+- Ijapc 2018 Volume 8 Issue 2 www.ijapc.com 10/3/2018 Greentree Group Received08/01/18Accepted23/02/18Published 10/03/18 ________________________________________________________________________________________________________ Anju B Uppin 2018Greentree Group © IJAPC Int J Ayu Pharm Chem 2018 Vol. 8 Issue 2 www.ijapc.com 125 [e ISSN 2350-0204] Greentree Group Int J Ayu Pharm Chem REVIEW ARTICLE www.ijapc.com e-ISSN 2350-0204 Clinical Implication of Portacaval Anastomosis and its Relevance in Ayurveda w.s.r. to Haemorrhoids Anju B Uppin* *Ayurveda Practitioner, Gulbarga, Karnataka, India ABSTRACT Portal circulation is the flow of blood from one capillary bed to another capillary bed. Porta- caval anastomosis is the communication between tributaries of portal vein and systemic veins. These communications form important routes of collateral circulation in portal obstruction. In the rectal region the superior rectal vein (portal) anastomoses with the middle and inferior rectal veins (systemic).Haemorrhoid is a pathological condition where rectal veins become dilated and tortuous as a result of portal hypertension. Arshas mentioned in our classics is a condition where in there is formation of mamsaankura and raktasrava from the gudamarga. This arshas may be compared with haemorrhoids where there is tissue prolapse and bleeding per rectum. This paper discusses about the importance of porta-caval anastomosis and its role in a pathological condition of haemorrhoid and its comparison with arsha, mentioned in Samhitas. KEYWORDS Porta-caval Anastomosis, Haemorrhoids, Arsha Greentree Group Received08/01/18Accepted23/02/18Published 10/03/18 ________________________________________________________________________________________________________ Anju B Uppin 2018Greentree Group © IJAPC Int J Ayu Pharm Chem 2018 Vol. 8 Issue 2 www.ijapc.com 126 [e ISSN 2350-0204] Int J Ayu Pharm Chem INTRODUCTION MATERIALS AND METHODS Our body consists of three types of . Literature regarding Porta-caval circulation viz. systemic circulation, anastomosis, Hemorrhoids and Arshas were pulmonary circulation and portal circulation. collected from Samhitas and other relevant The term ‘portal’ refers to a vein interposed modern books and journals. between two sets of capillaries. Portacaval How internal haemorrhoids are formed? anastomosis is the communication between There is one tributary of the superior rectal portal vein or its tributaries and systemic vein in each anal column. However, the veins. Major sites of Portacaval anastomosis tributaries located in the left lateral, right are at the region of umbilicus, oesophagus posterior, and right anterior positions are and rectum. In the rectal region, superior largest and the first to enlarge. These rectal veins communicate with the middle enlargements are called primary piles. When and inferior rectal veins. Any obstruction at the anal canal is viewed with the patient this anastomotic channel may lead to portal lying supine with the thighs raised hypertension and cause dilation and (lithotomy position) the position of primary tortuousness of the veins. In haemorrhoids piles is often described with reference to a rectal veins are dilated and become tortuous. clock. They are said to be located at the 3 Arshas, which is one among asta mahagada O’clock, 7 O’clock and 11 O’clock may be compared to haemorrhoids. Arsha is positions. Secondary piles may form later at of mainly of two types, shuska and other positions. Sub mucous connective ardraarsha. Shuskaarsha is caused by rakta, tissue at the anorectal junction is very loose pitta, or raktapitta and raktasrava from guda and the radicles of the superior rectal vein is the major symptom. lie unsupported in this tissue. The veins pierce the muscle coat and are pressed upon AIMS AND OBJECTIVES when the muscle contracts during . To understand porta-caval defecation. This increases pressure within anastomosis and its role in pathological them. There are no valves in the superior condition, the Haemorrhoid. rectal or inferior mesenteric veins. The . To compare haemorrhoids with arsha tributaries of these veins in the anal and understand porta-caval anastomosis in columns, therefore, bear the pressure of the Ayurveda. entire column of blood right up to the portal ________________________________________________________________________________________________________ Anju B Uppin 2018Greentree Group © IJAPC Int J Ayu Pharm Chem 2018 Vol. 8Issue 2 www.ijapc.com 127 [e ISSN 2350-0204] Int J Ayu Pharm Chem vein. This explains why haemorrhoids are fromthe anus and bleed frequently. They are more liable to occur in persons who have to also