Rasaushadhis in the management of hemorrhoids

Hemorrhoids are one of the most common conditions seen in ano-rectal OPD, caused by repeated straining while having a bowel movement, like in cases of constipation /diarrhea. Hemorrhoids often described as "varicose veins of the anus and rectum", hemorrhoids are enlarged, bulging blood vessels in and about the anus and lower rectum. In Ayurveda, it can be well correlated with Arsha, based on the marked similarities of the clinical features of these two disease entities. Because of inefficient medical management and high denying rate for surgical intervention, there is a need of an alternative treatment approach. As per Ayurveda, specific treatment protocol can be applied in the form of topical/systemic treatment, along with internal medicationKasthaushadhi, Rasaushadhis etc. Ayurvedic Alchemy has a great importance in Ayurvedic treatment. It mainly deals with minerals, animals and some herbal products for therapeutic as well preventive purpose. Amongst one such product is Rasaushadhi, having the qualities like quick action, tasteless, palatable, more therapeutic benefit, longer shelf life and less dosage is enough for therapeutic action. Enormous Rasaushadhis are mentioned in the management of Arsha, like Arsha kutara rasa, Chancha kuthara rasa, Cakrakhya rasa, Shila Gandhaka Vati, Nityodita rasa, Chandra prabha Gutika, Manadya Loha, Jati paladi vati, Astanga Rasa, Panchanana Vati, Rasa Gutika, Teekshnamukha Rasa etc. This paper was aimed to highlight the utility of single & compound formulations in the management of Hemorrhoids (Arsha).To know about properties of the Rasoushadhis & Bhaishajya yogas, their effective benefits in day-today practice.


Introduction
The term 'Haemorrhoids' is popularly used for pathological varicosity of the haemorrhoidal veins due to increased pressure that may result from chronic constipation or diarrhoea, straining during defecation or pregnancy etc. Hemorrhoids often described as "varicose veins of the anus and rectum", hemorrhoids are enlarged, bulging blood vessels in and about the anus and lower rectum. Hemorrhoids are usually found in three main locations: left lateral, right anterior and right posterior portions. They lie beneath the epithelial lining of the anal canal and consist of direct arteriovenous communications, mainly between the terminal branches of the superior rectal and superior Hemorrhoidal arteries, and, to a lesser extent, between branches originating from the inferior and middle Hemorrhoidal arteries and the surrounding connective tissue. 1 The prevalence of Hemorrhoids is 50-85% of people around the world and in India 75% of the population (The prevalence of hemorrhoids in India according to recent surveys is around 40 million), affecting as much as half the population by the age of 60.

Classification
Hemorrhoids can be classified according to their location and degree of prolapse. Internal hemorrhoids are located above the dentate line and covered by columnar epithelium. On the other hand, external hemorrhoids, are located below the dentate line and covered with squamous epithelium.
Mixed hemorrhoids are known as "interno-external" hemorrhoids and are located both above and below the dentate line. 3 Internal hemorrhoids are further graded according to Goligher's classification which depends on the degree of prolapse into: (1) Grade Ⅰ hemorrhoids: Anal cushions bleed without prolapse; (2) Grade Ⅱ hemorrhoids: Anal cushions prolapse on straining but reduce spontaneously; (3) Grade Ⅲ hemorrhoids: Anal cushions prolapse on straining or exertion and require manual reduction; and (4) Grade Ⅳ hemorrhoids: The prolapse is irreducible and remains out all the time. 4 In Ayurvedic classics it can be correlated with Arsha as maximum concepts are similar to each other. Arsha is derived from "Ris" Dhatu that which damages the normal proceeding or the activities of body like enemy, in classics it has been explained that this disease kills the afflicted like an enemy, hence it is coined as Arsha. The disease is initiated with Agnimandya (Improper digestion) due to improper food habits and lifestyles. However, haemorrhoids can reoccur even after proper management hence it is mentioned as one among Ashtamahagada. 5

Treatment of Haemorrhoid (Arsha): 6
In modern medical science, many procedures are described for management of haemorrhoids, like Conservative treatment (Oral medications, Topical treatment), rubber band ligation (RBL), sclerotherapy, infrared coagulation, radiofrequency coagulation, bipolar diathermy, directcurrent electrotherapy, cryosurgery and laser therapy, of which haemorrhoidectomy is commonly preferred by surgeons, but after sometime of excision there is great possibility of reappearance of the disease. 7 But in Ayurveda fourfold management of Arsha has been indicated eg. Bheshaja, Kshar Karma, Agnikarma and Shastra Karma according to chronicity and presentation of the disease. 8 However, the basic management principle for every disease in Ayurveda is to avoid the causative factor, which helps either in breaking etiopathogenesis at basic level of the disease.

Ayurvedic Management Nidana (Causative factors) Aharaja Nidana:
The dravya like guru, madhura, sheeta, abhishyandi and vidahi, ahara like masha, rukshamamsa, ikshu rasa, oil cakes, germinated corns & pulses, freshly harvested corns & cereals (Navannaha) makes shithilata in mamsa dhatu. All these are non-fiber diet which causes constipation which makes protrusion of pile mass. Viharaja Nidana: Ashya sukha, Diwa swapna, Avyayama, Avyavayi is reputed kaphakara bhavas. But vegavarodha here should be taken mala vegadharana which is the mulakarana of vata pratilomana, utkata asana is the one which create extra, intra abnormal pressure, Ativirechana leads to hypovalmic state in which loss of ions having an ability to create flaccidity in the muscles so evident in gudavalayas too.
Literature also provides a vishesha nidana where in sahaja arsha is one such disorder hereditary transmitted to offspring. In ayurveda considered as beeja doshaja of matruja & pitruja bhavas. Sushruta in particular as given a separate nidana which is the sinful act called papa karma lead in the past life; for this we do not have any reference in modern science. 9

Samprapti (Pathology)
Due to nidana sevana the vatadi dosha gets vitiated inturn leads to Agnimāndya that further hampers the functions of Apāna Vāyu. Normally, Apana Vayu contributes to evacuation of bowel but vitiated Apana Vayu leads to collection of faeces in gudavali, and eventually vitiates the other vayus, doshas, and twak, rakta, mamsa, medas giving rise to mamsankura in guda pradesha. 10 Therefore, it is the best medicine for itching, discomfort, constipation, white coating on tongue, loss of appetite, and poor digestive capacity.
It also improves liver functions and increases the flow of bile, which helps to relieve constipation too. Contra indication: bleeding piles (hot potency due to the presence of Shuddha Bhallataka). In bleeding piles, it increases bleeding and worsen the symptoms. Nityodita rasa: Effective & potent in vatakaphaj arsha and jirna raktarsha.
In jirna raktarsha atrophy, degeneration of muscles and nerves at anal region causes painful condition, where loha bhasma gives relief from such condition.
Vatsanabha possesses the properties like jwara shamaka, swedala hence can be used in kaphanubandhi arsha.