Gentle healing for haemorrhoids: the homoeopathic approach

Dr Shamitha MJ
Haemorrhoids or piles are the dilated or sided down vessels of the haemorrhoidal plexus in the anal canal. The clinical features include bright red rectal bleeding, soreness in the anus, itching, mucus discharge etc. 1

Prevalence of haemorrhoids in India 4-5%2. Nowadays Life style contributes to these issues. There are multiple factors such as sedentary work, mental stress, irregular dietary habits etc. According to age, 68.05%of people were between the age of 30&60. This information supports the observation that haemorrhoids are more commonly seen in people between these age groups since risk factors are more prevalent at these times.3

Post-operative complications such as recurrence, prolonged convalescence, anal stenosis and fecal urgency. So, there are still disagreements &controversies over current treatment strategies. Homoeopathy ranks the most popular among the traditional, complementary or alternative medicine. Homoeopathy based on the principle “Law of similars”.4

ETIOLOGY

CONSTIPATION can lead to increased straining during bowel movements. This strain raises the pressure within the abdomen, which can affect the pressure in the rectal veins.

LOW-FIBER DIET can cause hard stools, making you strain during bowel movements and increasing the risk of developing piles.

LACK OF PHYSICAL ACTIVITY disrupts the regular rhythmic movements of the bowels, contributing to constipation and increasing the risk of developing piles.

OBESITY also plays a role for developing piles by increasing pressure in anal venous areas.

PREGNANCY hemorrhoids during pregnancy result from the combination of hormonal shifts and the fetus exerting pressure on the abdomen, which causes the blood vessels to swell. The strain during childbirth further raises intra-abdominal pressure. Fortunately, surgical intervention is rarely needed, as the symptoms usually improve postpartum.

CHRONIC DIARRHEA also have the chance of developing piles.1

RISK FACTORS

Irregular bowel habits like constipation and diarrhoea with much straining, sedentary life style, low fibre diet, aging, pregnancy, obesity, depression, genetic issues, and the lack of a valve in the haemorrhoidal veins. All of these elements causes the cushions to enlarge, the supporting connective tissue to become more labile, and haemorrhoids to protrude across the anal canal.5

CLINICAL FEATURES:
Bright red rectal bleeding after, perianal pain and discomfort, mucus discharge and soiling, itching or soreness around the anus, history of constipation and straining during defecation.6 Internal hemorrhoids are located above the pectinate line, making them painless but prone to significant bleeding during bowel movements. When observed in the lithotomy position, they are typically found at the 3, 7, and 11 o’clock positions on the anal canal External hemorrhoids occur beneath the pectinate line, which makes them painful. They generally do not bleed during straining at stool.7

CLASSIFICATION OF HAEMORRHOID:

Hemorrhoids are categorized based on their location and the degree of prolapse. 8

CLASSIFICATION 1: ACCORDING TO LOCATION

1. EXTERNAL HEMORRHOIDS occurs below the pectinate line
2. INTERNAL HEMORRHOIDS are located above the pectinate line
3. a) Primary hemorrhoids are situated at the 3, 7, and 11 o’clock positions on the anal wall.
4. b) Secondary haemorrhoids are varicosities that occur in other parts of the anal canal other than primacy site.
5. C) Hemorrhoids can occur both above and below the dentate line, which are known as mixed (internal-external) hemorrhoids.8

CLASSIFICATION 2: ACCORDING TO DEGREE OF PROLAPSE

• Grade 1: bleeding only, no prolapse haemorrhoids
• Grade 2: prolapse, but reduces spontaneously.
• Grade 3: prolapsed but can manually reducible.
• Grade 4: permanently prolapsed cannot be reduced manually.8

DIAGNOSIS OF HAEMORRHOIDS
A definitive diagnosis of hemorrhoidal disease relies on a thorough patient history and detailed clinical examination. This assessment should involve a digital examination and anoscopy, with a visual inspection of the perianal area to check for external hemorrhoids.9 Physical Examination: Inspect and palpate the perianal area for any signs of thrombosis or excoriation. The patient should be assessed in either a prone-jackknife or left lateral position.

