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Introduction

The ailment is classified as Maharogas in Ayurveda since it is Dirghakalanubandhi, Dushchikitsya in nature, Tridoshik, and involves the Marma.[1] Mansakur (Protruding Mass), Rakta-Strava (per rectal Bleeding), and Panduta (Pallar) are all symptoms of Arsha, which is linked to Mans and Rakta Dhatu Dushti. Arsha is found in Gudabhaga, which is undoubtedly a Marma and is well-known for its chronicity and difficulties in digestion. Hemorrhoids or piles are dilated veins generated by the radicles of superior, middle, and inferior rectal veins within the anal canal in the subepithelial area. Haemorrhoids or piles are sensibly dealt with under the concept of Arshas, which can be found in nearly all ayurveda literature dealing with disorders and their treatment.

If we go back in history, great saints like Adishankara, who restored vedic literature, and prominent emperors like Napoleon also suffered from this ailment. Long continuous hours of work, a stressful existence, and the consumption of bad foods make individuals more susceptible to ano-rectal disorders such as fissure and haemorrhoid in today's sophisticated world. Internal haemorrhoids, which are concealed by the mucous membrane, are caused by dilatation of the veins of the internal rectal plexus. Haemorrhoids are most frequent in adults between the ages of forty and sixty, but they can afflict anyone of any age.[2] According to recent data, piles affect people of all ages, genders, and socioeconomic levels. In India, 1 million new instances are recorded each year, with a rate of 47 per 1000 increasing with age, and it is believed that 50-85 percent of persons worldwide develop haemorrhoids between the ages of 45 and 65.[3,4] In addition, guys are more likely than girls to develop haemorrhoids. Furthermore, many patients are hesitant to go to the doctor because of the location of the ailment, delaying the examination and treatment, resulting in the disease's worsening state.

Etymology [5]

Arsha is derived from the root word 'Hru gatau' and the suffix Asuna, which means "to take life."

The term Arsha is derived from Ash Dhatu when the suffix Ach is added, according to Shabdakalpadruma.The term "pile" comes from the Latin word "pila," which meaning "ball." As a result, piles are defined as a development in the anus that resembles a ball.

 Nirukti (Definition of Arsha): According to Acharya Charaka, only the Arsha mass in Gudavali is named Arsha, whereas the Adhimamsa mass at other locations is called Adhimamsa. So, Arsha is a sickness that is similar to a man's enemy in that it causes a pile of mass in the anal canal, which obstructs the passage of the anal canal and causes the patient a great deal of pain. The term Arsha can be derived by root word 'Hru gatau' and suffix Asuna which means to take life.

Synonyms of Arsha[6]

Darunaka

Duranama

Gudkila

Gudankura

Anamaka

Arsha

Classification of Arsha

Arsha is classified on the basis of origin, bleeding, and predominance of Doshas etc.

On tha basis of per-rectal bleeding

1. Aardra - also known as Sravi Arsha. They are bleeding piles due to vitiation of Rakta and Pitta mainly.[7]

2. Shushka: They are non-bleeding piles due to vitiation of Vata and Kapha Doshas.[8]

On the basis of Origin

1. Sahaja Arsha - A congenital abnormality caused by the Beejadosha disease (chromosomes).

2. Janmottarkalaja- These are acquired and occur as a result of poor lifestyle choices and eating habits, among other things.

According to site

1. Bahya - Occurr in Bahya Vali.

2. Abhyantara - Occurr in Madhya and Antar Vali.

On the basis of the predominance of Dosha[9]

1. Vataj

2. Pittaj

3. Kaphaj

4. Raktaj

5. Sannipataj

6. Sahaj

On the basis of Prognosis [10]

a. Sadhya Arsha (Curable)- There is just one Dosha involved in Samvarani, and it is readily treated.

b. Yapya Arsha (Palliative) - Two Doshas are involved, located in the second Vali, chronicity is less than one year, and treatment is tough.

c. Asadhya Arsha (Incurable) - They are inherited, include all three doshas, and are located in the internal Vali. This is an incurable disease. Oedema on the hands, face, feet, navel, anus, and scrotum, as well as pain in the heart area and sides, are all symptoms of piles.

On the basis of site of origin of Haemorrhoids [11]

1. Internal haemorrhoids are located along the dentate line and are hidden by the rectal mucosa.

2. External Haemorrhoids - Haemorrhoids that are located below the dentate line and are covered by skin. They arise as a result of varicose veins in the external haemorrhoidal plexus.

