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Case Report

Year: 2023 |Volume: 4 | Issue: 07 |Pages: 11-14


About Author

Tongale V.1 , Wankhade S.2 , Podhade S.3 , Ukhalkar V. 4

1MS Shalya PhD Scholar, Post graduate medical officer, District Hospital, Amravati, Maharashtra, India.

2Assistant Professor, Shri Gurudev Ayurved college, Gurukunj Ashram, Mozari, Amravati, Maharashtra, India.

3Associate Professor and Head of Department, Shri Gurudev Ayurved college, Gurukunj Ashram, Mozari, Amravati, Maharashtra, India.

4Professor and Head of Department, R A Podar Ayurved college, Worli, Mumbai, Maharashtra, India.

Correspondence Address:

Dr. Vipin Tryambakrao Tongale MS Shalya PhD Scholar, Post graduate medical officer, District Hospital, Amravati, Maharashtra, India. Email:

Date of Acceptance: 2023-06-18

Date of Publication:2023-07-10


Source of Support: Nill

Conflict of Interest: None declared

How To Cite This Article: Tongale V., Wankhade S., Podhade S., Ukhalkar V. Management of Abhyantar Gudarsha (Internal Haemorrhoids) Using Apamarga Kshar Ointment: A Case Study. Int J Ind Med 2023;4(7):11-14 DOI:


Haemorhoids is a disease of anal canal characterized with PR bleeding mass coming per anal and sometimes associated with per anal discharge [“1”]. Haemorrhoid management ranges from conservative to surgical procedures according to stages of disease. [“2”] Ksharkarma(chemical cauterization) is one of important parasurgical process as per Ayurveda. [3] In current case a 65 years female with anaemia due to per rectal bleeding. She was undergoing physical and local examination and diagnosed with internal haemorrhoids grade III. After informed consent she was treated with Apamarga Kshar ointment local application daily. Apamarga Kshar (caustic paste) ointment application is modification of Apamrga Kshar Pratisaran (local application). Follow up was taken regularly. Relief in per rectal bleeding was started since 3rd day and was stopped completely in 7 days. Also, mass coming through anus was reduced in 28 days. No recurrence was observed till 90 days follow up.

Keywords: Haemorrhoids, Ksharkarma, Apamarga Kshar Ointment, Case Study


A 65 years female patient, having complaints of per rectal bleeding and something coming out through anus attended OPD. She underwent complete history taking and clinical examination. On proctoscopy she was diagnosed as grade III internal haemorrhoids.[5] After written consent she was advised treatment with Apamarga Kshar Ointment local application and Avipattikar Churna (Powder) before meals along with Pathya (Dietary Restrictions). Proper follow up was taken on 3rd day and every 7th day till 28th day. After 28th day treatment was stopped and follow up was taken on 60th and 90th day. Patient relieved from per rectal bleeding after 7 days of treatment and was relieved from something mass prolapsing per anal after 28 days. No recurrence was observed till 90th day.

Case history: A 65 years female patient visited outpatient department. Patient was medium built, height approximate 65 kgs and height about 5’6”. Patient was having complaints of per rectal bleeding on and off for 1 year and bleeding was increased for 1 month. She was also having complaints of something mass coming out through anus while defecation and she needed to reposit the mass with fingers after defecation. She was having history of intermittent constipation and straining during defecation. She was not having any history of known medical illness or history of major surgery. She was asked for any allergies, which was not present.

Physical examination results.

On examination, patient was having general condition medium, minimal pallor, No icterus, clubbing, and cyanosis. She was not having any facial or pedal edema. On systemic examination no deformity was observed. On Local examination, she was not having any external fissure, haemorrhoids or external opening at anal region.

On per rectal examination, she was not having any spasm or palpable mass.

On proctoscopy,[6] it was observed that she was having internal haemorrhoids at 3,7 and 11 o’clock position with some active bleeding.

Investigation: -Hemoglobin 8.10 gm %:  Red blood cell: 3.04 mil/cmm TLC: 6130/cumm, N%:72, L%: 21, M%:06, E%: 01, B%: 0 Plt: 227000, CT: 5.10 mins, BT: 2.40 mins Blood Group: AB rh positive, Sr creat: 1.10 mg/dl, Blood Urea: 30 mg/dl, BSL r: 91 mg /dl, HBSAG: Negative, HIV I And II: NR,

URINE ANALYSIS: - Physical Examination Quantity: 10 ml, Colour: Pale Yellow, Appearance: Clear, Sp Gravity: 1.030,

Chemical ExaminationProtein: Nil, Sugar: Nil, pH: Acidic, Ketone bodies: Nil, Bile Salts: Absent, Bile Pigments: Absent,

Microscopic Examination: Pus (WBC) Cells: 3-4 /hpf, Epithelial Cells: 1-2/hpf, RBC: Occ/hpf, Casts: Absent, Crystal: Absent, Bacteria: Absent,

Treatment plan: Local Application of Apamarga Kshar Ointment was advised once a daily for 4 weeks at home.