Digital Examination: Although internal haemorrhoids cannot be detected through palpation, this examination is necessary to eliminate the possibility of a distal rectal mass, anorectal abscess, or fistula.10

Investigations:

Blood Tests: Show the presence of microcytic and hypochromic anemia.

Stool Test: Results indicate the presence of occult blood.

Colonoscopy: This examination is commonly carried out to exclude other possible causes of bleeding, such as rectal cancer, especially in individuals older than 50 years. Anoscopy, Sigmoidoscopy and Flexible Proctoscopy: These examinations are performed with special focus on assessing the position, size, location, and severity of inflammation and bleeding related to the hemorrhoids.10

DIFFERENTIAL DIAGNOSIS

Skin Tags there will be history of previously healed hemorrhoids and presently no bleeding. these are skin-colored growths resembling tags around the anus, they are not situated on the mucosa.

Anal fissure The patient reports bleeding with bowel movements along with sharp, tearing pain. A rectal examination is painful in case of fissure.

Perianal abscess typically presents with gradually increasing pain and a tender mass, which is covered by skin rather than rectal mucosa.

Anal cancer often causes pain around the anus and, in advanced stages, may lead to weight loss. It typically presents as an ulcerating lesion in the anal area.

Anal condylomata usually appear as a mass in the anal area without bleeding and are often

associated with a history of anal intercourse. The lesion has a cauliflower-like appearance.18 Rectocele -this also cause fullness in the rectum, giving the patient a similar sensation to an internal hemorrhoid.

Colorectal cancer may present with symptoms such as weight loss, blood in the stool, abdominal pain, and changes in bowel habits. A family history of cancer is often a risk factor, and an abdominal mass or tenderness may be detected.

Inflammatory bowel disease is characterized by abdominal pain, constitutional symptoms, and diarrhea, often with a family history of the condition. A normal external rectal examination is common, but in rare cases, fistulas and colitis may be observed during anoscopy.5

COMPLICATIONS:
Chronic blood loss from haemorrhoids can occasionally result in anaemia. When the blood supply to an internal haemorrhoid is compromised, it is referred to as a strangulated haemorrhoid, causes severe pain and discomfort.11Several complications can arise in cases of internal haemorrhoids, including bleeding, infection, faecal incontinence, urinary retention, and anal stenosis.5 Suppuration, Portal pyaemia, Liver abscess, Fibrosis, Cor pulmonale, Congestive cardiac failure.12

CONSERVATIVE TREATMENT
Constipation and diarrhoea are significant contributors to the onset of haemorrhoidal diseases. Consequently, it is advisable for individuals to ensure they consume enough fibre and fluids to help relieve symptoms. Furthermore, patients should be cautioned against sitting on the toilet for extended periods—beyond 10 to 15 minutes—since this can elevate abdominal pressure and worsen haemorrhoid swelling. Various topical treatments, such as suppositories, steroid creams, and medicated wipes, are also accessible for managing this condition.5

HOMOEOPATHIC MANAGEMENT

Nux vomica
The typical Nux patient tends to be slim, energetic, quick-moving, and often tense or irritable. This person usually engages in considerable mental activity, facing intense mental strain and a largely sedentary lifestyle often associated with prolonged office work, studying, or a heavy focus on business, with its stresses and pressures. Seeking relief from the strains of this indoor and mentally demanding life, they may turn to stimulants like coffee or wine, sometimes excessively. Alternatively, they may try to calm their agitation by using tobacco or, in some cases, addictive substances such as opium.14Nux vomica is indicated for individuals suffering from backache associated to haemorrhoids, which worsens after masturbation. Patients are prone to indigestion and haemorrhoids. Nux vomica is an effective remedy for itching, non-bleeding haemorrhoids accompanied by frequent but ineffectual urges to pass stool, often worsened by strong medications. Key symptoms include frequent, small bowel movements with significant straining and persistent discomfort in the rectum. 13

