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Introduction

A 65 years female patient, having complaints of per rectal bleeding and something coming out through anus attended OPD. She underwent complete history taking and clinical examination. On proctoscopy she was diagnosed as grade III internal haemorrhoids.[5] After written consent she was advised treatment with Apamarga Kshar Ointment local application and Avipattikar Churna (Powder) before meals along with Pathya (Dietary Restrictions). Proper follow up was taken on 3rd day and every 7th day till 28th day. After 28th day treatment was stopped and follow up was taken on 60th and 90th day. Patient relieved from per rectal bleeding after 7 days of treatment and was relieved from something mass prolapsing per anal after 28 days. No recurrence was observed till 90th day.

Case history: A 65 years female patient visited outpatient department. Patient was medium built, height approximate 65 kgs and height about 5’6”. Patient was having complaints of per rectal bleeding on and off for 1 year and bleeding was increased for 1 month. She was also having complaints of something mass coming out through anus while defecation and she needed to reposit the mass with fingers after defecation. She was having history of intermittent constipation and straining during defecation. She was not having any history of known medical illness or history of major surgery. She was asked for any allergies, which was not present.

Physical examination results.

On examination, patient was having general condition medium, minimal pallor, No icterus, clubbing, and cyanosis. She was not having any facial or pedal edema. On systemic examination no deformity was observed. On Local examination, she was not having any external fissure, haemorrhoids or external opening at anal region.

On per rectal examination, she was not having any spasm or palpable mass.

On proctoscopy,[6] it was observed that she was having internal haemorrhoids at 3,7 and 11 o’clock position with some active bleeding.

Investigation: -Hemoglobin 8.10 gm %:  Red blood cell: 3.04 mil/cmm TLC: 6130/cumm, N%:72, L%: 21, M%:06, E%: 01, B%: 0 Plt: 227000, CT: 5.10 mins, BT: 2.40 mins Blood Group: AB rh positive, Sr creat: 1.10 mg/dl, Blood Urea: 30 mg/dl, BSL r: 91 mg /dl, HBSAG: Negative, HIV I And II: NR,

URINE ANALYSIS: - Physical Examination Quantity: 10 ml, Colour: Pale Yellow, Appearance: Clear, Sp Gravity: 1.030,

Chemical Examination:  Protein: Nil, Sugar: Nil, pH: Acidic, Ketone bodies: Nil, Bile Salts: Absent, Bile Pigments: Absent,

Microscopic Examination: Pus (WBC) Cells: 3-4 /hpf, Epithelial Cells: 1-2/hpf, RBC: Occ/hpf, Casts: Absent, Crystal: Absent, Bacteria: Absent,

Treatment plan: Local Application of Apamarga Kshar Ointment was advised once a daily for 4 weeks at home.

Dosage as required depending upon surface.

Dosage schedule – After defecation in morning once a day.

Route of administration - Topical (Locally on internal haemorrhoids)

On very first day patient was taken for local application after hot sitz bath. Patient was given left lateral position. Then local application at haemorrhoids was done. Remnant of ointment at anal region was wiped out. After that, a sterile pad kept at the anal verge to avoid soilage of clothes. Same procedure was advised to patient to be done at home.

Pathya for both Groups

• Hot sitz bath twice a day
• Advice the patient to keep the local site hygienically clean.
• Laxative – Avipattikar Churna[7] 2-6 gm at bedtime with lukewarm water (Dose was adjusted as per requirement of patient. when constipation was not relieved dose may be increased).
• Dietary control was advice.

Discussion

“Pratisaraneeya teekshna kshara causes coagulation of Hemorrhoid plexus, necrosis of tissue followed by fibrosis of plexus, adhesion of mucosal, submucosal coat helps in prevention of further dilatation of veins and prevents prolapse of regional mucosa of anus” And hence relives complaints of haemorrhoids [4]. Apamarga Kshar ointment is having same effect. It was observed that per rectal bleeding was reduced on 3rd day and it was nil since 7th day. It was observed due to localized chemical cauterization effect of Apamarga Kshar which is ingredient of Apamaraga Kshar ointement. Also, base sikth of Apamarga Kshar ointment is useful in maintaining localized soothing and lubrication. It helped in smooth passage of stools during defecation and was helpful in reducing friction between stool a haemorrhoidal cushion. Degree of haemorrhoid reduced on 28th day. It was due to fibrosis of haemorrhoidal cushion and reducing its size. 

Discharge from haemorrhoids was reduced to nil on 3rd day. It was due to reduction of inflammation of haemorrhoidal mucosa. Avipattikar churna helped in making stool passage smooth with reducing requirement of straining during defecation. Overall effect of Apamarga Kshar ointment application was as like that of Kshar pratisaran. But in current treatment advantage was all procedure was done by patient himself at home unlike in Apamarga Kshar Pratisaran, where Apamarga Kshar Pratisaran was to be done by expert physician, with assistant in OPD setup.

Conclusion

Thus, Apamrag Kshar ointement application locally was effective in patient of internal haemorrhoids in reducing per rectal bleeding and degree of haemorrhoids.

Thus, Apamrag Kshar ointement application locally was effective in patient of internal haemorrhoids in reducing per rectal bleeding and degree of haemorrhoids.