A review article on Arsha Chikitsa according to Charaka Samhita w.s.r. to Hemorrhoids

/ Academic Research Vol. 01, Issue 04, October 2024 / Leave a Comment

Vol.01, Issue-04, October 2024

Author: Dr. Manish Singh Tomar, MD, PhD Ayurveda

Abstract

Hemorrhoids, known as Arsha in Ayurveda, are a common anorectal condition characterized by swollen veins in the lower rectum and anus. The ancient Ayurvedic text Charaka Samhita provides a comprehensive understanding of Arsha, including its etiology, pathogenesis, classification, clinical features, prognosis, and therapeutic approaches. This article explores Arsha Chikitsa (treatment of hemorrhoids) as outlined by Acharya Charaka, correlating it with modern medical knowledge. By integrating traditional Ayurvedic insights with contemporary science, we aim to enhance the understanding of hemorrhoids and promote holistic management strategies.

Table Of Contents
  1. Abstract
  2. Introduction
  3. Etiology (Nidana) of Arsha
  4. Pathogenesis (Samprapti) of Arsha
  5. Classification of Arsha
  6. Symptoms (Lakshanas) of Arsha
  7. Prognosis (Sadhya-Asadhya) of Arsha
  8. Treatment (Chikitsa) of Arsha
  9. Herbal Formulations and Medications
  10. Lifestyle and Dietary Recommendations
  11. Conclusion
  12. References

Introduction

Hemorrhoids are a prevalent health issue affecting millions worldwide, causing significant discomfort and impacting the quality of life. They result from the swelling and inflammation of veins in the rectal and anal region. Common symptoms include bleeding during bowel movements, itching, pain, and prolapse of hemorrhoidal tissue.

In Ayurveda, hemorrhoids are referred to as Arsha, which literally means “enemy,” symbolizing the pain and discomfort they inflict upon individuals. The Charaka Samhita, an authoritative ancient Ayurvedic text attributed to Acharya Charaka, dedicates an entire chapter to Arsha, offering in-depth insights into its causation, types, clinical manifestations, and treatments.

This article delves into the Ayurvedic understanding of Arsha as presented in the Charaka Samhita, correlating it with modern medical perspectives. By exploring the classical descriptions and comparing them with contemporary knowledge, we aim to highlight the relevance of Ayurvedic principles in the current medical landscape and promote integrative approaches to managing hemorrhoids.

Etiology (Nidana) of Arsha

Ayurvedic Perspective

Acharya Charaka identifies two primary origins of Arsha:

  1. Sahaja Arsha (Congenital Hemorrhoids):
    • Genetic Factors (Bija Dushti): Defects in the reproductive elements (sperm and ovum) due to parental misconduct or past karmas lead to congenital hemorrhoids.
    • Embryological Factors: Disturbances during fetal development affecting the anal region.
  2. Jatottara Arsha (Acquired Hemorrhoids):
    • Dietary Factors:
      • Consumption of heavy, sweet, unctuous, and cold foods.
      • Overeating and irregular eating habits.
      • Intake of incompatible foods (Viruddhahara).
      • Excessive consumption of meat from animals like cow, fish, pig, buffalo, and goat.
      • Eating stale, putrid, or contaminated food.
      • Overindulgence in fermented foods and alcohol.
    • Lifestyle Factors:
      • Sedentary habits and lack of physical activity (Avyayama).
      • Suppression of natural urges, especially defecation and urination (Vegavidharana).
      • Excessive sexual activity (Ativyavaya).
      • Sitting on hard, uneven surfaces or engaging in activities causing pressure on the pelvic region.
      • Straining during bowel movements due to constipation.
    • Other Factors:
      • Repeated pregnancies and complicated childbirth in women.
      • Trauma or injury to the anal region.
      • Chronic conditions like dysentery or worm infestations.

