Efficacy of palashadi ointment as local application in pediatric second degree piles: A case report

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Introduction

Haemorrhoids, also called piles, are vascular structures in the anal canal. In their normal state, they cushious that help with stool control. They become a disease when swollen or inflamed. The signs and symptoms of hemorrhoid depend on the type present. haemorrhoids are usually present with painless, bright red rectal bleeding when defecating [1]. External haemorrhoids often result in pain and swelling in area of the anus.it is manifested due to disturbed life style or daily routines, improper or irregular diet intake, prolonged standing or sitting, faulty habits of defecation etc. haemorrhoids are usually found in 3 main locations. Left lateral, Rt anterior and Rt. Posterior positions. Arsha is being described by all the classics of Ayurveda; Acharya sushruta even placed this disorder in the astha mahagad. Arsha occurs in guda region, which is undoubtedly marma [2]. Mithaaharvihar and sedentary life style result in disturb of jatharagni leading to vitiation of tridosa, mainly vata dosha. These vitiated doshas get localized in guda vali and pradhan dhamani which further vitiates twak, mans, and meda dhatus due to annavha shroto dusti lead to development of arsha [3].

General features of arsha

Bleeding per anum: It is the first and earliest symptom. Bright red blood may appear as streaks on toilet paper adhering to faecal residue, or it may be a slow trickle for a short while following bowel movements [4].

Prolapse: It is a later symptom. Patients may complain of protruding mass on straining during defecation in anal region [5].

Pain in anal region: It is not characteristic of haemorrhoids unless there is associated thrombosis or other complications. Pain occurs due to involvement of external haemorrhoidal plexus, over-stretching of skin, congestion or associated acute anal lesion such as fissure in ano or an anal abscess [6-8].

Mucus discharge per anum: It may be seen in permanently prolapsed haemorrhoids, which softens and excoriates the skin at the anus. This mucous discharge is due to engorged mucous membrane.

Pruritus ani: It is caused by mucous discharge in prolapsed haemorrhoids.

Anaemia: It is seen in long standing cases o haemorrhoids due to persistent and profuse bleeding. If anaemia is severe, patient may develop exertion, dizziness, pallor, lethargy etc [9].

Examination of arsha

Inspection: The second degree haemorrhoids are only visible at the anal verge when the patient strains. While the third degree piles are readily recognized as a prolapsing mass in the outer part covered with skin, the inner portion with red or purple colored anal mucosa, and the junction being marked a linear furrow [10-12].

Palpation: Per rectal examination the early stages of piles, they are soft and collapsible on quite impressible examination. But with chronicity and repeated attacks of the thrombosis the subcutaneous connective tissue undergoes fibrosis and then the piles are palpable as a soft longitudinal fold to the palpating finger on per rectal examination [13].

Proctoscopy: An important investigation done by proctoscope. One can see pile masses under direct vision at different position.

• Sigmoidoscopy

• Colonoscopy

• Barium enema

Case Presentation

A 10 yr old male was brought to shalyatantra Out- Patient Department (OPD) with complaints of feeling of mass at anal region and hard stools on and off since 1 year with associated complaints of mild constipation 2 months. He was having no pain and intermittent fresh bleeding associated with stool from last 6 months. His mother narrated complaints that baby cries very loudly for a long period of time after defecation. After a day she give complaint of appearance of blood in stool. As per mother observation she give his history that some mass is coming out from anal region while defecation and goes in automatically. These complaints aggravate by taking spicy and junk food. He was having low weight gain associated with lack of appetite from last 1 year. Developmental history and birth historyuneventful. Immunization History shows all vaccines were given according to schedule till the study workup. The patient used to daily take spicy food in her diet. Once or twice a week he was having habit of consuming Chinese and junk food, he used to take only 2-3 glasses of water in a day. On examination, vitals and systemic examination was normal. Local examination shows 2^nd degree piles. No tenderness. No active bleeding was present. On palpation revealed no induration or no any other deformity. After clinical examination this case was confirm diagnosed as 2nd degree prolapsed pile (Tables 1-3) [14].

Table 1. Showing the points of ashtavidha pariksha (general examination) with systemic examination.

Table 2. Showing the internal medicines.

Table 3. Showing the internal medicines and local application given to patient for 14 days.

Pathya

• Increase liquid intake.

• Advised take 1 tsf of ghrita in her food.

• Advise to take buttermilk with pinch of rock salt and cumin seeds.

• Avoid spicy and junk food.

Advice to take fibrous food in dietlike oats, carrots, apple, oranges, broccoli, etc.

Results and Discussion

Therapeutic treatment of haemorrhoids ranges from dietary and lifestyle modification to radical surgery, depending on degree and severity of symptoms. The primary objective of most topical treatment aims to control the symptoms rather than to cure the disease. The number of topical preparations contains various ingredients such as local anaesthesia, corticosteroids, antibiotics and anti-inflammatory drugs. No radical topical is available. Hence radical non-surgical treatment form of topical ointment is need of time [15].

Sushrut has mentioned four broad principles of treatment as:

• Bheshajachikitsa

• Ksharakarma

• Agnikarma

• Shastra karma

There is difficult to use agnikarma and Shastra karma in children. Hence bheja chikitsa is the best method to treat arsha in children. In Dhanvantari nighantu and bhavprakasha samhita, palash is indicated for arsha. Kutaja churna act as raktastamshan (hemostasis) in arsha. Honey increases nitric oxide, decreases prostaglandins, liberates H₂O₂ acidity effect, Osmolality effect, antioxidant effect, anti-inflammatory effect, healing property, antimicrobial effect, modulate cytokines production. Beewax decreases prostaglandins antioxidant effect anti-inflammatory effect healing property decreases leukotriene b4.

Palashadi ointment is effective in subsiding the symptom such bas relieve burning, discomfort, inflammation, irritation, bleeding per rectum, reducing pile mass. On day 30 the pile mass was completely shrinked and no other complain was observed. Gandharva Haritaki choorna acts as laxative and helps to relieve constipation and Mgso4 sitz bath was given to quickly relieve burning pain. To sort out these problem we need treatment which is cost effective and non-surgical [16].

In the present study, weekly assessment was done to find out the symptoms like bleeding per rectum, etc. Patient got excellent result without need of surgical procedures. After treatment, patient had very mild discomfort during defecation [17].

• No pain at anal region.

• Fissure was healed.

• Burning sensation was absent, occasional itching was present.

• Consistency of stool become normal.

• Irritability reduced.

• Internal medicine were advised to continue for 1 month.

Conclusion

The palashadi ointment given was found effective relief from pain, bleeding, itching at perianal region using which has anti-inflammatory activity, antibacterial, antifungal scavenging activity, antiulcer, anti-proliferative activity, antioxidant activity. Changing in lifestyle and healthy diet also plays important role in the management of piles. The outcome of this management is that palashadi ointment is effective in the management of pediatric piles. New palashadi Ointment for local application should be expand in market for benefits of patients which is easily admistrable, cost effective and quick in actions. Patients who take all follow-up after treatment will have less chance of symptom reoccurrence.

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