Sulphur
The Sulphur patient is often a thin, stoop-shouldered, and dyspeptic person prone to indigestion. However, it can also frequently be prescribed to individuals who are plump, round, and well-nourished15. Patients are forgetful and difficulty with clear thinking. They may have delusions, seeing ordinary objects, like rags, as beautiful or believing they are extraordinarily wealthy. They are constantly busy, yet very self-centered, with little concern for others. Additionally, they may suffer from a deep, religious melancholy. Anal itching and burning, with hemorrhoids related to abdominal congestion. Persistent but unproductive urge for bowel movements; stools are hard, lumpy, and inadequate. Hemorrhoids cause oozing and belching as well.14 Haemorrhoids, moist, blind, or flowing dark blood, with violent bearing-down pains from small of back toward anus.15 Experiencing pain, pressure, burning and itching in the rectum. Hemorrhoids developed, especially during pregnancy, with both internal and external piles that are swollen, sore, tender, raw, burning, and prone to bleeding and stinging. Delays bowel movements due to pain16.

Lycopodium Clavatum
Feeling melancholy and fearful of solitude. Easily irritated by minor things, highly sensitive. Reluctant to start new tasks. Becomes stubborn and proud when unwell. Lacks self-confidence and tends to rush through meals. Constantly worries about breaking down under pressure.14For individuals who are intellectually sharp but physically frail, with a thin upper body and a tendency for swelling in the lower body, often prone to lung and liver issues, particularly in very young children and the elderly. Diarrhoea with sluggish bowel movements. Ineffective urge to pass stool, which is hard, difficult, scanty, and incomplete. Painful hemorrhoids that are sensitive to touch and cause aching.17Stools contain small amounts of sand and are difficult to pass; the initial part is hard and painful to expel, while the last part is softer, even thin and gushing. This is followed by a feeling of faintness and weakness. Haemorrhoids are present, with aching pain that improves with hot bathing but is tender to the touch.13

Pulsatilla Nigricans
Suitable for individuals with an indecisive, slow, and phlegmatic temperament; those with sandy hair, blue eyes, and a pale complexion; easily moved to laughter or tears; affectionate, mild, gentle, timid, and accommodating in nature. All complaints are associated with thirstlessness. Hemorrhoids with itching and sharp, prickling pain. Dysentery with mucus and blood, accompanied by chills.17 The stools are variable, with each one being different from the others; they are green and have a sickly appearance. They worsen after midnight. There are also blind hemorrhoids that become worse during menstruation and when lying down.16

Arsenicum album
Severe prostration accompanied by a quick decline in vital energy; fainting may occur. The mood is characterized by feelings of depression, melancholy, despair, and indifference. There are also feelings of anxiety, fear, restlessness, and overwhelming distress. The individual may be irritable, sensitive, and easily annoyed. As suffering intensifies, so do feelings of anguish, restlessness, and fear of death.17Arsenicum album primarily affects the portal venous system, leading to congestion that can result in haemorrhoids. This condition is often associated with chronic constipation, where the stools are hard, dark, and dry, necessitating significant straining, which may cause bleeding. Patients typically experience itching and burning sensations around the anus, often accompanied by piles. A key symptom of Arsenicum album is a burning sensation, which can occur in both acute and chronic cases, with notable relief from warmth. In instances of haemorrhoids associated with Arsenicum album, patients may feel sharp, stitching pain while walking or sitting, making it difficult to sit or sleep comfortably. Symptoms tend to worsen after midnight and in cold conditions, while they improve with heat and warm drinks.13

Aloes socotrina
Aloe is an effective remedy for hemorrhoids and has key characteristics such as a constant sensation of pressure in the rectum, accompanied by bleeding, soreness, and heat, which is alleviated by cold water. The hemorrhoids protrude like grapes which are bluish, tender, sore and there is a feeling of rectal weakness when passing flatus. After a bowel movement, a large amount of mucus may be passed, along with rectal pain. Additionally, there is itching and burning in the anus, which can disrupt sleep. 14

Bryonia Alba
Patients who benefit from Bryonia often exhibit irritability and are prone to outbursts of anger. They typically have dark or black hair, a darker complexion, a strong muscular build, and tend to be dry, nervous, and slender. It is particularly suited for individuals with a tendency toward gout or rheumatic conditions, who are prone to what are known as bilious attacks. Constipation characterized by hard, dry stools that feel as if they are burnt and appear too large. The stools are brown, thick, and occasionally bloody. Symptoms worsen in the morning, with movement, during hot weather, after exposure to heat, and after consuming cold drinks. Each episode of hot weather exacerbates the condition.14