Shloka References:

  • “Gurumadhuraśītābhiṣyandividāhiviruddhājīrṇapramitāśanāsātmyabhōjanāt…” (Verse 9)
  • “Vātamūtrapurīṣavēgōdīraṇāt samudīrṇavēgavinigrahāt…” (Verse 9)

Modern Correlation

The Ayurvedic etiological factors align with modern medical understanding of hemorrhoid development:

  • Dietary Causes:
    • Low-fiber diet leading to constipation.
    • Excessive consumption of processed and spicy foods.
    • Dehydration affecting stool consistency.
  • Lifestyle Factors:
    • Prolonged sitting or standing increasing pressure in rectal veins.
    • Sedentary lifestyle contributing to poor bowel habits.
    • Straining during bowel movements due to constipation.
    • Obesity increasing abdominal pressure.
  • Other Factors:
    • Pregnancy and childbirth causing increased intra-abdominal pressure.
    • Aging leading to weakening of supportive tissues.
    • Chronic diarrhea or anal infections.

Pathogenesis (Samprapti) of Arsha

Ayurvedic Perspective

The development of Arsha involves the interplay of aggravated Doshas (Vata, Pitta, Kapha) affecting the anal region.

  1. Impairment of Digestive Fire (Agni Mandya):
    • Improper diet and lifestyle weaken the digestive fire, leading to the formation of Ama (toxins).
  2. Vitiation of Doshas:
    • Vata Dosha: Aggravated by factors like cold, dry foods, and suppression of natural urges. Vitiated Vata accumulates in the rectal veins, causing dryness and constriction.
    • Pitta Dosha: Aggravated by hot, spicy foods, and anger. Vitiated Pitta leads to inflammation and bleeding.
    • Kapha Dosha: Aggravated by heavy, oily foods, and lack of exercise. Vitiated Kapha causes swelling and mucous discharge.
  3. Obstruction of Channels (Srotorodha):
    • Accumulated Doshas obstruct the normal flow in the anal vessels, leading to swelling and protrusion.
  4. Involvement of Gudavali (Anal Folds):
    • Hemorrhoids originate in the three anal folds (Gudavali), which serve as the site for Arsha development.

Shloka Reference:

  • “Prakupitō Vāyur Apānas Taṁ Malam Upacitam Adhōgam Āsādya Gudavaliṣv Ādhattē…” (Verse 9)

Modern Correlation

  • Increased Venous Pressure:
    • Straining during defecation increases pressure in the hemorrhoidal veins, causing them to swell.
  • Degeneration of Supportive Tissues:
    • Aging and chronic straining weaken the connective tissues supporting hemorrhoidal vessels.
  • Vascular Hyperplasia:
    • Enlargement of blood vessels due to increased blood flow.
  • Anal Cushion Displacement:
    • Downward displacement of anal cushions leads to hemorrhoid formation.

Classification of Arsha

Ayurvedic Perspective

Arsha is classified based on origin, Dosha predominance, and specific characteristics.

  1. Based on Origin:
    • Sahaja Arsha: Congenital hemorrhoids present from birth.
    • Jatottara Arsha: Acquired hemorrhoids developed after birth.
  2. Based on Dosha Predominance:
    • Vataja Arsha (Vata-dominant):
      • Dry, hard, rough hemorrhoids.
      • Severe pain, pricking sensation.
      • Dark discoloration.
    • Pittaja Arsha (Pitta-dominant):
      • Soft, inflamed, bleeding hemorrhoids.
      • Burning sensation, redness.
      • Yellowish or reddish coloration.
    • Kaphaja Arsha (Kapha-dominant):
      • Large, pale, firm hemorrhoids.
      • Mucous discharge, itching.
      • Heavy feeling in the anal region.
    • Sannipataja Arsha (Tridoshic):
      • Combination of symptoms from all three Doshas.
      • Complex and difficult to treat.
    • Raktaja Arsha (Blood-related):
      • Associated with vitiated Rakta Dhatu (blood tissue).
      • Profuse bleeding, anemia.

