J.R.A.S. Vol. XXXI, No.4, Oct. -Dec. 10 pp. 101-112

A Case Study of ThrombosedHaemorrhoids Treated with

Leech ApplicationR. Govind Reddy', Anil Mangal', A. D. Jadhav', P. S. Tathed4

and Paresh'

Abstract

Minimal invasive technique of the ancient medical science whichrequire documentation of their effect on different ailments. One of thesetechniques is blood letting with the help of leeches, was used in a case ofinoperable thrombosed haemorrhoids, six different symptoms and signswere graded and studied, the scores were entered in the case paper. Resultswere studied at the end of two months when the patient becamesymptomless. Inference was drawn and the mode of action of the modalityis suggested.

Introduction

Sushruta the ancient father of thesurgery, though they describe manycomplicated surgical procedures butstill believed in minimum invasiveprocedures to manage surgicalconditions. Such procedures arecalled minimal invasive para-surgical procedures in the modemdays and are gaining importance in

day to day practice as they inflictminimum pain to the patient and arecost effective. These Para-surgicalprocedures include a) ksharakarmab) Agnikarma c) Raktamokshanawhich are further subdivided andadopted as per the requirements inthe given situation.

Haemorrhoids amongst the ano-rectal diseases is one such diseasewhich requires surgical intervention.

1. Research Officer (Ay.) 2. Research Officer CAy.) 3. Research Officer CAy.)I/c R.A.Poddar Central Research Institute CAy.)WorJi Mumbai 4. Dean, YM.T. AyurvedicMedical College and Research Centre, New Mumbai and 5. M.Sc. Pharmaceuticalrviecicme.

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Though the surgical procedures arequite successful there is a possibilityof recurrence. At times thehaemorrhoids may Prolapse, theprolapsed part may becomethrombosed and painful, or becomestrangulated.

This type of situation posesproblems of ulceration, infection,pyelephlebitis and gangrene of thehaemorrhoids. This pecu liarsituation problem for the surgicalprocedures and the surgeon has towait till the thrombus and painsubsides and the inflammatoryswelling around the haemorrhoidsreduces. The conservative measuresemployed are far from satisfaction.Hence there is a need for moreeffective modalities.

Rakta mokshana (Blood letting)is one such modality which seems tobe promising. Rakta mokshana issubdivided into two 1) Blood lettingwith the help of instruments2) Bloodletting with the help of leech whichcan be called as Bio apparatus. 1)Theinstruments includes a) Shrunga(cow's hollowed horn) b) Alabu:dried and hollowed bitter guard c)Prachchana with the help of knife,multiple superficial incisions on the

affected part of the body d)Siravedha by cutting the vein at theaffected part. 2) Application ofleech: leech is a blood suckingcreature which has the capacity toselectively suck the blood which isaffected by doshas. The applicationof leeches at the site ofhaemorrhoids and around isadvocated by the ancient authors ofAyurveda shastra. It is also in theday to day practice of manypractioners but the documentationis scanty. Here is humble attempt todocument a case study of a patientof thrombosed haemorrhoidstreated with leech application.

Presenting complaints

>- Burning and itchingsensation at the anal region.

>- Continuous Pain in theanal region.

>- Increased with change ofthe posture and defecation.

>- Something coming out ofthe anus.

>- Bleeding P/R.>- Difficulty in defecation

and also while passing flatus>- Blood stained mucus

discharge.

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A CASE STUDY OF THROMBOSED .

Past history of disease

Pain, burning and itchingsensation off and on since 5 years.Occasional bleeding whiledefecation & chronic constipation.

Past history of patient

Known case of HypertensionlDiabetes Mellitus IIschaemic HeartDisease - 12 years & Hemiplegia - 2years.

History of previous surgery

Patient was operated forglioma-a large cystic lesion in rightcorpus callosum.

History of blood transfusion - 3units.

Patient was admitted atM.A.Podar Ayurvedic hospital withthe above mentioned complaints.Manual reduction was tried withoutsuccess. The pain aggravated due toforceful attempt of manualreduction. Patient was referred toK.E.M Hospital, parel, Mumbai.The operation was considered butas the general condition of thepatient was not satisfactory. ThePatient was put 0.1 conservative lineof treatment without much

satisfactory effect. Hence patientwas discharged on his request andwas brought to R.R.A. Podarcentral research Institute, Worli;Mumbai. Patient was admitted inthe ward and was treated onfollowing lines.

Patient's family history

Nothing particular was noted.

Personal history and addictions

Mixed diet, addicted to alcoholand tobacco chewing and smoking.Disturbed sleep, emotional stressdue to family problems.