Hamamelis virginica
Haemorrhoids with heavy bleeding; accompanied by a burning sensation, a feeling of fullness and heaviness; back pain as if it might break; a strong urge to have a bowel movement. Additionally, there is itching around the anus.14 Hamamelis virginica is primarily characterized by venous hemorrhages, which appear very dark and clotted, with swollen and tender veins. The anus may feel sore and irritated due to hemorrhoids, resulting in significant bleeding and discomfort.16

Aesculus Hippocastinum
Aesculus is a remedy for haemorrhoids characterized by sharp, shooting pains that extend up the back, with both blind and bleeding haemorrhoids worsening during the climacteric phase. The anus feels raw and sore, with intense pain following a bowel movement. A key symptom is a burning sensation in the anus, coupled with chills running up and down the back. The mucous membranes appear swollen, obstructing bowel movements. Aesculus is also useful for haemorrhoids accompanied by dryness and heat in the rectum, with the sensation that it is full of small sticks, and sharp, knife-like pains shooting up the rectum. One of the most significant indications for Aesculus is the excruciating pain in the anus,where the patient feels unable to sit, stand, or lie down. The pain is likened to a knife sawing back and forth, causing extreme suffering. This remedy is also indicated for back pain associated with haemorrhoids. 14

Collinsonia Canadensis
A sharp, stick-like sensation in the rectum, accompanied by a feeling of tightness. There is swelling of the rectal blood vessels and dry stools, leading to severe constipation and protruding hemorrhoids. There is pain in the anus and lower abdomen. This condition may worsen during pregnancy, with symptoms related to painful menstrual cycles and after childbirth. It includes painful, bleeding hemorrhoids, as well as dysentery with a constant urge to defecate. Patients may experience alternating episodes of constipation and diarrhea, along with significant gas and itching around the anus.14 Collinsonia is beneficial for uterine prolapse that is associated with haemorrhoids and is indicated when haemorrhoids result from congestion in the portal venous system. Symptoms worsen with cold and improve with warmth. 13

Podophyllum
Constipation characterized by hard, dry stools that are clay-colored and difficult to pass. This is accompanied by alternating episodes of constipation and diarrhea, along with both internal and external hemorrhoids.15Podophyllum is indicated for hemorrhoids that are associated with diarrhea and rectal prolapse, especially when the condition is caused by congestion in the portal venous system. Symptoms worsen in cold conditions and improve with warmth. 13

Nitric acid
Easily annoyed, resentful, and quick to seek revenge; stubborn and inflexible. Overcome by a sense of hopelessness. Extremely sensitive to noise, pain, and touch, often startled. Fear of death.14 The key symptom of nitric acid is intense pain after passing stool, even if the stool is soft. The patient may pace in agony for one to two hours following a bowel movement. Bleeding occurs from all body orifices, and the blood is usually bright red. There is significant straining, but only a small amount is passed, and the rectum feels torn. Constipation is common, with fissures in the rectum and tearing pain during defecation. Abdominal cramps are alleviated by tightening clothing. 13

Ratanhia
The characteristic symptom of ratanhia is persistent pain and burning in the anus for hours after a bowel movement, which is temporarily alleviated by cold water. The discomfort feels like shards of glass in the area. There is a sensation of dry heat at the anus, accompanied by sudden, sharp pains. Bowel movements require significant effort, and there may be protrusion of hemorrhoids, along with anal oozing and itching.14

MIASMATIC ANALYSIS OF RECTAL COMPLAINTS

PSORA

• Experiencing constipation with no urge to have a bowel movement for several days, despite frequently feeling the need to go.
• The stool is hard and comes in small, round pellets, similar to sheep droppings.
• The stool appears dry and hard, almost as if it has been burnt. 18
• Haemorrhoids with discomfort and itching
• Soreness in rectum, pressive pain
• Obstinate constipation, hard stool with no desire or ineffectual urge.
• Diarrhoea<morning, Stool<cold, slightest exposure, motion and over eating and drinking, particularly cold things, >by pressure, warmth, warm drinks, hot food.19

