Management of Stage 3 Haemorrhoids with Homoeopathy – A case report

INTRODUCTION

Haemorrhoids or piles are defined as distal displacement and enlargement of the normal anal cushion. Haemorrhoids are the fourth leading outpatient gastrointestinal diagnosis, affecting men and women equally as per global prevalence.^[1]

Haemorrhoids are classified based on their location and degree of prolapse.

Internal haemorrhoids originate from the inferior haemorrhoidal venous plexus above the dentate line and are covered by mucosa. External haemorrhoids are dilated venous plexus located below the dentate line, covered with squamous epithelium and innervated by cutaneous nerves, which are branches of the pudendal nerve.^[2] Lunniss et al. state that external haemorrhoids are not a separate anatomical entity, but an extension of internal haemorrhoids, representing an evolutionary complication.^[3]

A 2018 study from Bangalore, Karnataka stated that the prevalence is higher in those aged 30– 60 years and rare in those under 20 years.^[4,5] Multiple factors are responsible for the development of haemorrhoids, including a history of constipation and prolonged straining while defecation.^[2]

Diagnostic assessment of haemorrhoids is usually done with the Goligher classification; however, it was deemed inadequate as it does not consider the associated symptomatology and extension of classification to the entire haemorrhoidal system is not available.^[3] Júnior et al. presented a new classification for haemorrhoidal disease, the bleeding, prolapse, reducibility, skin tags and thrombosis (BPRST) classification, which overcomes the limitations of the Goligher classification.^[6] Each element of the BPRST classification is further numbered to obtain a more precise diagnosis of an individual patient’s state.

Details are shown in [Table 1].

Conservative treatment includes lifestyle and dietary changes with topical treatment such as hydrocortisone cream and anti-itch medications. Non-surgical procedures include rubber band ligation, sclerotherapy and infrared coagulation. However, these may cause complications including pain, urinary retention, discomfort, bleeding and (very rarely) perineal sepsis. If symptoms persist despite conservative treatment, surgery is suggested.

In many cases, prescription of homoeopathic medicines is possible, where medicine is selected based on the similarity to the disease process or pathological changes at the tissue level.^[7] Such a course of treatment may help prevent surgery. A study has shown the effectiveness of homoeopathic medicines in treating haemorrhoid cases.^[8] Here, we present a case of external haemorrhoids treated with the homoeopathic remedy Aesculus hippocastanum.

CASE REPORT

A 60-year-old married woman, housewife, with an average height and moderate build visited the outpatient department of A.M. Shaikh Homoeopathic Medical College and Hospital on 29 November 2021.

Examination findings

General

Temperature – afebrile. Pulse – 80 beats/min. Respiratory rate: 17 cycles/min. Blood pressure – 130/90 mmHg. No pallor.

Systemic

Respiratory system – Air entry bilaterally equal. Cardiovascular system – S1 and S2 heard. Per abdomen – no abnormality detected. Central nervous system – conscious and oriented.

Local examination

On inspection, there was a protrusion of a mass, possibly two with swelling around the anal orifice and blue in colour. No discharge/bleeding from the affected site [Figure 1].

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Figure 1:

First visit, 29 November 2021.

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A digital examination was not done as she reported intense pain and tenderness.

Repertorial totality

• Rectum – Haemorrhoids – External

• Rectum – Haemorrhoids – Protruding – Prolapsed

• Rectum – Haemorrhoids – Bluish

• Rectum – Haemorrhoids – blind

• Rectum – Pain – stitching, sharp

• Rectum – Haemorrhoids – Walking – Aggravation

• Rectum – Haemorrhoids – Sitting – Aggravation

• Rectum – Constipation – Difficult stool.

Repertorial analysis was done with complete repertory using Hompath classic version 8.0 [Figure 2].

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Figure 2:

Repertorial sheet using hompath classic software, Mind Technologies, Mumbai, India.

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Follow-ups and outcomes

Changeability in symptoms, BPRST classification and staging were done at every follow-up. Details are shown in [Table 3].

Table 3: Follow-ups and outcomes.

S. No.	Date of visit	Symptoms	BPRST Classification	Prescription
1	First visit 29 November 2021	Intolerable stitching type of pain and tenderness in the anal region with feeling as if some mass is protruding and blocking the anal canal, aggravated by walking and sitting with constipation for a long time	B0, P2, R2, S1, T1. Stage 3 [Figure 3]	Aesculus hippocastanum 30C Thrice a day
2	30 November 2021 2nd day	After two doses of medicine, pain had reduced to 50%, but immediately after taking third dose of medicine, pain aggravated a bit. Bowels were satisfactory. No any new complaints were noted	B0, P2, R2, S1, T1 Stage 3	Placebo 30/2 days/Thrice a day. The patient was asked to report after 2 days
3	1 December 2021 4th day	Pain in anal region still persists. No new complaints were noted	B0, P2, R2, S1, T1 Stage 3	Aesculus hippocastanum 30C/3 doses/thrice a day. Instructed her to stop the medicine immediately once the pain is better
4	10 December 2021	After taking one dose of medicine, Pain and tenderness in rectum is reduced. Feeling of protrusion of mass from anal canal only during passing stools and spontaneously reduced after passing stools. Bowels: clear and satisfactory On inspection: Swelling around anal canal is reduced. The mass protrudes only on straining and spontaneously reduces	B0, P1, R0, T0 Stage 2 [Figure 3]	Placebo/thrice a day/1 month
5.	18 January 2022	All complaints recovered. No new complaints were noted	B0, P0, S0, T0 [Figure 4]	Placebo/1 week/Thrice a day

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Figure 3:

10 December 2021.

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Figure 4:

18 January 2022.

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DISCUSSION

External haemorrhoids are always considered to be effectively managed with surgery. However, in this case, the patient opted for homoeopathic treatment. Consideration of the patient’s most peculiar presenting symptoms and pathological changes indicated A. hippocastanum. A study by Ezberci et al. highlighted on the effectiveness of A. hippocastanum in the treatment of every stage of haemorrhoids due to its antiseptic, venotonic, vasoprotective and anti-inflammatory properties, which are due to its aescin content.^[13]

In this case, after the third visit, the complaints had not improved further; hence, we repeated the same medicine and potency with the instructions to stop the medicine once the pain reduces. Later, a single dose of medicine helped to improve the patient’s complaints subjectively; objectively, changes in the BPRST classification and staging were observed as well.

CONCLUSION

This case experience emphasises the role of homoeopathy in cases of Grade 3 haemorrhoids, preventing surgery. Consideration of pathological phenomena in the evolution of disease helped to select the remedy in this acute case. However, further larger studies with large sample sizes are required to assess the efficacy of homoeopathic treatment in Stage 3 haemorrhoids.