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Case Report International Ayurvedic Medical Journal ISSN:2320 5091

MANAGEMENT OF NON HEALING VARICOSE ULCER IN AYURVEDA


Dwivedi Amarprakash
Department of Shalya Tantra, Dr. D.Y. Patil College of Ayurveda, Mumbai, Maharashtra, India
ABSTRACT
Varicose ulcer is a severe clinical manifestation of chronic venous insufficiency. It is
responsible for about 70% of chronic ulcers of the lower limbs. The pathogenesis starts with
dysfunction of venous valves causing venous hypertension which stretches the veins resulting
in ulcer formation. If not treated properly, the ulcer may get infected leading
to cellulitis or gangrene and eventually may need amputation of the part of limb.
If the conservative management like compression stocking, foot elevation, antibiotics
and regular dressing of wound fails, then surgical treatment like skin grafting, sclerotherapy,
laser ablation or surgical correction of superficial venous reflux is practiced. However, recur-
rence of venous ulcers is common, ranging from 54 to 78% by the fifth year after healing.
In Ayurvedic prospective, varicose ulcers can be correlated with Siragat Vat janya
vran. Sushruta has advocated Jalauka (Leech) as one of the most effective method of
bloodletting, useful even in infected and non healing wounds.
Patient with varicose ulcers was advised to take Sariva Ghana vati internally, Teel
oil Dhara sweda over the lower limb along with weekly application of Leech around the
ulcer followed by dressing with Yashtimadhu Ghrita which proved very effective and the
ulcer healed completely in 30 days.
Keywords: Varicose ulcer, Siragat Vaat, Jalauka, Vrana

