1. Bijendra Shah 1, T. S. Dudhamal 2, Shivmangal Prasad 3
A Study on Efficacy of Ksharakarma in Management of Internal Haemorrhoids (Arsha)- Case Series
Bijendra Shah 1, T. S. Dudhamal 2, Shivmangal Prasad 3
1. MS (Ayu) Scholar, 2. Assistant Professor, Institute for Post Graduate Teaching and Research in Ayurveda, Gujrat Ayurveda University, Jamnagar, Gujarat, India. 3. Ayurveda Medical Development & Research Foundation (AMDRF), Kathmandu, Nepal.

2. Introduction
Ksharakarma is a process of application pratisaraneeya teekshna kshara. It is a non-surgical procedure of Ayurveda indicated for the management of Arsha (Hemorrhoids).
Kshara is an alkaline in nature derived from a combination of various herbs that is applied on the pile mass with help of a special slit proctoscope.
Sushruta has described it as one of the best Para-surgical tool for treatment of various surgical ailments.
Kshara are superior to the Shastra and Anushastra and due to its Tridoshaghna properties, potential to perform Chedana(excision), bhedana (incision) and lekhana (scrapping) because of their power to alleviate all the three doshas. It is a type of chemical cauterization. It destroys the unhealthy tissues and promotes healing process.
Arsha is muscular enlarged mass in the three vali of guda (sub mucosa of anal canal).
Ksharakarma procedure interpreted as “Potential cauterization Therapy” is the specific field taken in the present research work.
Ksharakarma treatment is found to be suitable and acceptable as compared with the prevalent methods in medical science.

3. AIMS AND OBJECTIVES
To catalogue the role of ksharakarma in managements of Internal Haemorrhoids (Arsha).
To focus and enlighten the path based on ksharakarma principles for new research scholars.
To simplify the basic surgical approaches.

4. MATERIAL AND METHODS Pratisaraneeya Tikshna Kshara
It is a standard kshara used in this study which was prepared according to classical protocal. It contains Apamarga (Achyranthes aspera) , Shukti(Pearl) powder, Citarak (Plumbago zeylanica), limestone, Shankha.
This kshara were prepared under the standard guidelines given by Sushruta.
Selection of patients:
33 Patients of Arsha (Haemorrhoids) were selected irrespective of their sex, religion, occupation from the OPD of Nepal Ayurvedic Panchakarma and Ksharsutra polyclinic, Kirtipur, Kathmandu Nepal.

5. Criteria of Diagnosis:
Inclusion criteria:
Patients with different age of years having internal piles of 1st , 2nd and 3rd degree were included in this study.
Exclusion criteria:
Following patients were excluded:- pregnancy, carcinoma rectum, hepatitis, heart diseases, 4th degree piles, external piles, tuberculosis, inflamed prolapsed, thrombosed piles.
Criteria of Diagnosis:
All Diagnosis was made on the basis of physical , P/R examination i.e. Inspection, palpation and Proctoscopic examination.
Investigation:-
All Routine examination of Blood, Urine, Stool and X-Ray were carried out.

6. METHODOLOGY Kshara karma Purva karma (Pre-operative)
After taking written consent for operation perianal hair was shaved according to need and the part was painted with antiseptic solution. The patient was kept nil orally for at least 6 hour before the procedure. Injection Tetanus toxoid (0.5ml) I/M was given and xylocain sensitivity test was performed in each patient. I/V line is get opened. The patient was given a light diet 2 hour before and afterwards keep it nil orally.
Pradhan Karma (Operative procedure)
After the patient was position in lithotomy on the operation table, local anaesthesia was given. The part was painted with antiseptic solution. The diseased part is exposed by special slit proctoscope and examined carefully. The adjoining healthy region of these organs was covered with gauze piece to prevent the spread of Kshara on healthy tissue exposed. The kshara is applied on proposed lesion by probe. Generally the kshara is applied up to the counting 100, but this depends on the nature of tissue so we should take 1-3 min. The mucosal covered part of the lesion take shorter time than hard skin covered parts..