3. Interno-External Haemorrhoids - They have internal and external haemorrhoids in various forms.

On the basis of pathological anatomy

1. Primary Haemorrhoids - There are three of them, and they are located at 3, 7, and 11 o'clock, respectively. The superior rectal artery is divided into two major branches, one on the right and one on the left. The left branch stops at 3 o'clock as a single vessel, whereas the right branch separates into two branches, one anteriorly at 11 o'clock and the other posteriorly at 7 o'clock.

2. Secondary Haemorrhoids - Haemorrhoids that exist between the primary haemorrhoids are referred to as secondary haemorrhoids.

On the basis of prolapse

1. First-degree haemorrhoids - Masses do not prolapse and are difficult to see, but veins get clogged and bleed during faeces.

2. Second Degree Haemorrhoids - During faeces, they extend into the lumen and descend to the anal orifice. During faeces, the patient notices a projecting mass that ascends / vanishes spontaneously following defecation.

3. Haemorrhoids of the Third Degree - A protrusion of the pile mass during faeces that stays prolapsed until manually restored.

4. Fourth-degree haemorrhoids: The pile masses are enormous enough that adequate replacement is impossible, thus they must be left outside permanently.

Nidana [12,13]

Aharaja Nidana –Dravya, such as guru, madhura, sheeta, abhishyandi, and vidahi, and ahara, such as masha, rukshamamsa, and ikshu rasa, create shithilata in the mamsa dhatu. All of them are low-fibre diets that promote constipation and pile mass protrusion.

Viharaja Nidana – Ashya sukha, Diwa swapna, Avyayama, and Avyavayi are well-known kaphakara bhavas. However, in this case, vegavarodha should be taken in the form of mala vegadharana, which is the mulakarana of vata pratilomana, and utkata asana, which creates additional abnormal pressure.

Samprapti:

The key and crucial aspect in Samprapti of all sorts of Arsha is Apana vata, which is caused by various Nidana and is the location of the intestines that is worsened in Grahani. In modern words, the Sahaja samprapti can be linked to an anatomical abnormality induced by genetic reasons. Anal infection, persistent constipation, and exciting reasons are linked to Doshaja samprapti, whereas Agantuja samprapti is linked to rectal congestion, laxity of the external sphincter, occupation, pregnancy, parturition, and surgical pathology.

In the aspect of Kriyakala:- [14,15]

1. The Sanchaya stage (stage of accumulation) includes Mityahara vihara, Nidana sevana, and the accumulation of Doshas in regular places.

2. Prakopa (stage of provocation) - Dosha aggravates Vata, Pitta, and Kapha, and the effects are permanent, even if stimulating sources are avoided.

3. Prasara (provocation stage) - Vitiated Dosha migrates to its own location, circulates throughout the body, and manifests as incomplete widespread symptoms.

4. Sthana samshraya (Stage of localisation or Prodromal symptoms) — Vitiated Doshas in Gudavali, Pradhana dhamani induce Twak, Mamsa, Meda, and Rakta dusti, which produce Purvarupa laxanas.

5. Vyakthi (Stage of Manifestation) — Manifestation of well-defined clinical symptoms of Arshas, such as extreme pain in Vataja, burning sensation and bleeding in Pittaja, and intense itching in Kaphaja Arsha.

6. Bheda (Stage of Complication) – Arsha may become chronic or incurable due to complications like excessive bleeding, Gudapaka, Gulma, Sopha, Atisara, Pandu, obstruction of faces and urine.

Arsha Rogi Pariksha

For Guda Pariksha, Acharya Sushruta had advised three way clinical examination method[16]

• Darshanam (Inspection) - Internal haemorrhoids, thrombotic pile masses, rectal prolapse, anal warts, pruritic diseases, external haemorrhoids external apertures of fistulas, abscess of perianal and ischio-rectal origin may be tentatively identified during Darshanam (examination).

• Palpation (Sparshanam)- This procedure can be utilised to validate palpable features for a final diagnosis.

• Prashna (Interrogation)- When it comes to pain, throbbing denotes the creation of an abscess, intense intermittent pain suggests a fissure, and quick onset of discomfort proves thrombotic piles.

External haemorrhoids can have anal epithelioma, condyloma acuminata, condylomalatam, sentinel tag, and internal haemorrhoids can have pedunculated polyps, sessile and adenomatous polyps, hypertrophied anal papilla, Haemangioma and Lymphosarcoma, and rectum cancer as differential diagnosis.

