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Introduction

The disease described as Arshas in Ayurveda can be resemble as Piles or haemorrhoid in modern medical science. Arsha includes a variety of conditions pertaining to Ano- rectal and other part of the body. Any growth in anorectal region (Guda) whereas at other sites it is called Adhimamasa. Considering its severity Sushruta considered it is one among the Ashta mahagada.1 Acharya Vagbhata has mentioned it as fleshly projections, kill the life like an enemy and create obstruction in the anal passage. The word Arsha is self-explanatory by itself, indicating that the disease troubles a person like an enemy. According to Acharya Vagbhata and Yogaratnakara in Arsha the mamsa keelaka which obstructs the anal passage, and kills the person like an enemy.2 Ayurvedic literature described that the Arsha is difficult to cure and trouble to the patients like as enemy. Symptoms of Arsha is clinically resemble as feature of haemorrhoids in modern science.

Objectives: To critical review on etiopathogenesis review of Arsha vyadhi according to Ayurveda.

Methodology:

Conceptual review of Arsha vyadhi done from Various Ayurvedic treatises and other classical Ayurveda books, similarly review done from published paper in national and international journals.

Anatomy of Guda:

Acharya Charaka has mentioned Guda is having two parts, viz. uttara guda and adho guda. In uttara guda purisha is stored and is excreted through adho guda3. Guda is situated in guda asthi vivara or shroni guha.4

Pramana: Guda is about 4½ Angula pramana. Guda is divided into three valis, as abhyantara, madhya and bahya situated at a distance of 1½ anguli pramana. Acharya Sushruta and Vagbhata described the presence of three vali (fold or curvatures) named pravahini, visarjani and samvarini.5

Etiopathogenesis of Arsha:

Nidana of Arsha:

Sahaj and janmottaraja are considered the main causative factors for Arsha.6

Nidan of Sahaja Arsha:

The cause of sahaja Arsha is dushti (vitiation) of beej-bhaga, which produces in the guda vali.7 Beej-bhaga vitiation occurs due to Mithya aahar vihar of parents Poorvajanmakarma.8 According to Acharya Sushruta the vitiated shonita and shukra is the hetu of sahaj- arsha.9

1. Aaharaj hetu :

Atisevan of Guru, madhur, sheeta, abhishyandi, vidahi, virudhdha-bhojan, pramit- bhojan, asatmya-bhojan; nava shami dhanya, pinak, shaluka, matsya, varaha, mahisha, aja-mansa; krusha-prani mansa; shushka mansa; nava shuka dhanya, shastika, shrungataka, shushka teela, gud-vikruti, vasa, viruddha dhanya, kilat, lashuna, mrunala, atikranta madya, ati-snehapan, aama moolaka, gurushaak, kasheruka, dadhi, guru jala, ikshu ras, ksheer, manda, mansa yoosha are considered as causative factor for Arsha.10

1. Viharaj hetu:11,12,13

According to Charaka, Sushruta and Vagbhata the Viharaj hetu are described as shown in the following table:

Table no. 1 Viharaj hetu according to Charaka, Sushruta and Vagbhata

Hetu	Sushruta	Vagbhata	Charaka
Agnimandya	+	+	+
Ati Vyayama / Vyavaya	+	+	+
Guda gharshana	+	+	+
Utkatukasana	+	+	+
Vegodeerana	+	+	+
Vego vidharana	+	+	+
Ati Pravahana	_	+	+
Aamagarbha bhransha	_	+	+
Guda kshanan	_	+	+
Kathin aasan	_	+	+
Visham aasan	_	+	+
Aasan sukh	_	_	+
Asamyak sansodhan	_	_	+
Asamyak bastinetra prapidan	_	_	+
Avyavaya	_	_	+
Basti vibhransha	_	_	+
Divaswapna	_	_	+
Garbhat peedana	_	_	+
Shayya sukh	_	_	+
Sheetambu sparsh	_	_	+
Ushtra yaan	_	_	+
Amaatisara / Atisara / Grahani	_	+	_
Gulma	_	+	_
Jeerna kaasa	_	+	_
Jwara	_	+	_
Pandu	_	+	_
Kshawathu	_	+	_
Vibandha	_	+	_
Vyadhijanya krishata	_	+	_
Yaan sankshobha	_	+	_

Poorva Roopa :

The condition in which sensation is felt before the appearance of the main sign and symptoms is called poorva roopa. Acharya Charak, Sushrut and Vaghbhata have described poorvaroopa. They are Amlika, annavishtambha, antra kunjana, atopa, grahani-udar-pandu rog ashanka, pakti, udar bahulya, alpa purisha, shwash, kasa, gud-parikartan, paridaha, balhani, bhrama, daurbalya, karshya, pipasa, sakhti sada etc.14

Roopa (Symptoms) :

Acharyas described symptoms (Roopas) of Arsha was divided into two groups; they are general (samanya) and specific (vivesh). The symptoms of Arsha are angamarda, arochaka, ashmari, asyavairasya, asthi shul, atinishprabha, badhirya, bhinna swara, deenata, hatotsaha, hridaya shul, jwara, kasa, payu shula, pinasa, pipasa klaibya, klama, krishata, akshamata, ksham swar, kshavathu, nabhi shoola, pandu, , parva shula, srava shthivan, shwash, timir, etc.15

