Venous ulcers (stasis ulcers, varicose ulcers) are the wounds occurring due to inappropriate functioning of venous valves, usually of the legs. It is one of the most serious chronic venous insufficiency complications. The overall incidence rate is 0.76% in men and 1.42% in women. When a venous valve gets damaged, it prevents the backflow of blood, which causes pressure in the veins that leads to hypertension and, in turn, venous ulcers. These are mostly along the medial distal leg, which is often very painful, can bleed, and get infected. Treating varicose ulcers is a difficult task to the physician and a nightmare to the suffering patients, though a good number of the treatment principles are mentioned and practiced in allied sciences. In Ayurveda, this condition is considered as dus.t.a vran.a. It can be managed with the specific s’odhana therapy. So, the same treatment protocol was used to treat the case discussed here, i.e. with Nitya virecana and by Basti karma. The wound was successfully treated and, therefore, is discussed in detail.
Case Report
A 61-year-old male patient presented to KLE Ayurveda Hospital, Belgaum, Karnataka, with the complaint of reddish ulcers above lateral malleolus of the right leg for 2 weeks, associated with pricking pain, burning sensation around the ulcers, edema, and blackish discoloration over the right lower limb. For the last 5 years, the patient had been suffering from varicose veins, and 2 years back, he developed varicose ulcer on the medial aspect of the ankle joint on the same leg and was treated with biomedicines successfully. Patient was addicted to Bīd.i (Indian cigarette filled with tobacco flake and wrapped in a Bauhinia racemosa leaf tied with a string at one end) smoking for 20 years, but had stopped it for the last 2 years. He was habituated to standing for long hours in his job, i.e. about 8 to 10, hours for the past 22 to 30 years. There was no history of any chronic illness such as diabetes mellitus and hypertension.
On examination, a reddish large ulcer and many small oval ulcers with sloping edges were found, along with mild serous discharge around lateral malleolus of the right leg. The large ulcer measured 3 cm in length, 2 cm in width, and 1.75 cm in depth, with three to four small ulcers without granulation tissue. The patient also had swelling and blackish discoloration around right ankle joint and feet, with grade III tenderness around an ulcer. Varicosity on calf region of the right lower limb tested positive for Trendelenburg test and negative for Moses’ sign, but pedal pulse was present which was suggestive of varicose ulcer features.
On the basis of symptoms such as attivivr.ttavran.a (spreading nature), utsanna (elevated margin), raktavarn.a (reddish), srāva (secretion), dāha (burning sensation), and shopha (swelling) present in the patient, he was diagnosed as having dus.t.a vran.a with vātapradhānatridoshajavran.a. Informed consent was obtained from the patient for documentation and publication of his case history.
Treatment
The following treatment schedule was executed:
Nimbāmr.tādi castor oil (processed castor oil with Azadirachta indica and Tinospora cordifolia) – 50 ml orally used for Nitya virecana with 50 ml Śunt.n hīkashāyam for three continuous days
Nitya virecana is the specific therapy in Ayurveda in which the medicine may be processed in oil or as decoction is administered orally for cleansing the bowel and liver system. This improves the Agni metabolism of the individual. This is the first and necessary step in any Basti therapy.
Next therapy is the main line of treatment, i.e. Basti karma (specific scheduled course of medicine administered through rectal route).
On day 4 of management, Maρjis.t.hādi Basti karma was started with Balagud.ūcyādi Anuvāsana Basti (60 ml) in kāla basti pattern. The schedule was planned in accordance with the chart given below.
In the preparation of enema decoction, the above order was followed for the mixing of medicine, and decoction enema was usually administered on empty stomach.
In N2 Basti, Go arkam (distilled cow’s urine) is not added for the decoction and the Kaśāyam (decoction) preparation is changed to Kāyam (decoction) preparation is changed to Ks.īrapāka preparation.
Specific decoction processed in milk -Maρjis.t.hā + Gud.ūci + Yas.t.himadhu Ks.īrapāka (300 ml) used to prepare enema decoction.
AB, Anuvāsana Basti (enema for oleation consists of only the medicine processed in oil or ghee).
Outcome
The pain was measured on visual analogue scale (VAS), the edema was measured by figure-of-eight method of measuring ankle joint swelling, [4] and the ulcerated wound was assessed by measurement and granulation tissue formation.
Noticeable improvement in the symptoms was seen, it was upto 60% in Śotha (edematous swelling), Dāha (burning sensation) was reduced up to 40%, and Toda (pricking sensation) was reduced up to 30% after Nitya virecana. Moreover, Basti karma, Śotha (edematous swelling) was reduced to 95%, Dāha to 70%, and Toda (pricking sensation) was reduced to 80%. Healing of the ulcerous wound started with the proliferative stage by the 3 rd day of the Basti course and the wound got healed up to 90% after the whole course of Basti karma with no adverse event during the entire course of treatment
Probable mode of action
Nitya virecana (bowel and liver system cleansing therapy)
This therapy is indicated in śothāvasthā (edematous condition) where kaphadośa predominance (retention of fluidity) is observed. It is helpful to reduce kledāmshatā (fluid retention) in the Dhātu (tissues), thus reducing excess fluid retention extra- and intracellularly, which in turn facilitates proper microcirculation and reduces the duration of the edematous stage.
This therapy involves laxative actions, using through processed medicines like Nimba (A. indica and T. cordifolia), it stimulates the liver system
In addition, Dhātugata Agni (digestive and assimilation capacity and enzymatic functions through the liver system) was improved by the Nitya virecana. By the laxative actions it creates osmotic effects in the gut to suck the extra fluid retained anywhere in the body and is ultimately helpful in the wound healing process. Therefore, Nitya virecana was the first line of management in the present case.
Three days of treatment with Nitya virechana results in good appetite, reduction in the edematous swelling around the foot, and starting of granulation tissue formation in the ulcerative wound.
Basti karma (medicated drug enema)
In the context of Vran.a Cikitsā (a chapter for the treatment of ulcer-like wound), Basti Chikitsā (rectal enema therapy) is mentioned as a śodhana or a specific purification therapy where medicines are administered through rectal route. The Vāta Doshaja Vran.a and Adhan.kāyaja Vran.a (ulcers prone to lower limbs) are treated with Basti karma or āsthāpana Basti (medicines processed with kaś?yam administered through rectal route)āyam administered through rectal route).
Drug action
Maρjis.t.ha- (Rubia cordifolia)
It has properties like tikta-kashāya rasa, kat.u vipāka, us.n.a vīrvya, kapha-pitta-shāmaka; shleshma-śotha nāśaka. Also, a study proved the significance of Maρjis.t.hā in chronic wound healing. [6]
Yas.t.imadhu (Glycyrrhiza glabra)
Madhura rasa; śīta vīrya; pitta-vata shāmaka; vran.ashothahara; vedanāhara; are its properties. It has anti-inflammatory activity. [7]
Gud.ūci (T. cordifolia)
Tikta-kaśāya rasa; madhura vipāka; us.n.avīrya; tridośaśāmaka; dīpanīya, and dāhanāśaka are its properties. The chloroform and benzene extracts of gud.ūci were found to possess significant antibacterial activity as compared with the standard. Gud.ūci leaf extract is useful in infections due to Proteus vulgaris, Staphylococcus aureus, Streptococcus pyrogens, Bacillus subtilis, and Escherichia More Details coli.
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