Shloka References:

  • “Vidyāt Vātōlbaṇānyarśāṁsi…” (Verse 11)
  • “Ślaiṣmikāṇāṁ Samuddiṣṭam Ētat Kāraṇam Arśasām…” (Verse 19)

Modern Correlation

Modern medicine classifies hemorrhoids based on their location and severity:

  1. Based on Location:
    • Internal Hemorrhoids:
      • Located above the dentate line.
      • Covered by mucous membrane.
      • Less painful due to fewer nerve endings.
    • External Hemorrhoids:
      • Located below the dentate line.
      • Covered by skin.
      • More painful due to rich nerve supply.
  2. Based on Severity (Grading):
    • Grade I: No prolapse, vessels protrude into the lumen.
    • Grade II: Prolapse during defecation but reduce spontaneously.
    • Grade III: Prolapse requiring manual reduction.
    • Grade IV: Permanently prolapsed, cannot be reduced.

Symptoms (Lakshanas) of Arsha

Ayurvedic Perspective

Symptoms vary according to the dominant Dosha:

  1. Vataja Arsha Symptoms:
    • Severe pain, pricking sensation.
    • Dry, rough, hard hemorrhoids.
    • Constipation, bloating.
    • Dark or blackish discoloration.
    • Aggravated by cold, relieved by warmth.
  2. Pittaja Arsha Symptoms:
    • Burning sensation, inflammation.
    • Bright red bleeding.
    • Soft, swollen hemorrhoids.
    • Yellow or reddish coloration.
    • Thirst, fever, irritability.
  3. Kaphaja Arsha Symptoms:
    • Mild pain, itching.
    • Large, pale, firm hemorrhoids.
    • Mucous discharge.
    • Feeling of heaviness.
    • Aggravated by dampness, relieved by dryness.
  4. Raktaja Arsha Symptoms:
    • Profuse bleeding.
    • Weakness, anemia.
    • Dizziness, palpitations.

Common Symptoms:

  • Swelling or mass protruding from the anus.
  • Pain during defecation.
  • Bleeding per rectum.
  • Mucous discharge.
  • Itching and discomfort in the anal area.

Shloka Reference:

  • “Viṣṭambhō’nnasya Daurbalyaṁ Kukṣērāṭōpa Ēva Ca…” (Verse 21)

Modern Correlation

Symptoms commonly observed in hemorrhoid patients include:

  • Bleeding:
    • Bright red blood during or after defecation.
  • Pain and Discomfort:
    • Especially in external hemorrhoids.
  • Itching and Irritation:
    • Due to mucous discharge.
  • Swelling:
    • Lumps around the anus.
  • Prolapse:
    • Hemorrhoidal tissue protruding outside the anal canal.

Prognosis (Sadhya-Asadhya) of Arsha

Ayurvedic Perspective

Prognosis depends on various factors, including the type of hemorrhoids, Dosha involvement, location, and chronicity.

  1. Incurable (Asadhya) Hemorrhoids:
    • Sahaja Arsha: Congenital hemorrhoids are considered difficult to treat.
    • Involvement of Internal Anal Sphincter: Hemorrhoids arising from the innermost anal fold.
    • Complicated Cases: Presence of systemic symptoms like anemia, cachexia, severe pain, or other anorectal disorders.
  2. Difficult to Cure (Kricchra Sadhya):
    • Dvandvaja Arsha: Hemorrhoids involving two Doshas.
    • Located in the Middle Anal Fold: Require more intensive treatment.
    • Long-standing Cases: Chronic hemorrhoids with recurrent symptoms.
  3. Easily Curable (Sukha Sadhya):
    • Ekadoshaja Arsha: Hemorrhoids involving a single Dosha.
    • Located in the Outer Anal Fold: More accessible for treatment.
    • Recent Onset: Acute cases respond well to therapies.

