A Randomized Controlled clinical study of Katutumbi bijadi Guda varti with Apamarga Ksharasutra Ligation in the patients of Arshas(II and III Degree Haemorrhoids)

In Ayurveda, since Vedic period Arshas has been the main area of concern among anorectal disease. The great Indian Surgeon Susrutha known as father of surgery has described Arshas in Susrutha samhitha Nidana sthana 2 nd chapter (K.R..Srikantha Murthy,2017, p.233) and its chikitsa in Chikitsa sthana 6th chapter. He considered Arshas as one of the Astha Mahagadas means diseases which are very difficult to treat. Arshas is an torious for its troublesome pain like enemy, which afflicting mankind for thousands of years.

This condition can be correlated with Haemorrhoids in modern science, in which dilated veins within the anal canal in the sub-epithelial region formed by radicals of superior, middle and inferior rectal veins. Haemorrhoids are engorgement of the Haemorrhoidal venous plexus, characterized by bleeding per rectum, constipation, pain, prolapse and discharge.

Acharya Susrutha has mainly narrated the four types of treatment modalities for successful management of Arshas viz., Bhesaja [Internal and external medications], Shastra [Surgical methods], Kshara [Caustic cauterization], and Agnikarma [Thermal cauterization].

Despite of many more modern treatments like Rubber band ligation, Sclerotherapy, Photocoagulation, Cryosurgery, Haemorrhoidectomy, etc., Ayurveda is well known for the treatment of Arshas for its negligible rate of recurrence, cost effective, less chances of pain, Haemorrhage, infection and anal incontinence.

According to Bhaisajya ratnavali, only three applications of Gudavarti prepared by pounding Tumbi bija and Audbhida lavana with kanji alleviate Arshas. During the course of treatment, the patient is to be kept on Buffalo’s curd diet.

Gudavarti are solid dosage preparations which are prepared by moulding or compression methods intended for its insertion into rectum. It facilitates vata anulomana and which there by eases the expulsion of Mala and also intended to exhibit udavarthahara karma. Katutumbi beeja is having katu vipaka and which has anti-thrombotic property makes bandana of sonitha srava. Because of having tikta rasa it acts on tvak and mamsa dhatu makes mamsa sthirikarana which may prevents degenerative process in collagen fibers and fibro-elastic tissue. That which may help’s in reducing the congestion and pooling of blood from the hamorrhoidal masses and increases the tone of vasculature so that mass start decreasing in size gradually and in the end it may completely shrinks the mass.

There are several therapeutic reasons affecting bioavailability of drugs from rectal suppositories, one among these is to partly avoid hepatic first- pass elimination or metabolism following rectal administration. Colorectal absorption is a simple diffusion process through the lipoidal membrane in which there is carrier mediated mechanism. It is also believed that rectal pH of about 7.3 provides a convenient environment for the drug to be chemically stable on insertion. No issues with oral compliance of the patient thus avoiding nausea and vomiting. It also proves to be a convenient drug delivery option in patients especially with rectal complaints. The rectal temperature ia around 37.8ºC-38.9 ºC where as the melting point of this prepared Gudavarti is 36ºC which is easly soulbe in rectal temperature and hence play a good mode of action.

Among the four treatment modalities in Arshas mentioned by susrutha, kshara karma and Agnikarma are considered as para-surgical procedures. These para-surgical procedures are having many advantages viz., They are simple, safe, effective, ambulatory and minimal or no complications, less time to study in hospital and minimal interference in patients routine work.

Ksharasutra treatment is very suitable and acceptable as compared to prevalent methods in modern medical science. Even though, it has been accepted by medical society for its good efficacy in treatment of Bhagandara there is still need in of standardization of Ksharasutra Ligation in the treatment of arshas.The Ksharasutra ligation performs excision by virtue of its mechanical pressure and phytochemical cauterization effect and ligation is expected to reduce the engorgement and finally peels the lesion in the post operative period and may prove superior to the conventional Haemorrhoidectomy.

The present study compares the efficiency of Katutumbi Bijadi Gudavarti with Apamarga Ksharasutra Ligation in the patients of  Arshas.