On Examination:

General examination

General condition fair, afebrile,asthenic.

Pulse: 90/min, regular, volumegood

Respiratory Rate: 22/min

Temperature: normal

BP: 190/1 OOmmofHg (fluctuatingthrough out day)

RS: clear

H.S.:NAD

Urine: passed normally

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Stools: Hard stools with blood andmucus

Nails: pallor

Conj unctiva: pallor.

Tongue: coated, foul smellingbreath.

Systematic Examination

Respiratory System

NothingAbnormal Detected.

Cardiovascular system

History of chest pain andbreathlessness known case ofIschaemic Heart Disease.

Heart Sound: NAD

Alimentary system

Loss of appetite, Nausea,Discomfort in the abdomen, Liverjust palpable, tender on deeppalpation, spleen not palpable.

Central Nervous System

History of operation of gliomawith left Hemiplegia.

Urinary System

Bladder catheterised due todribbling of urine after operation.

Local Examination

Swelling with discolourationof the anal region, painful on touch.

Firm swelling, bleeds on touch andtender. 3rd and 4th degree prolapsedand thrombosed piles at the 3, 7 and1100 clock positions.

Investigations

Routine laboratory investigationand radiological investigationsWithin Normal Limits except Hb andblood sugar.

Hb- 10.5 gm/dl Blood sugar fasting-150mg/dI, Post prandial- 21Omg/dl,(Patient is under Allopathictreatment for blood sugar)

BT-2-3 min} W.N.L.

CT-3 min

ECG: Q wave in 2nd and 3rd

AVL V4V5V6 with ST depression

and T wave inversion suggestive ofold healed infarct with leftventricular hypertrophy.

Differential diagnosis

Possibility of rectal Prolapse,Carcinoma anal canal or rectum andprolapsing rectal polyps wasexcluded clinically.

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A CASE STUDY OF THROMBOSED .

Diagnosis: Prolapsed thrombosed haemorrhoids.

Thrombosed (Prolapsed) Hemorrhoids with Gangrene (Before the Treatment)

Management

Application of leeches aftercleaning mass with normal saline andsterile dry gauze piece alternate days

for I week. There after every 3rd day tillthe swelling completely subsided andthe mass of the haemorrhoids could beplaced in the rectum without difficulty.

Jalaukavacharan Vidhi (Application of leeches) in Thrombosed Haemorrhoids

Local treatment

Local application ofkasisadi tailafor 1week there after kasisadi tailaintroduced through anus 5 ml withPaediatric Catheter alternate day.Local fomentation with a ball of gaugepieces socked in dettol lotion. Sitz

bath twice daily in lukewarm potassiumpermanganate water.

Internal Medication1) Tab. Kumarika vati 500mg

S.O.S. (for pain)

2) Tab. Sukshma Triphala 500mgT.O.S.

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3) Tab. Arogyavardhini Vati 500mgT.D.S.

4) Syp. Abhyarishta 20 ml+ 20mllukewarm water at bedtime.

5) GandharvaHartitaki churna 5gmat bed time.

Results &Observation

It was observed that the intensityof pain reduced after the firstapplication of the leech. Though thesize ofthe mass did not change.

After one week the pain becametolerable though did not disappearcompletely. The reddish blackdiscolouration became bright red.

Local burning sensation reduced. Theswelling of the mass reduced and alittle finger could be passed withoutdiscomfort to the patient. Thisfacilitated the introduction of catheterand kasisadi taila could be introducedin the rectum. Mucus dischargereduced.

On completion of two weeks oftreatment the pain further reduced andpatient did not require Kumarika vatito be given. Burning sensation reducedfurther, the firmness and swellingaround the pile mass reduced whichallowed index finger to be introducedin the anus with slight discomfort.

Thrombosed (Prolapsed) Haemorrhoids (Middle of the Treatment)(After 6 sittings/2 weeks)

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A CASE STUDY OF THROMBOSED .

After completion of three weeksof treatment the pain was present onlyat the time of defecation, swellingreduced and the colour of the swellingimproved further and became normal.There was no mucus discharge.

On completion of one month

treatment the pile mass furtherreduced, pain at the time of defecation,swelling also reduced. There was nodiscomfort at the time of introductionof catheter for introducing kasisaditail. The blood and mucus dischargecompletely stopped. The generalcondition of patient improved.

Thrombosed (Prolapsed) Haemorrhoids (Middle of the Treatment)(After 9 sittings/ 4 weeks)

After six week of treatment thepile mass further reduced and could bepushed in the rectum, which prolapsed

on passage of stools and flatus at times.There was no pain, tenderness, bloodor mucus discharge.