Shloka References:

  • “Yasyāsādhyō’rśasō Hi Saḥ…” (Verse 26)
  • “Bāhyāyāṁ Tu Valau Jātānyēkadōṣōlbaṇāni Ca Arśāṁsi Sukhasādhyāni…” (Verse 31)

Modern Correlation

Prognosis is based on the severity, complications, and response to treatment:

  • Good Prognosis:
    • Early-stage hemorrhoids.
    • Responsive to conservative treatments.
    • No significant bleeding or prolapse.
  • Guarded Prognosis:
    • Hemorrhoids requiring surgical intervention.
    • Recurrent cases.
    • Presence of comorbid conditions.
  • Poor Prognosis:
    • Advanced hemorrhoids with complications like thrombosis.
    • Patients with systemic diseases (e.g., portal hypertension).
    • Elderly patients with reduced healing capacity.

Treatment (Chikitsa) of Arsha

Ayurvedic Perspective

Treatment involves a holistic approach addressing the root cause, alleviating symptoms, and preventing recurrence.

  1. General Treatment Principles:
    • Nidana Parivarjana (Avoidance of Causative Factors):
      • Eliminating factors that aggravate Doshas.
      • Correcting dietary and lifestyle habits.
    • Shodhana (Purification Therapies):
      • Virechana (Purgation): For Pitta-dominant hemorrhoids.
      • Anuvasana Basti (Oil Enema): For Vata-dominant hemorrhoids.
      • Niruha Basti (Decoction Enema): For Kapha-dominant hemorrhoids.
      • Raktamokshana (Bloodletting): Especially in Raktaja Arsha.
    • Shamana (Pacification Therapies):
      • Use of herbal formulations to balance Doshas.
      • Local applications like ointments, pastes, and suppositories.
  2. Specific Treatments Based on Doshas:
    • Vataja Arsha Treatment:
      • Snehana (Oleation): Internal and external use of oils.
      • Swedana (Fomentation): Applying warmth to alleviate pain.
      • Herbal Enemas: Medicated oils like sesame oil processed with Vata-pacifying herbs.
    • Pittaja Arsha Treatment:
      • Cooling Therapies: Application of cold pastes and poultices.
      • Purgation with Bitter Herbs: To eliminate Pitta Dosha.
      • Bloodletting (Raktamokshana): To remove vitiated blood.
    • Kaphaja Arsha Treatment:
      • Drying Therapies: Use of astringent and pungent herbs.
      • Herbal Fumigation: To reduce swelling and congestion.
      • Alkaline Preparations (Kshara): Application of herbal alkaline substances to shrink hemorrhoids.

Shloka References:

  • “Tatra Śuṣkārśasāṁ Pūrvam Pravakṣyāmi Cikitsitam…” (Verse 38)
  • “Jalaukōbhis Tathā Śastraiḥ Sūcībhir Vā Punaḥ Punaḥ…” (Verse 61)
  1. Use of Kshara (Alkaline Therapy):
    • Application of herbal alkaline preparations to cauterize hemorrhoids.
    • Considered effective for both dry and bleeding hemorrhoids.
  2. Surgical Interventions:
    • Kshara Sutra (Medicated Thread Ligation):
      • A minimally invasive procedure using a medicated thread to ligate hemorrhoids.
    • Sastra Karma (Surgical Excision):
      • Removal of hemorrhoids using surgical instruments.
    • Agni Karma (Cauterization):
      • Use of heat to cauterize and reduce hemorrhoidal tissue.
    Note: Surgical treatments are recommended when conservative therapies fail and should be performed by experienced practitioners to avoid complications.

Shloka Reference:

  • “Ast yetad Bhūritantrēṇa Dhīmatā Dṛṣṭa-Karmaṇā Kriyatē Trividhaṁ Karma…” (Verse 34)
  1. Herbal Formulations and Medications:
    • Takra (Buttermilk) Preparations:
      • Buttermilk is highly valued in Arsha treatment, especially for Vata and Kapha types.
      • Takrarishta: A fermented preparation of buttermilk with herbs.
    • Medicated Ghee (Ghrita):
      • Chitrakadi Ghrita: Prepared with Chitraka (Plumbago zeylanica) and other herbs.
      • Benefits: Improves digestion, reduces inflammation, and promotes healing.
    • Herbal Pastes (Pralepa) and Ointments:
      • Application of pastes made from turmeric, Haritaki (Terminalia chebula), and other herbs to reduce swelling and pain.

