ABSTRACT- Hemorrhoids also known as piles are swelling or varicosity of haemorrhoidal vein. Hemorrhoids can develop inside the rectum, known as internal hemorrhoids. They can also develop under the skin around the anus, known as external hemorrhoids. A 36 years old female reported with a complaint of external hemorrhoids from the last 2 years. A complete case history was taken and on the basis of totality of symptoms, Nitric acid was given. Hemorrhoids symptom severity score was used for assessment of condition of patient. After 4 months of regular treatment and follow up, the patient recovered remarkably by individualized homeopathic remedy.
KEYWORDS- Case report, Individualized homeopathic remedy, Hemorrhoids, Nitric acid
Hemorrhoids, also known as Piles, are a very common anorectal condition that affects millions of people around the world and represents a major medical and socioeconomic problem. It is defined as a dilated veins within the anal canal formed by radicals of superior, middle and inferior rectal veins. In other words, these are also known as symptomatic enlargement and distal displacement of normal anal cushions. (1)
EPIDEMIOLOGY OF HEMORRHOIDS-
An epidemiologic study by Johanson et al shows that 10 million people in the United States are suffering from hemorrhoids, leading to a prevalence rate of 4.4%. The peak prevalence of hemorrhoids occurs between the age of 45-65 years in both males and females and development of hemorrhoids before the age of 20 years are very unusual. According to this study, people of high socioeconomic status are affected more frequently then people of low socioeconomic group.(2)
CLASSIFICATION OF HEMORRHOIDS-
Hemorrhoids are classified(3) on the basis of location into 3 categories:-
- Internal Hemorrhoids- it is within the anal canal and present internal to the anal orifice. It is present above the dentate line and covered with mucous membrane. It is bright red or purple in color.
- External Hemorrhoids- Situated outside the anal orifice and it is covered by skin.
- Intero-external Hemorrhoids- when above two varieties are coexist together
Internal Hemorrhoids are also classified on the basis of degree into 4 categories-
- First degree hemorrhoids- the anal cushions bleed but do not prolapsed
- Second degree hemorrhoids- the anal cushions prolapse through the anus on straining but reduce spontaneously
- Third degree hemorrhoids- the anal cushions prolapse through the anus on straining and require manual replacement into anal canal.
- Fourth degree hemorrhoids- prolapse stays out at all times and is irreducible
RISK FACTORS FOR DEVELOPMENT OF HEMORRHOIDS
Constipation and prolonged straining during stools are believed to be the major risk factor for the development of hemorrhoids. This is because hard stools and increased intra-abdominal pressure causes obstruction of venous return, resulting in engorgement of hemorrhoidal plexus. Other risk factors includes-(1)
- Pregnancy- causes compression of the superior rectal veins which leads to congestion of anal cushion and leads to development of hemorrhoids but it will resolve spontaneously soon after birth
- Carcinoma of rectum and uterine tumors- compresses on superior rectal veins and give rise to hemorrhoids
- Difficulty in micturition- stricture of urethra or enlarged prostate will cause increased intra-abdominal pressure and raises the venous pressure in the superior hemorrhoidal veins to cause hemorrhoids.
- Dietary factors- Many dietary factors include low fiber diet, spicy foods and alcohol intake leads to development of hemorrhoids.
- Bleeding- Hemorrhoids are one of the major causes of painless rectal bleeding. Bleeding is painless, bright red and occurs along with defecation. The patient complains that it splashes in the pan as the stool comes out. As the condition progresses, the partial prolapse will occur.
- Pain- It is not characteristic of hemorrhoid unless there is associated thrombosis or there is associated fissure in ano.
- Mucous discharge- It is a particular symptom of prolapsed hemorrhoids, which softens and excoriates the skin at the anus. This mucous discharge leads to pruritus ani.
- Anaemia- Present in long standing cases of hemorrhoids due to persistent and profuse bleeding.
On examination- first degree internal hemorrhoids do not show any abnormal features. In case of second and third degree hemorrhoids, internal hemorrhoids are seen only when patient strains and that prolapse disappears after the straining is over. During fourth degree, the prolapsed piles can be seen at 3, 7, 11 O’ clock positions.
- Bleeding- This is the main symptom of hemorrhoids mainly in the first degree and early stage of second degree. In fourth degree, bleeding is not profuse.
- Thrombosis- Thrombosis occurs because of high venous pressure during excessive straining efforts.
- Strangulation- More common in second degree internal hemorrhoids
- Fibrosis- occurs after thrombosis of internal hemorrhoids.
Lifestyle modification should be advised to all patients with any degree of hemorrhoids as a part of treatment and as a preventive measure. These changes include increasing the intake of high fiber diet and oral fluids, having regular exercise, improving anal hygiene and abstaining from both straining and reading on the toilet.
The treatment of hemorrhoids depends upon its degree. Various surgical options include rubber band ligation, cryosurgery and complete haemorrhoidectomy for large third degree and fourth degree hemorrhoids.
Homeopathy is a holistic science. Homeopathy works upon the root cause of the disease and the remedy should be selected on the basis of totality of symptoms.(5) So here presents a case of a 36 years old female suffering from external hemorrhoids cured completely after 4 months of regular treatment and follow-up.