Samprapti of Arsha :

Samprapti is a composite of etiological factors for produce disease. Samprapti is nothing but etiopathology of disease.16

According to Acharya Sushruta, due to nidan sevan dosha prakop occurs. The main hetu for Arsha is mandagni, which is mentioned as ‘visheshto mandagne’. These prakupit doshas alone or all together with or without rakta, enters in the pradhan dhamani (main channel), go downward and reach at guda. By vitiating the guda valies, produces the mansa-prarohas are known as arsha. 17 Acharya Charak and Vagbhat also support this description of samprapti.18

Shat Kriya kaal:19

These are the complex stages of aetio-pathological process of disease. It is mentioned only by Acharya Sushruta. The management of disease in each stage of shat kriya kaal is different. The symptoms of disease occur after sthan sanshraya avastha. Hence if the treatment up to this stage is given, disease cannot occur. Diagrammatic presentation of shat-kriya kaal of Arsha.

Sadhya Sadyata (Prognosis)

Acharya Sushruta has enumerated Arsha as one amongst eight mahagadas, hence by nature the disease is very much difficult to treat.20 Assessment of sadhyasadhyata is based on the factors like doshik involvement, vyadhi sthana, vyadhi kala and association of upadravas. Those arise in the bahya vali, caused by single dosha and manifested recently are sukha sadhya. Those which are caused by combination of two doshas, located in the madhyam vali and of more than one year, are kashta sadhya.Those which are caused by combination of three doshas, located in the madhyam vali and of more than one year, are kashta sadhya. Tridosa Arshas are yapya. 21 Arsha, which are sahaja, involving all the three doshas and located in the abhyantara vali should be discarded due to kashta sadhya nature. If rogi (patient) has developed shotha in hasta, pada, mukha, nabhi, guda, andakosha, severely debilitated and also if hrudaya and parshva shoola is present should be discarded due to asadhya. However, if life span is remnant, the chikitsa chatushpada is provided and agnibala can be stimulated, then they can be treated otherwise should be rejected.22

Pathya:23

Anna varga –                       godhuma, yava, raktashali, sastika, kulattha, priyangu, neem juice, yusha

Shaka varga –                    surana, nimba, patola, punarnava, shringu, balamula, kusumbha, jeera, sohanjana, shali, rasana, chitraka, bathua

Ksheera varga –                aja ksheera, takra

Phala varga –    amalaki, kapittha

Ahara Upavarga –           palandu, maricha

Mamsa varga –                  goha, mushaka, go, vanara, ashva, hirana, kukuta, aja, chataka mutra varga – go mutra

Apathya: Ahara- viruddha, vishtambhi, abhishyandi, guru ahara, anupa mamsa, dushta udaka, dosha prakopaka anna, anupa desha pashu and pakshi mamsa, matshya, tila khalli, dadhi, rooksha ahara, kareer, bilva patra, tumbi, jaliya kanda.

Vihara- vegadharana, atistreesanga, uttkatukasana, prushtayana, atapasevana, atijalapana, vamana, basti, poorva desha vayu sevana, viruddha dravya in rasa, veerya, vipaka.

Discussion

Piles often described as "varicose veins of the anus and rectum", Piles are enlarged, bulging blood vessels in and about the anus and lower rectum. Piles are usually found in three main locations: left lateral, right anterior and right posterior portions. Haemorrhoids are progressively increasing in the society. It is manifested due to multifold factors viz. disturbed lifestyle or daily routines, improper or irregular diet intake, prolonged standing or sitting, faulty habits of defecation etc. which results in derangement of Jatharagni leading to vitiation of Tridosha, mainly Vata Dosha These vitiated Doshas get localized in Guda Vali and Pradhana Dhamani which further vitiates Twak, Mansa, and Meda Dhatus due to Annavaha shrotodushti leads to development of Arsha. In order to prevent the Arsha vyadhi and its further complication one has to follows all Pathya pathya as Arsha is very difficult to treat or sometime it hampers quality of life . In Ayurveda its treatment has been described in very well manner with four types. Aushadhi chikitsa, Agnikarma, Kshar and lastly Surgery (Shalya). This depend upon chronicity and type of Arsha which chikitsa has to be done. The chances of recurrence is also increasing due to current lifestyle and diet pattern. The mass awareness in the community about prevention of Arsha vyadhi is needed.

Conclusion

Arsha its detailed description regarding etiopathogenesis, Pathyapathya and treatment given by all the classics of Ayurveda. Acharya Sushruta even placed this disorder in the ‘Ashta Mahagada.’ Acharya Sushruta said that doshas vitiated along with Rakta dosha and they travel downwards through pradhan dhamani to reach guda (anal canal). The factors cause obstruction in this Dhamani it can be termed as ‘Sanga’ of rakta and it leads to srotodusti that causing Arshas. Treatment can be done according to stage of Arsha vyadhi as described in Shatkriyakal. This vyadhi is occurs due to faulty lifestyle, lack of exercise, due to specific occupation and dietary habits, most of time it results due to constipation. It is a very painful condition as sometimes patient is afraid of defecation because of pain with bleeding per rectum. It needs life style and diet changes as per described in Ayurveda for the prevention as well as to avoid its recurrence.