestion in haemorrhoids. With the above discussion it is to conclude that the Unani Formulations Habb-e-Rasaut and Habb-e-Muqil are much effective drugs to manage 1st and 2nd degree internal haemorrhoids when used in combination for a long period (at least 60 days). The drugs showed promising results in improving the symptoms of the internal haemorrhoids and appreciating result in improving haemorrhoidal mass (53.3% cases). It is proposed that if a study will be done with a larger sample size and drugs used for a longer period, better results may be observed. REFERENCES 1. Shenoy, K. Rajgopal, (2005). Manipal Manual of Surgery, 2nd Edn., CBS Publishers & Distributors, New Delhi, pp. 524-527. 2. George, D. Zuidema and Charles, J. Yeo, (2002). Sackelford s Surgery of the Alimentary Tract, 5th Edn., W.B Saunders Company, A. Hartcourt Health Science Company, Philadelphia, pp. 403-408.

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