SYCOSIS

• Bleeding hemorrhoids, itching, and typically a small amount of thin, watery discharge oozing from the rectum with a fishy or brine-like odor.18
• Blind and non-bleeding haemorrhoids and polyps. Prolapse of rectum.
• Haemorrhoids with extreme sensitiveness and pain.
• Stitching pain in rectum with pulsating sensations.
• Jet like expulsion of feces, tenesmus with slimy stool < change in weather, cold, getting wet, eating fruits >lying on Abdomen or pressure on lower part.19

SYPHILIS

• Haemorrhoids with putrid and foetid discharges.
• Bleeding haemorrhoids
• Complaints < night, warmth, >Cold.19

TUBERCULAR
Rectal diseases alternating with heart, chest, or respiratory issues—especially asthma and breathing difficulties—can show a connection. For instance, if hemorrhoids are surgically treated or suppressed, they are often followed by lung problems or asthma, and sometimes heart complications. Rectal bleeding may also occur.18

RUBRICS RELATED HAEMORRHOIDS

Rubrics related to haemorrhoids from Kent repertory9

• Rectum- Haemorrhoids
• Morning agg.
• Night agg
• Alternating with palpation
• Beer agg.
• Bleeding (haemorrhage from anus)
• Blind
• Bluish
• Children, in
• Chronic
• Cold amel.
• Congested
• Drunkards, in
• Excitement
• External
• Flatus, protrude when passing
• Hard
• Inflamed (congestion)
• Internal
• Itching (Itching)
• Large
• Menses, before, during agg, after
• suppressed, during
• Mental exertion
• Mercury, after abuse of
• Milk, agg.
• Motion, agg.
• Offensive (fetid)
• Pregnancy, during
• Stool, preventing
• Protrude, during
• Strangulated
• Suppressed
• Suppuration
• Touch, agg.
• Ulcerating
• Urination, protrude during
• Walking agg.
• Warmth, external amel.
• Wiping, after stool agg.
• Rectum- heaviness (dragging)
• Rectum- Itching
• Rectum- Lump, sensation of (see weight)
• Rectum- Moisture
• Rectum- Pain.

Rubrics related to hemorroids from Boericke Repertory9

• Hemorroids (piles)
• Bleeding
• Dark, venous blood
• Blind
• Bluish, purplish Burning, smarting
• Inflamed (See Sensitive.)
• Itching
• Mucous piles, continually oozing
• Protruding-Grape-like, swollen
• Urinating [When]
• Sensitive, exquisitely painful
• White piles

CONCOMITANTS

• Abdominal plethora [With]
• Backache [With] (See Back.)
• Constipation [With]
• Debility [With]
• Epistaxis [With]
• Fissures, soreness of anus [With]
• Heart disease [With]
• Hypochondriasis [With]
• Pelvic congestion [With]
• Prolapsus ani et uteri [With]
• Spasm of sphincter [With]
• Stitches in rectum during cough [With]
• Sudden development in marantic children [With]
• Tenesmus [With]
• Anal and visceral, diarrhea
• Constriction, lancinating pains
• Dysenteric stools
• Pregnant females [In]
• Vicarious bleeding [With]

AGGRAVATION

• Confinement [After] (See Female Sexual System.)
• Stool for hours [After]
• Rheumatic symptoms abate [As]
• Climacteric [During] (See Female Sexual System.)
• Menses [During]
• Sitting [During]
• Alcoholic abuse [From], in sedentary persons
• Coughing, sneezing [From]
• Leucorrhea suppressed [From]
• Talking, thinking of them [From]
• Walking [From]

AMELIORATIONS

• Cold water [from]
• Hot water [from]
• Lying down [from]
• Walking [from]

REFERENCES

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Dr Shamitha M.J
PG Scholar, Department Of Organon of Medicne and Homoeopathic Philosophy, GHMCH , Bengaluru.
Under the Guidence of Dr Shobha B Malipatil