Shloka References:

  • “Vāta-Śleṣmārśasāṁ Takrāt Paraṁ Nāstiha Bhēṣajam…” (Verse 77)
  • “Pippalī-Pippalī-Mūlaṁ Citrokaṁ Hastipippalīm…” (Verse 89)
  1. Dietary Recommendations:
    • For Vataja Arsha:
      • Warm, unctuous, and easily digestible foods.
      • Avoid dry, cold, and rough foods.
    • For Pittaja Arsha:
      • Cooling foods like milk, ghee, and sweet fruits.
      • Avoid spicy, sour, and hot foods.
    • For Kaphaja Arsha:
      • Light, dry, and warming foods.
      • Avoid heavy, oily, and sweet foods.

Shloka Reference:

  • “Raktaśālyōdanaṁ Dadyād Rasaiḥ Tair Vātaśāntayē…” (Verse 127)

Modern Correlation

  1. Conservative Management:
    • Dietary Modifications:
      • High-fiber diet to soften stools and reduce straining.
      • Adequate hydration.
    • Lifestyle Changes:
      • Regular exercise.
      • Avoiding prolonged sitting or standing.
      • Proper toilet habits without straining.
    • Topical Treatments:
      • Creams and ointments containing hydrocortisone or witch hazel.
      • Warm sitz baths to alleviate symptoms.
  2. Minimally Invasive Procedures:
    • Rubber Band Ligation:
      • A rubber band is placed around the base of the hemorrhoid to cut off blood flow.
    • Sclerotherapy:
      • Injection of a solution to shrink hemorrhoids.
    • Infrared Coagulation:
      • Use of infrared light to coagulate hemorrhoidal tissue.
  3. Surgical Interventions:
    • Hemorrhoidectomy:
      • Surgical removal of hemorrhoids.
      • Recommended for large, prolapsed, or thrombosed hemorrhoids.
    • Stapled Hemorrhoidopexy:
      • Procedure to reposition hemorrhoidal tissue and reduce blood flow.

Herbal Formulations and Medications

Ayurvedic Preparations

  1. Takrarishta (Fermented Buttermilk Preparation):
    • Ingredients:
      • Pippali (long pepper), Chitraka (Plumbago zeylanica), Dhanyaka (coriander), and other digestive herbs.
    • Benefits:
      • Improves digestion, balances Vata and Kapha, alleviates hemorrhoid symptoms.
    Shloka Reference:
    • “Takraprayōgō Māsāntaḥ Kramēṇōparamō Hitaḥ…” (Verse 82)
  2. Medicated Ghee (Ghrita) Preparations:
    • Chitrakadi Ghrita:
      • Processed with Chitraka, Pippali, and other herbs.
      • Benefits: Enhances digestion, reduces inflammation, promotes healing.
    • Triphala Ghrita:
      • Prepared with Triphala (three fruits) for laxative and healing properties.
  3. Herbal Pastes and Ointments:
    • Pralepa:
      • Topical application of pastes made from turmeric, Haritaki, and other herbs.
      • Benefits: Reduces swelling, pain, and itching.
  4. Arishtas (Fermented Herbal Tonics):
    • Abhayarishta:
      • Contains Haritaki and promotes bowel movements.
      • Benefits: Mild laxative, improves digestion, reduces hemorrhoidal symptoms.
    Shloka Reference:
    • “Asyābhyāsād Ariṣṭasya Gudajā Yānti Saṅkṣayam…” (Verse 141)

Modern Correlation

  • Over-the-Counter Medications:
    • Topical Agents:
      • Creams containing hydrocortisone for inflammation.
      • Local anesthetics for pain relief.
    • Suppositories:
      • Provide lubrication and deliver medications directly to the affected area.
  • Herbal Supplements:
    • Horse Chestnut Extract:
      • Strengthens vein walls, reduces swelling.
    • Witch Hazel:
      • Astringent properties reduce bleeding and inflammation.
  • Dietary Supplements:
    • Fiber Supplements:
      • Psyllium husk to soften stools and promote regularity.