7. METHODOLOGY Kshara karma Purva karma (Pre-operative)
After taking written consent for operation perianal hair was shaved according to need and the part was painted with antiseptic solution. The patient was kept nil orally for at least 6 hour before the procedure. Injection Tetanus toxoid (0.5ml) I/M was given and xylocain sensitivity test was performed in each patient. I/V line is get opened. The patient was given a light diet 2 hour before and afterwards keep it nil orally.
Pradhan Karma (Operative procedure)
After the patient was position in lithotomy on the operation table, local anaesthesia was given. The part was painted with antiseptic solution. The diseased part is exposed by special slit proctoscope and examined carefully. The adjoining healthy region of these organs was covered with gauze piece to prevent the spread of Kshara on healthy tissue exposed. The kshara is applied on proposed lesion by probe. Generally the kshara is applied up to the counting 100, but this depends on the nature of tissue so we should take 1-3 min. The mucosal covered part of the lesion take shorter time than hard skin covered parts..

8. Paschat Karma (Post-Operative)
As soon as the sign of Samyak dougdha (proper cauterization) appears, the Kshara is rapidly neutralised by acidic fluid like lemon water. Later, on the cauterised part is washed out with distilled water. Jatyadhi tail/ghrit is applied on the cauterised lesion and dressing is done. It should be neutralized and washed out completely and carefully, otherwise it produces severe complications rather than cure.
Patient were allowed to orally sip liquids after 6-8 hour of ksharkarma and were shifted to normal diets. Later patients were advised for Avagha Sweda with Sphatikadiyoga (5g/sitting) upto atleast 10 min with maintenance of equal warm water. Alternative days dressing with warm water and 10ml Jatyadhi tail/ghrit as matra vasti was given.
Sign of Samyak dougdha (Proper cauterization)
Within 1-3min after Kshara application the tissue of the diseased part becomes purple or dark black in colour and cauterised lesion is shrinked, pain and discharge relieved. The patient feels easiness with relief of prominent symptoms.
Signs of Heen dougdha (Improper cauterization)
The colour of treated area looks reddish with aggravation of pain discharge and itching.
Feature of Ati dougdha (Extensive cauterization)
It is followed by burning and severe pain, redness of the cauterised area, ulceration with purulent discharge, fever, generalised pain in the body, intense thirst and shock, even death may occur.
For the two week period following medication were prescribed to reduce pain , inflammation and promote healing. Orally – Tab. Gandhak rasayan 250mg *BD, Tab. Sigru guggulu 250mg *BD, Tab. Triphala guggulu 250mg*BD, and Jatyadhi tail -LA* 3ml * BD

9. OBSERVATIONS AND RESULTS
After kshara application all patients were follow up weekly interval for 4 weeks.
During each follow-up visit, signs and symptoms were assessed. There was moderate to mild pain, tenderness, inflammation and brownish black discharge on first visit and second visit. During the third and fourth visit there was no pain, tenderness, discharge or anal stricture and the internal haemorrhoids had completely resolved. (table-1)
Kshara karma shows significant improvement on clinical features of arsha like rectal bleeding, pain in ano and constipation.
In over all of therapy by kshara karma therapy near 70% of the patient got cured. (table-2)
Average time taken for removal of pile mass was 21 days by kshara karma without bleeding, pain.

10. Criteria of assessment: All the signs and symptoms were assigned a score depending as their severity to assess the effect of the procedure objectively. The following grading pattern was adopted for the scoring
Pain:-
Severe- To relieve from pain , analgesic injection are required. Moderate – To relieve from pain , Oral analgesic are required. Mild – Feeling discomfort within tolerable limit, no required of analgesic. Nil – No discomfort in any manner in the site, no analgesic.
Bleeding:-
Severe – Changing sanitary pads or cotton pads minimum 2 times a day. Moderate- changing of pads once a day only. Mild – No requirement of pad. Nil- Area is completely dry.
Tenderness:-
Severe – Patient feeling pain by touching perianal area. Not possible to perform examination. Moderate- Little finger P/R can be done , patient feeling very much tolerable pain. Mild- Index finger P/R done with very much tolerable pain. Nil- Index finger insertion to anal canal without any pain or discomfort.