Symptoms (Lakshana)

Primary symptoms are bleeding per rectum, mass like protrusion coming out from anal canal, painful defecation and itching at anal region, whereas, associated prodromal features are Ajeerna (indigestion), Agnimandya (low digestive fire), Malavrodha (obstructive syndrome/constipation), Gudparikartan (anal fissure), Gudabhransha (rectal prolapse), Grahani (irritable bowel syndrome) and Yakrut vikar (deranged liver functioning due to hepatitis, portal hypertension) etc. [17,18]

Treatment according to Ayurveda 19,20,21,22

1. Bheshaj Chikitsa - When symptoms are light and simple, with onset less than a year and fewer vitiated Doshas, Bheshaj Chikitsa is recommended. The core conservative Ayurvedic management focuses on Agni Deepan-Pachan (increasing digestion), Vata Anuloman (calming bowel motions), and Rakta shodhan (blood purifier) – stambhan Chikitsa (Hemostatic medicines).

Constipation can be treated conservatively

Using laxatives such as Triphalachurna and Pancha-sakar churna.

Deepan-Pachan-Chitrakadivati, Agni tundivati, etc.

Arshoghna- Arshoghnivati, Arshkutharras etc.

Hot sitz bath- Sphatic bhasma, Triphala kwath etc.

Internal Medicines for Dry Piles - (Shushka Arsha)

• Kankayan Guti + Triphala Guggulu + Arogyavardhini vati – Each 2 Tab. 3 times a day with lukewarm water after meals.

• Abhayarishtha - 4 tablespoon with equal amount of water 2 times after meals.

• Amrutbhallatak Awleha - 1 tablespoon each morning with luke warm water.

• Gandharva Haritaki Churna - 1 tablespoon at bed time with warm water.

Local application in Dry Piles

• Arshoghn Lepa - Topical Application to promote fibrosis and delay the protrusion such as Snuhi Latex+Haridra , Haridra+Pippali+Gomutra, Nimbadi Malhar etc.

• Apply Sarjarasa malhar or Shatadhaut ghruta locally (anal canal) Fumigate with Guggulu, Vacha, Dhoopa, Ajmoda etc. (Sthanik Dhupan) Apply Chukra, Kashisadi or Pippalyadi Tail and advice Seitz bath.

Internal medicines for Bleeding Piles- (Rakta Arsha)

• Praval pishti + Kamaduha ras+ Bolbaddha ras - 2 Tab. 3 times a day with water before meals (given when Pitta dosha is aggravated leading to bleeding piles).

• Kutajarishta+ Ashokarishta - 30ml each with equal amount of water, twice after meals (if Piles due to IBS).

• Nagkeshar +Lodhra Churna – 500mg each with butter and warm water 3 times a day.

• If severe weakness due to bleeding – Mauktik Bhasma 50 mg + Nagkeshar churna 500 mg + Tapyadi loha vati 2-tab BD –with Lohasav 40ml mixed with equal quantity of water twice a day (as hemostatic and to improve haemoglobin due to blood loss).

Kshara karma- Sushrut samhita mentions kshar karma, or the application of 'Pratisaraneeya Kshar' (alkaline-caustic paste) on the pile pedicle. Kshara is the chemical that expels the "Dushta Tvaka Mamsadi" by its Ksharana activity. [32] It is made up of alkaline derivatives of plant medicine ashes in the form of liquids, powders, or crystals. When it is administered, it induces Ksharana of Mamsa and other Dhatus [33], which is why it is named Kshara. It is also regarded as a possible cauterising agent since it indirectly cauterises the tissue after application. This is used to treat non-bleeding internal haemorrhoids in grades II and III where the pedicle is Mridu (soft), Prasrut (extensive), Avagaadh, and Uchhrita (Projecting).

Kshar Sutra Ligation- It is a special excision technique by means of mechanical pressure and chemical action without the use of a knife. It is a parasurgical procedure that, slowly excises the pile mass.

Agni karma - When the pile pedicle is Karkash (rough), Sthir (firm), Prithu (thick), and Katthin (thin), this is an indication (Hard- fibrosed). This can be linked to electrocoagulation and sophisticated laser techniques for Grade II and III hemorrhoid ablation, in which various heat sources are employed to achieve thermal/heat burn. Because the condition does not reoccur, it is seen to be better to other techniques. The method can be carried out directly using fire or indirectly with fire-related things. Vata Kaphaja Arshas, which is rough, flat, wide, and hard, indicates Agnikarma. Even in prolapsed and third-degree Arshas, it can be used. In the Raktaj and Pittaj types of Arsha, it is contraindicated.