Lifestyle and Dietary Recommendations

Ayurvedic Perspective

  1. Dietary Modifications:
    • Recommended Foods:
      • Light, easily digestible grains like rice and barley.
      • Green gram (Mudga), lentils, and lean meats.
      • Buttermilk and light soups.
    • Foods to Avoid:
      • Heavy, oily, and spicy foods.
      • Excessive intake of meat from heavy animals.
      • Fermented, stale, or incompatible foods.
  2. Lifestyle Changes:
    • Encouraged Activities:
      • Regular physical exercise appropriate to one’s capacity.
      • Maintaining proper hygiene in the anal region.
    • Activities to Avoid:
      • Prolonged sitting or standing.
      • Suppression of natural urges.
      • Excessive sexual activity.
  3. Hygiene and Local Care:
    • Anal Cleansing:
      • Washing the anal area with warm water after defecation.
      • Use of medicated decoctions for cleansing.
    • Sitz Baths:
      • Soaking the anal region in warm water infused with herbs to reduce discomfort.

Modern Correlation

  1. Dietary Recommendations:
    • High-Fiber Diet:
      • Fruits, vegetables, whole grains to soften stools.
    • Adequate Hydration:
      • Drinking plenty of water to prevent constipation.
  2. Lifestyle Modifications:
    • Regular Exercise:
      • Promotes bowel regularity.
    • Avoiding Straining:
      • Responding promptly to the urge to defecate.
    • Proper Toilet Habits:
      • Not spending excessive time on the toilet.
  3. Hygiene and Local Care:
    • Warm Sitz Baths:
      • Soaking in warm water several times a day.
    • Gentle Cleaning:
      • Using moist wipes or damp toilet paper.
    • Avoiding Irritants:
      • Using unscented, gentle soaps.

Conclusion

Arsha Chikitsa, as outlined in the Charaka Samhita, offers a holistic approach to managing hemorrhoids by addressing dietary habits, lifestyle choices, and utilizing herbal remedies. The emphasis on balancing the Doshas, improving digestion, and strengthening the body’s natural healing mechanisms aligns with modern principles of treating hemorrhoids.

Integrating Ayurvedic practices with contemporary medical treatments can enhance patient outcomes by providing comprehensive care that addresses both symptoms and underlying causes. Recognizing the value of ancient wisdom and its applicability in today’s healthcare allows for more personalized and effective management strategies for hemorrhoids.

References

  1. Charaka Samhita, Chikitsa Sthana, Arsha Chikitsa Adhyaya.
  2. Sharma, P. V. (1981). Charaka Samhita: Text with English Translation. Chaukhambha Orientalia.
  3. Lad, V. (2002). Textbook of Ayurveda. Ayurvedic Press.
  4. Dash, B., & Kashyap, L. (2001). Diagnosis and Treatment of Diseases in Ayurveda. Concept Publishing Company.
  5. Murthy, K. R. S. (2012). Astanga Hridaya (English Translation). Krishnadas Academy.
  6. Singh, R. H. (1998). Essentials of Ayurveda. Motilal Banarsidass Publishers.
  7. Ferguson, J. A. (2004). Management of hemorrhoids. BMJ, 328(7451), 61-64.
  8. Riss, S., et al. (2012). The prevalence of hemorrhoids in adults. International Journal of Colorectal Disease, 27(2), 215-220.
  9. Mounsey, A. L., et al. (2011). Hemorrhoids. American Family Physician, 84(2), 204-210.

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