11. Table - 1 Follow up visit Total average of all
1st visit (after 7 days)
2nd visit (after 14 days)
3rd visit (after 21 days)
Appetite
Normal to all
Normal
Bowels
Regular
Sleep
Micturition
Blood pressure
Pulse
Pain
Moderate
Mild
Nil
Pus
Mucus
Blood
Itching
Mild (occasional)
Burning sensation
Discharge
Sloughing
Tenderness
Inflammation
Discolouration
Red
Colour of scar

12. Table-2 Total Effect of therapy No. of patients Percentage (%) Cured23
69.7
Marked Improvement 5
15.1
Improved 3
9.1
Absent in flowup 2
6.1

13. Table 4 - Effect of Ksharkarma
Days
Patient's observation
Surgeon's observation
1st day - Immediately after kshara application.
Mild pain, moderate burning sensation
Coagulation of haemorrhoid plexus, blackish discolouration of mass looks like jambu phala
2nd day
Pain, swelling
Edema and softening of coagulated mass, with initiation of sloughing
3rd to 7th day
Blackish discharge , with tissues sloughing, pain, burning sensation
Sloughing, necrosis of mass
8th to 14th days
Mild to moderate burning sensation while passing motion lasts for 30 minutes, stools mixed with few drops of bleeding
Mucosal ulcer on the site Mass get reduced on site
15th to 21st days
No symptoms except mild discomfort like itching.
Healing of ulcer
After 21 days
No symptoms
Scar on the site with complete obliteration and adhering of scar to muscular coat

14. Before Ksharkarma

15. During Ksharkarma

16. After Ksharkarma

17. DISCUSSION
Pratisaraneeya tikshna kshara was applied to the 1st, 2nd and 3rd degree internal hemorrhoids(arsha). It was observed that the pile mass became black in 60 seconds as described in the Sushruta Samhita. Lemon juice was used to neutralize the kshara after proper burning of pile mass.
The kshara cause coagulation of the haemorrhoid plexus (cauterization of pile mass), necrosis of tissues followed by fibrosis of plexus, adhesion of mucosal, sub mucosal coat helps in prevention of further dilation of veins. It prevents relapse of regional mucosa of anus and makes permanent radical obliteration of haemorrhoids During the oozing of blood, which is ceased by the sclerosing effect of the kshara by it coagulating property of protein. Hence there was no chance of bleeding during kshara application. The chance of infection is least due to the sustained action of the anti-microbial property of kshara.
Application of kshara is found to be safe, efficacious and cost effective method for management of internal 1st, 2nd and 3rd degree haemorrhoids.
Complication of case reports and comparative clinical studies are needed to standardize the treatment protocol and catalogue outcome measures.

18. CONCLUSION
This study manifests that Pratisaraneeya tikshna kshara was found effective in obliterating the 1st , 2nd and 3rd degree Arsha(hemorrhoids) mass within days of application.
Kshara karma procedure can be conducted at OPD level or can be performed with proper prophylactic measures. It is very effective procedure, no primary and reactionary haemorrhage is caused.
It requires less time and can perform his/her routine work from next day of ksharakarma.
Antibiotic and anti-inflammatory drugs requirements are quite less.
It takes less hospitalization time and there is least possibility of recurrence.
There is no adverse effect during the post operative period, like anal stenosis /stricture, incontinence, bowel irregularities.
This study finally manifests that a combination of kshara karma, conservative treatment, diet restriction and life style modification administered over a period of minimum of 6 month is effective in obliterating the 1st ,2nd and 3rd degree pile mass as well as preventing recurrence on a long term basis.

19. ACKNOWLEDGEMENTS
I would like to express my deep gratitude to professor Dr. D. B. Roka , Professor Dr. S.K. Gupta, Dr. T.S. Dudhmal, Dr. V.D. Mahanta, Dr. Galib & Dr. Shivmangal Prasad for their guidance, enthusiastic encouragement and useful critiques of this work.
My special thanks are extended to the staff of Ayurveda Teaching Hospital-IOM, TU. , AMDRF and NAPKC Kathmandu, Nepal.
Finally, I wish to thank my parents for their support and encouragement throughout my study.