A 36 years old female presented with a complaint of constipation with dry hard stools and mass per rectum from the last 2 years. The patient also reported a sticking pain that occurs during stool and remains a long time after stool. She also reported bleeding from anus but that was present very occasionally. She was also suffering from recurrent mouth ulcers from the last 8-9 months.
The patient was vegetarian and of a tall, lean build. She had an increased appetite with normal thirst. She loves to eat fatty food and salty and spicy food. She had an offensive perspiration more profuse on head and axilla. Stools were dry, hard in character followed by stitching and burning pain in anal region that persists for a long time after stools. Thermally she was chilly.
Family history– Father was suffering from hemorrhoids and mother had rheumatoid arthritis.
Menstrual history- regular and copious menses, blood clots sometimes present. Dysmenorrhea on the first day and gets relieved when flow begins.
Mental Generals- Irritable and she is very hopeless towards her disease. Desire company and fear of being alone. Cannot bear loud noises, it causes headaches.
DIAGNOSIS- Diagnosis was based on clinical symptoms and physical examination. She was suffering from External Hemorrhoids.
Case Analysis and Evaluation of Symptoms-
|Type of Symptom
|Hopeless towards her disease
|Fear of being alone
|Cannot bear loud noises
|Desire fatty food, salty and spicy food
|Constipated, dry hard stools
|Sticking and burning pain occurs long after stool
|Bleeding and mass per rectum
|Totality of Symptom
|Hopelessness about disease
|Mind, Despair: Recovery, of
|Desire for Company
|Mind, Company: Desire for
|Fear of being alone
|Mind, Fear: Alone, being: solitude of
|Oversensitive to loud noises
|Mind, Sensitive, Oversensitive: Noise, sounds, to
|Desire for fatty food
|Generalities, Food and Drinks: Fat and rich food
|Desire for salty food
|Generalities, Food and Drinks: Salt or salty food
|Constipation with dry, hard stools
|Rectum, Constipation: Hemorrhoids, from:
|Sticking and burning pain occurs long after stool
|Rectum, Pain: Sticking: Hemorrhoids, with:
|Bleeding in stools and mass per rectum
|Rectum, Hemorrhoids: Protruding, prolapsed: Bleeding in stools
The repertorization was done by complete repertory using ZOMEO software.(7)
- Nitric Acid- 29/10
- Sepia- 26/9
- Arsenic Album- 25/8
- Nux vomica- 24/7
- Phosphorus- 23/9
SELECTION OF THE REMEDY AND POTENCY:-
The reportorial result showed that nitric acid covers maximum symptoms with the highest gradation. So on the basis of consultation with materia medica(8), a single individualized constitutional remedy, NITRIC ACID 200C was selected and prescribed.
After 4 months of regular treatment, there is much improvement. The improvement was assessed on the basis of visual analogue scale. The vas scoring was on a scale of 0-10. At the time of first prescription, it was reported as 8 i.e. severe stabbing pain occurs during stool and remains long after that. After 4 months of regular treatment and proper management, the hemorrhoids was completely relieved and scoring was reduced upto 1.
|Constipated with dry hard stools and bleeding and mass per rectum, stabbing pain in anus during and remains long after stool
|Nitric Acid 200C/1 doseRubrum met 30/BD/ 10 daysSitz bath advised.
|Bleeding is better, constipation same as before, pain and mass per rectum same as before
|Rubrum met 30/BD/21 daysSitz bath advised.
|Bleeding completely relieved, pain is better, mass per rectum same as before
|Rubrum met 30/BD/15 daysSitz bath advised.
|Pain same as before, mass per rectum same as before, case comes to standstill.
|Nitric Acid/1M/1 doseRubrum met 30/BD/21 daysSitz bath advised.
|Pain completely relieved, mass per rectum same as before
|Rubrum met 30/BD/15 days
|Size reduced, pain completely relieved, general condition much better
|Rubrum met 30/BD/1 month
|Mass per rectum and pain completely relieved
|Rubrum met 30/BD/1 month
Management and Outcome:- Patient were generally advised to:-
- Intake of high fiber diet
- Sitz bath
- Avoid mental stress, if possible
- Meditation and Yoga
The duration of treatment was around 4 months after which there is much improvement seen in the patient’s general health as well as in her physical complaints.
The treatment of hemorrhoids is quite difficult as it is a multifactorial disease and many risk factors are responsible for its development including age, chronic constipation, intake of low fiber diet, less water intake, poor eating habits, intake of highly spicy food, obesity etc. In our case, the patient had external hemorrhoids in which bleeding was not present normally but it was painful and the case was complicated because of chronic constipation. An individualized homeopathic medicine was prescribed on the basis of the totality of symptoms. In this case, chronic constipation was acting as a maintaining cause and the case comes to standstill in 4th follow up. So, according to Kent second prescription(9), the case was reevaluated and the same remedy was prescribed in higher potency. After that, there was not any relapse of symptoms and the patient was completely relieved both mentally and physically.
Homeopathy along with lifestyle modification are useful in treating the cases of hemorrhoids when remedy is prescribed on the basis of individualization. More study is needed to validate the result.
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