INTRODUCTION long standing occupation etc. The


Varicose ulcers are wounds that are pathogenesis starts with persistently
thought to occur due to improper increased intravenous pressure which
functioning of valves in the veins, causing damages the venous walls and results in
venous stasis usually in the legs. Varicose stretching, loss of elasticity, hyper lipo-
ulcers appear when these enlarged veins dermato-sclerosis and finally ulcer
become congested with fluid buildup and formation. Confirmation of diagnosis is
infection occurs. It is the major cause done by Duplex Doppler ultrasound
of chronic wounds, occurring in 70% to 90% scanning of the lower limb venous System.
of chronic wound cases. 1 They are also Conservative management of venous
known as stasis ulcer or venous ulcers and ulcers includes use of compression stocking
are most commonly seen the female or bandage to prevent worsening of varicose
population. veins, foot elevation, antibiotics and regular
The etiological factors include cleaning and dressing of ulcer. How ever, if
increased intravenous pressure, secondary to patient do not respond, then surgical
deep vein thrombosis, chronic constipation, measures like skin grafting, terminal
Dwivedi Amarprakash: Management of Non Healing Varicose Ulcer In Ayurveda
interruption of reflux source technique Further, the venous insufficiency
(TIRS) by sclerotherapy, laser ablation of causes leukocytes to accumulate in small
varicose veins or surgical correction of vessels which releases inflammatory factors
2
superficial venous reflux is performed. causes chronic wound formation.
If varicose ulcer is not treated Ayurvedic treatment for siragata vata
properly or left untreated then, wound janya vrana:
infection causing increased pain, swelling, Acharya Sushruta has exclusively
redness and pus, loss of mobility and even mentioned the treatment regime for
severe complications like osteomyelitis, Siragata Vata which includes local
septicaemia or malignancy etc. may occur. oleation and fomentation along with Leech
Statistics revealed that recurrence of therapy.3 Sushruta has advocated 60
venous ulcers is quite common, ranging procedures (Shashthi upakramas) for wound
from 54 to 78% by the fifth year after management which can be practiced as per
healing. Hence, we can say that in spite of stage of wound and necessity. He has given
all advances in health sciences, varicose the utmost importance to Bloodletting
ulcer management is still a difficult task for therapy and considered Leech as the most
the surgeons. unique, effective method of bloodletting
In Ayurvedic prospective, we can co even in infected wounds and in abscess
relate varicose ulcers with Siragat Vat management. Sushruta has also specified
janya vran. Sushruta has described wound that the wounds over the lower limb delays
management in a most scientific way and in healing.
given the utmost importance to Bloodletting References of indication of leech therapy
therapy and considered Leech as the most in wounds:
unique and effective method of bloodletting Leech therapy is considered as most
even in infected wounds and abscesses. unique and effective method of bloodletting.
Pathology in delaying varicose ulcer It can be tried in all mankind including
healing: Females, Children, Old and Patients having
The pathogenesis of varicose ulcer poor threshhold to pain. It drains impure
starts with dysfunction of venous valves blood, useful in Pitta dushit Rakta diseases,
causing venous hypertension which stretches various skin disorders and all types of
the veins. This allows blood proteins to leak inflamatory conditions.
into the extra vascular space. It isolates extra In Sushruta samhita Chikitsasthana,
cellular matrix molecule and growth factor, chapter 12 and 16, Sushruta has advocated
preventing them from helping to heal the that bloodletting by Leech can be practiced
wound. in all inflammatory, suppurative and painful
Similarly, leaking of fibrinogen and conditions to relieve pain and inhibit
deficiency in fibrinolysis cause fibrin to suppuration including that of non healing
build up around vessels preventing oxygen ulcerative lesions. 4
and nutrients from reaching cells. This also Case report:
plugs the vessels causing ischemia around Objective of case study: To evaluate clinical
the wound resulting in delaying in wound efficacy of adjuvent Leech therapy in the
healing. patient with Varicose ulcer.
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Dwivedi Amarprakash: Management of Non Healing Varicose Ulcer In Ayurveda
Type of study: Observational single case lower limb; Competent SF and FP valves;
design without control group No evidence of DVT or Ischemia
Study center: Dr. D.Y. Patil Ayurvedic Local examination: (On day 1): Site of
Hospital, Nerul, Navi Mumbai. ulcer - Medial aspect of left lower limb; Size
Name of the patient- Not mentioned here of ulcer - 4 x 2.5 x 0.5 cm; Shape- Oval;
Registration no: PH/OPD/2013/43362 and Smell Foul smell+; Discharge: + +; Hyper
IPD/2013/8128 pigmentation: +++; Epithelisation: +;
Date of Admission- 07/02/2013, Age- 30 Granulation Tissue: +; Edges: Fibrosed,
yrs, Gender- Male, Religion- Hindu, Sloping; Ankle flare Positive; Local
Occupation- Hotel waiter, Diet- Veg - Non Temperature: Normal; Arterial Pulsation:
Veg Both Dorsalis pedis and Post tibial Normal.
Chief complaints and its duration- Pain Diagnosis: Non healing varicose ulcer
and Swelling over Left lower leg, Infected MATERIAL AND METHODS
wound on medial aspect of left leg, Skin 1. After the assesment, wound was washed
discoloration and Serous discharge from the with Normal Saline. There after 6 Leeches
wound since 2 years were applied all around the lesion. When
Brief history (including onset and progress) Leeches left the site by their own (after
Patient has been suffering from sucking blood for approx. 30 min.) wound
above symptoms since last 2 years. He took was cleaned and dressing with guage piece
treatment for the same at private clinic but soaked in Yashtimadhu Ghrit (glycyrrhiza
wound got infected and was not healing glabra) was done.
inspite of treatment for around 2 years. 2. Dressing was changed on alternate day,
Hence, he came to Dr. D. Y. Patil Ayurvedic where as Leech therapy was repeated
Hospital for further management. Patients weekly for 4 sittings. Total duration for
brief history did not revealed evidence of treatment was 30 days and during the
Diabetes, Hypertension, Asthama, Tu- treatment assessment was done on Day-01,
berculosis, Heart disease or any other major Day-07, Day-14, Day-21 and Day-30.
illness. Similarly, there was no history of 3. Patient was advised to take Sariva Ghana
previous surgery in past. vati (hemidesmus indicus)-250mg (Two
General examination (On day 1) tablets three times a day) internally and
All the vital parameters were within normal Dhara sweda(fomentation) was done daily
limits. for 20 minutes (except the day of Leech
Hb 12.5 gm/dl; Wbc 8,000 /cu mm of therapy) with lukewarm Teel oil (sesamum
blood; RBSL 120 mg/dl; ESR 12 mm indicus at 98.6F temp) adjuvant to Leech
/hour;Viral Markers Negative; Coagulation therapy.
profile Normal; X-ray left leg Essentially OBSERVATIONS
normal study; Other Examinations- Parameters of observation included Ankle
Abdomen/Rectal Examination No IVC flare, Perpheral Hyperpigmentation, Size of
obstruction, Pelvic tumor etc. ulcer, Granulation tissues and relief in Pain.
Arterial and venous colour Doppler: Patient was observed on above parameters
Multiple incompetent perforators seen in the on every week for 5 weeks.