Dosage as required depending upon surface.

Dosage schedule – After defecation in morning once a day.

Route of administration - Topical (Locally on internal haemorrhoids)

On very first day patient was taken for local application after hot sitz bath. Patient was given left lateral position. Then local application at haemorrhoids was done. Remnant of ointment at anal region was wiped out. After that, a sterile pad kept at the anal verge to avoid soilage of clothes. Same procedure was advised to patient to be done at home.


Pathya for both Groups

  • Hot sitz bath twice a day
  • Advice the patient to keep the local site hygienically clean.
  • Laxative – Avipattikar Churna[7] 2-6 gm at bedtime with lukewarm water (Dose was adjusted as per requirement of patient. when constipation was not relieved dose may be increased).
  • Dietary control was advice.


“Pratisaraneeya teekshna kshara causes coagulation of Hemorrhoid plexus, necrosis of tissue followed by fibrosis of plexus, adhesion of mucosal, submucosal coat helps in prevention of further dilatation of veins and prevents prolapse of regional mucosa of anus” And hence relives complaints of haemorrhoids [4]. Apamarga Kshar ointment is having same effect. It was observed that per rectal bleeding was reduced on 3rd day and it was nil since 7th day. It was observed due to localized chemical cauterization effect of Apamarga Kshar which is ingredient of Apamaraga Kshar ointement. Also, base sikth of Apamarga Kshar ointment is useful in maintaining localized soothing and lubrication. It helped in smooth passage of stools during defecation and was helpful in reducing friction between stool a haemorrhoidal cushion. Degree of haemorrhoid reduced on 28th day. It was due to fibrosis of haemorrhoidal cushion and reducing its size. 

Discharge from haemorrhoids was reduced to nil on 3rd day. It was due to reduction of inflammation of haemorrhoidal mucosa. Avipattikar churna helped in making stool passage smooth with reducing requirement of straining during defecation. Overall effect of Apamarga Kshar ointment application was as like that of Kshar pratisaran. But in current treatment advantage was all procedure was done by patient himself at home unlike in Apamarga Kshar Pratisaran, where Apamarga Kshar Pratisaran was to be done by expert physician, with assistant in OPD setup.


Thus, Apamrag Kshar ointement application locally was effective in patient of internal haemorrhoids in reducing per rectal bleeding and degree of haemorrhoids.

Thus, Apamrag Kshar ointement application locally was effective in patient of internal haemorrhoids in reducing per rectal bleeding and degree of haemorrhoids.


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2] Agarwal N, Singh K, Sheikh P, Mittal K, Mathai V, Kumar A. Executive Summary - The Association of Colon & Rectal Surgeons of India (ACRSI) Practice Guidelines for the Management of Haemorrhoids-2016. Indian J Surg. 2017 Feb;79(1):58-61. doi: 10.1007/s12262-016-1578-7. Epub 2017 Jan 9. PMID: 28331268; PMCID: PMC5346092

3] Dudhamal TS, Gupta SK, Bhuyan C, Singh K. The role of Apamarga Kshara in the treatment of Arsha. Ayu. 2010 Apr;31(2):232-5. doi: 10.4103/0974-8520.72406. PMID: 22131716; PMCID: PMC3215370.

4] Anita Mahapatra, A. Srinivasan, R. Sujithra, and Ramesh P. Bhat Management of internal hemorrhoids by Kshara karma: An educational case report, J Ayurveda Integr Med. 2012 Jul-Sep; 3(3): 115–118.  doi: 10.4103/0975-9476.100169, PMCID: PMC3487235, PMID: 23125506

5] American Gastroenterological Association medical position statement: Diagnosis and treatment of hemorrhoids. Gastroenterology. 2004; 126:1461–1462.

6] Buntzen S, Christensen P, Khalid A, Ljungmann K, Lindholt J, Lundby L, Walker LR, Raahave D, Qvist N; Danish Surgical Society. Diagnosis and treatment of haemorrhoids. Dan Med J. 2013 Dec;60(12):C4754. PMID: 24355455.

7] Hishagratna GD. Bhaishajyaratnavali. 1st ed. India: Chaukhambha Sanskrit Bhawan series; 2006.

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