Thrombosed (Prolapsed) Haemorrhoids (After the Treatment)(After 14 sittings/ 6 weeks)

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On completion of the treatment atthe end of 2nd month the frequency ofprolapse of pi Ie mass was reduced andwas observed only at defecation,which went into rectum of its own.

There was no pain, bleeding, or mucusdischarge. Hence the patient wasdischarged and was advised only oraltreatment.

Thrombosed (Prolapsed) Haemorrhoids (After the Treatment)

Table-IResults of the treatment of Leech application in Thrombosed Haemorrhoids

Sr. Symptoms Before 7 Days of 15 Days of 30 Days of 45 Days of 60 Days ofNo. treatment Treatment Treatment Treatment Treatment Treatment

Pain +++ ++ ++! +~ 0 0

2 Swelling +++ ++ ++ + +~ 0

3 Tenderness ++++ +++ ++ + 0 0

4 Discoloration ++ + +!

0 0of skin

0

5 Burning +++ ++~ + +~ 0 0sensation

6 Mucus Present Present Present Absent Absent Absentdischarge

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A CASE STUDY OF THROMBOSED .

A. Pain

Grade III (Severe pain): Constantagonising pain without change ofposture requires sedatives likeKumarika vati.

Grade II (Moderate): Pain tolerable atrest, intensifies with change of posturer e q u ir e s Kumarika vati afterdefecation or local interference.

Grade I (Mild): Tolerable pain at thetime of defecation, no pain at rest or atchange of posture requires no painkillers.

Grade 0 (No pain)-O

8. Tenderness

Grade 111- Patient does not allow totouch and pain intensifies on change ofposture.

Grade II- Though the patient allows totouch but experience intense pain withlight touch and does not allow tointroduce finger.

Grade 1- Pain on firm touch and whiledoing P/R examination.

Grade 0- No tenderness- 0

C. Colour

GradelII- Black

Gradell- Blue Black

Grade 1-Red Blue

Grade 0- Bright Red

D. Swelling

Grade III-Obstructing the analopening completely along with perianal swelling

Grade 11- Obstructing the analopening from where ribin like stoolcan pass without much perianalswelling

Grade 1- Obstructing the anal openingcan allow tip of the little finger withpain

Grade 0- No swelling

E. Burning sensation

Grade 111- Constant anal burningsensation, patient becomes restless

Grade 11- Occasional burningsensation even after passing flatus

Grade 1- Burning sensation at the timeof defecation

Grade 0- No burning sensation

Suggested action of the treatmentmodality

It seems that the blood sucking

creature when applied at the

thrombosed piles sucks the blood

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and/ or sucks the blood stainedexudates from and around the pilemass. though only about SOc.c., theswelling which compresses thenerve endings is reduced, thisprobably helps in relieving theintensity of pain. So also as thecongestion is relieved, the fresharterial blood flow increases whichmight facilitates the phagocytic

activity of the white cells.

Now it is established that thesecretions from the mouth of theleech contains certain chemicalswhich have anaesthetic effect, alongwith Hirudin which is anti-coagulant and anti inflammatory(Researcher believe that 65-polypeptide amino acid isresponsible for such action) thisprobably dissolves the microthrombi in the capillaries aroundthe pile mass ensuring increase III

the circulation of both the arterialand venous ends of the capillaries,so also it contains certain chemicalswhich probably has anti-bioticaction which helps in combating the

super added infections, whichmight set in due to stasis of theregion.

Conclusion

Leeches were applied in thepatient, at inoperable thrombosedpiles at periodical intervals. Firstapplication of the leeches reducedthe intensity of pain and theswelling around the pile mass theblackish discolouration which wassuggesting that the piles arebecoming gangrenous were alsoreduced on subsequent applicationsof the leeches. Though it took abouttwo months to achieve satisfactoryrelief the modality seems to bepromising in the patients ofthrombosed piles.

Though many researchers havestudied different aspects andchemicals of the saliva of theleeches, still much remains to bestudied. Probably action on themicro thrombi suggested in thisstudy remains to be explored.

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A CASE STUDY OF THROMBOSED .

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Rao, M.M. et al. (2006) A Clinical Study on the Management of Arsha(Haemorrhoides) by Ayurvedic drug regimen - JRAS.Vol.XXVII, No.3-4.pp.48-58.

Govinda Dasa, (2001). Bhaishajya Ratnavali 14th Edition, Vidyothini HindiVyakhya byAmbikadatta Sastry, Varanasi: Choukhamha Sanskrit Sansthan.

Nadakarni, K. M. (1982). Indian Materia Medica. Bombay: PopularPrakashan Pvt.Ltd. 3'drevised and enlarged Edition. Vol. I& II.

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