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Dwivedi Amarprakash: Management of Non Healing Varicose Ulcer In Ayurveda
Table 1: Parameters of Observation
Parameters Grade
Ankle flare Base line 100 % 3=75% 2=50% 1=25%
Peripheral Hyper pigmentation Base line 100 % 3=75% 2=50% 1=25%
Size of ulcer (cm) Base line 100 % 3=75% 2=50% 1=25%
Granulation tissue Base line 0% 1=25% 2=50% 3=75%
Pain Base line 100 % 3=75% 2=50% 1=25%
RESULT non healing ulcer. The images during and
With Leech Therapyand adjuvant after treatment supports the statement
management, the wound completely healed mentioned.
within 30 days i.e. patient was cured from
Table 2: Progressive report
st nd th th
Parameters 1 week 2 week 3rd week 4 week 5 week
Ankle flare Base line 100 % 50 % 25 % 0 0
Peripheral Hyper
Base line 100 % 75 % 50% 50% 25%
pigmentation
Size of ulcer (cm) Base line 100 % 75 % 50% 5% 0
Granulation tissue Base line 0% 25% 50% 5% 0
Pain Base line 100 % 75 % 25% 25% 0
Eglins in the saliva which prevents
Probale mechanism of action of leech leukocyte accumulation in the surrounding
therapy: vessels, thus inhibits release of
Leech application corrects venous inflammatory factors which causes chronic
hypertension, reduces vascular congestion wound formation.
due to presence of Carboxypeptidase A
inhibitors, Histamine like substances and
Acetylcholine,5 thus it venous valve
dysfunction and extra vascular fluid
perfusion. This prevents leakage of proteins
and isolation of extra cellular matrix
molecule and growth factors, thus helps to
heal the wound. Fig.1 Presentation of varicose ulcer on Day 1

Leech application has peripheral


vasodilator effect due to presence of
vasodilator constituent in the saliva which
improves blood circulation and corrects
ischemia around the wound, thus promotes
wound healing. 6
Leech applications has Anti-
inflammatory action on nerves due to Fig.2 Leech application in Varicose
presence of substance like Bdellins and ulcer

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Dwivedi Amarprakash: Management of Non Healing Varicose Ulcer In Ayurveda

Fig.3 Teel oil Dhara swed Fig.4 Prognosis on Day 15 Fig.5 Prognosis on Day 30
in Varicose ulcer
Probale mode of action (ayurvedic valvular dysfunction when used internally
perspective): along with adjuvant therapy.
1. Vrana shodhana and ropana effect: However, a multi centric
After Leech application expulsion of impure comparative clinical trial along with
blood takes place, due to which local valvular studies is needed to evaluate impact
vitiated doshas (toxins andunwanted of Leech Therapy on promoting wound
metabolites ) are removed. Similarly, it healing w.s.r.to varicose ulcer.
facilitates fresh blood supply and promotes CONCLUSION
wound healing by formation of Healthy With Leech Therapy and adjuvant
7
Newer Tissues. Ayurvedic treatment, the non healing
2. Effect of adjuvent therapy: varicose ulcer completely healed within 30
a) Teel oil fomentation improves blood days. On the basis of this case study, we can
circulation, corrects skin discoloration and roughly conclude that Ayurveda can give a
pacifies venous valvular dysfunction. Thus, ray of hope in the treatment of varicose
it breaks the pathogenesis of varicosity at veins and ulcer. None of the complication
cellular level and helps in wound healing. like severe bleeding,wound infection or
b) Yashtimadhu Ghrit has both hypersensitivity were observed during the
Vedanashamak and vran ropan property. therapy. Leech therapy proves to be
Hence, it helps in Healing of wounds and effective, time saving, affordable and
relieves pain too. acceptable treatment. Though treating non
c) Sira and Snayu are the bi product healing Varicose ulcer is a difficult task,
(updhatu) of Rakta and Sariva Ghanvati we have managed to treat it with Leech
has Raktaprasadniya character. Hence, it Therapy along with conventional
facilitates formation of Healthy Newer (Ayurvedic) methods of wound care. A
tissues and also strengthens the blood multi centric comparative clinical trial
vessels, thus corrects venous valvular alongwith valvular studies is needed to
dysfunction As per Ayurvedic texts, Sariva establish this unique treatment protocol.
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Dwivedi Amarprakash: Management of Non Healing Varicose Ulcer In Ayurveda
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(This book is an authorized and Revised Source of support: Nil
translation of German Edition published and Conflict of interest: None Declared
copyright 2006 by Karl F.,HangVerlag.Title
of German Edition-Bluteqeltherapie)

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