very painful3. stand for long periods. This also explains Arshas why the tendency to formation of piles is AcharyaSushruta considered arsha among increased in portal hypertension. The most asta mahagada4. Arsha is defined as the one important clinical feature of piles is painless which tortures like an enemy in the bleeding which may take place every time gudapradesha and causes malaavarodha5. the patient passes stools2. Arsha adhisthana takes place at the Grades of Haemorrhoids gudapradesha which is 41/2 angulavistsra and Haemorrhoids are grouped into different has three valli viz pravahini, visarjini and grades based on the severity. They include: samvarani from proximal to distal6. • Grade One: This is the least painful and Explaining samprapti it is said that due to problematic of all haemorrhoid grades. nidana sevana vitiated vatadi doshas single Symptoms include a slight enlargement of or with other doshas or along with rakta the haemorrhoidal veins, with the possibility moves towards major dhamani of shareera of some slight bleeding. and forms mamsaankura in the guda • Grade Two: during this stage of pradesha7.Arsha is basically of two types, haemorrhoidal growth, haemorrhoids sahajajaanmottara and uttarajanmaja. prolapse during straining, but recede on their Sahajajaanmottara is of six types as vataja, own. pittaja, kaphaja, samsargaja, tridoshaja and • Grade Three: a more complicated and raktaja8. Acharya Charaka mentioned two painful type of haemorrhoid. In this grade, types of arsha as sushka and ardraarsha. the swollen tissue containing dilated and Shuska arsha is vata, kaphaor vatakapha engorged blood vessels prolapses and must be pradhana and ardr aarsha is rakta, pitta or manually pushed back in. Bleeding usually raktapittapradhana with raktasrava as major occurs as a result of rupture of symptom9. haemorrhoidal veins during forced defecation. DISCUSSION • Grade Four: the most painful of all Portal hypertension causes blood within the haemorrhoids, grade fourth, is so large that portal vein to reverse its flow and enter the they are always noticeably protruding inferior venecava to return to heart. As a ________________________________________________________________________________________________________ Anju B Uppin 2018Greentree Group © IJAPC Int J Ayu Pharm Chem 2018 Vol. 8Issue 2 www.ijapc.com 128 [e ISSN 2350-0204] Int J Ayu Pharm Chem result collateral channels are formed at the arsha may be the site of portacaval sites of Portacaval anastomosis, leading to anastomosis as mentioned in modern important clinical signs. One such condition science. is the haemorrhoids where rectal veins gets dilated and become tortuous. Haemorrhoids CONCLUSION may be internal or external.The rectal veins Arshas is a pathological condition in which form an important portal–systemic there is rakthasrava from the gudamarga. anastomosis because the superior rectal vein Raktasrava is one of the main symptoms of drains ultimately into the portal vein and the arsha seen due to vitiated dhamaniin the inferior rectal vein drains into the systemic gudapradeshawhich is similar to rectal system. bleeding in haemorrhoids from dilated rectal In Internal haemorrhoids, there may be veins. Hence we may infer that guda may be bleeding per rectum along with tissue the site of portacaval anastomosis which in prolapse. The most common cause for this is pathological condition may cause arsha. the pressure exerted on the rectal veins. During defecation when person puts pressure, the dilated rectal veins burst and start bleeding. This bleeding per rectum is similar to the raktasrava in arsha as mentioned by acharya Charaka. Also explaining about samprapti of arshas acharya Sushruta mentioned that, vitiated vatadi dosha either single or along with other doshas or along with rakta takes ashraya in main dhamani of shareera and through these dhamani moves towards guda and produces mamsaankura. These dhamani may be compared to rectal veins which gets dilated and become tortuous in haemorrhoids. With this explanation we may say that dhamani which causes raktasrava in ________________________________________________________________________________________________________ Anju B Uppin 2018Greentree Group © IJAPC Int J Ayu Pharm Chem 2018 Vol. 8Issue 2 www.ijapc.com 129 [e ISSN 2350-0204] Int J Ayu Pharm Chem REFERENCES editor. Varanasi: Chouhkamba Surbharathi 1. Harshmohan : Textbook of Pathology; 6th Prakashan; 2014; 956:490. edition; Jaypeebrother’s medical 9. Acharya Agnivesha, Charaka Samhitha. publishers;2010; 933:318 VaidyaJadavjiTrikamjiAcharya. editor. 2. 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