Shalya karma (Excision of Pile mass)- Shalya karma i.e., excision of piles is indicated when pile mass is of Tanu Mool (Narrow Base), Uchhrita (Projecting/Prolapsed) and Kled yukta (Discharging/Bleeding) resembling III grade & IV prolapsed hemorrhoids.

Treatment of Arsha according to Dosha [23]

1. Vataj Arsha - Snehan, Swedan, Vaman, Virechan, Anuvasan and Asthapan Basti.

2. Pittaj Arsha - Virechan.

3. Kaphaj Arsha - Ardraka and Kultha preparation.

4. Raktaja Arsha - Sanshaman.

5. Tridoshaja Arsha - Medicated milk according to vitiation of specific Dosha.

Pathya- Every night, mix ghee with warm milk for a calming effect on the large intestine. Green veggies in abundance, including Tikta and a mild Kashaya cooked in Ghee. Natural desires should not be suppressed, and normal sleep, nutrition, and other habits should be disregarded. For Arsha patients, yavagu, vegetable rasa, mutton soups, pomegranate, milk butter, and milk are pathya.

Apathya- Indulging in the causative factors, such as hot foods, excessive driving and sitting, constipating foods, Viruddha, Vistambika, Vidahi dravya, fried foods, Maida products, and so on.

Discussion

Arsha has become the most frequent and unpleasant disease in the twenty-first century. Symptomatic haemorrhoids afflict at least half of the population at some point in their life, with about 5% of the population experiencing symptoms at any one moment. Mandagni, according to Acharya Vagbhata, is the root of all diseases. The irrationality of jatharagni is the primary cause of anorectal problems, which leads to constipation. Constipation causes piles by increasing back pressure in the haemorrhoidal veins. The sufferer is completely humiliated by this condition. Due to the abundance of nerve endings, the perianal skin is one of the most pain-sensitive areas of the body. As a result, even a modest kind of illness might cause the sufferer a lot of pain. The issue isn't complicated. Suppression of Apana Vayu, Mandagni, and constipation are caused by Virruddhahara, Adhyasana, irregular food habits, overriding, and other factors. Rakta Dhatu, which goes via Pradhana dhamani and impacts Gudavali, is vitiated as a result of this. The Meda, Mamsa, and Twak (anal cushions) are then affected, resulting in the creation of a fleshy lump known as haemorrhoids.Arsha therapy includes a variety of therapeutic techniques such as Abhyanga, Swedana, Dhupana, Avagahana, Lepana, Raktamokshana, Deepana, and Pachana. The Dhupana, Lepana, and Abhyanga treatments, according to Acharya Vagbhata, are designed to drain blood from engorged veins, resulting in relief. External piles are treated with sesame or balalakshadi oil, followed by fomentation.The decoction of Asana, Vasa, and Eranda leaves is excellent for inducing piles and relieving discomfort. Unless it is very chronic, Arsha is Bheshajasadhya. If the texture of the pile masses is soft to the touch, reddish in colour, and slightly protruding, it is said to fall under the Ksharsadhya category, however if the pile masses are hard, stable, and profuse, they must be treated to Agnikarma to prevent recurrence. In circumstances when the mass is thin, rooted with a reddish tint, protruded yet kledayukta, only Shastrakarma can root out the Arshas. Other methods of therapy are ineffective against such pile masses.

Conclusion

Arsha falls within the Mahagadas group, according to the classics. It first emerges in the Sadyahpranahara Marma area in Guda. The upright position in humans causes extremely high pressure on the valveless rectal venous plexus, making people vulnerable to this condition. Ayurveda has enormous potential to tackle many of the world's most difficult and unsolved medical problems. A haemorrhoid is a frequent annoyance that becomes worse by delaying treatment, which has a direct economic impact. Based on the stage of Arsha, Sushruta recommended four types of therapy for Arsha: Bheshaja/Aushadhi chikitsa (Medicinal treatment), Kshar karma (Application of Alkaline paste), Agni karma (Heat Burn Therapy), and Shalya karma (Excision of Pile Mass). Bheshaja, Kshar karma, and Agni karma are also effective.