Effect of Irsale Alaq (leech therapy) in thrombosed pile mass: a case study

INTRODUCTION

Haemorrhoids are dilated veins within the anal canal.¹ Among all the diseases of gastrointestinal disorders haemorrhoid is the commonest and troublesome disease. This disease is not life threatening but making the life of the sufferer more miserable. Haemorrhoids are one of the common causes of bleeding from anal canal. In Unani system of medicine haemorrhoids are called ‘Bawaseer’, which is the most common cause of bleeding during defecation and it may be associated with pain, itching, mucous discharge, discomfort and prolapse of haemorrhoids.² Human body, as stated by Hippocrates, contains four types of humours (body fluids). The healthy state of a person is maintained as long as these exist in equilibrium. Any change in quantity or quality of these humours results in disease³. The main cause of Bawaseer is accumulation of morbid humours in the body. These morbid humours accumulate within the Jigar (liver) which are then pushed towards the Maqad (anus) and results in the formation of Bawaseer. The blood which comes from Bawaseer is harmful and Tabiyat expels it out of the body so this bleeding results in lightness in the body. Hippocrates stated that if Bawaseer are at many places then cut one of them so that the waste blood which comes towards that will not return back into the body because its excretion is much better than its accumulation.⁴ Bloodletting is the treatment of choice for Bawaseer because if the waste blood remains in the body it will cause Aklah, Junoon, Melancholia, Sura-e-Saudavi, Humra, Taqashshur, Jarb, Qooba (Dandruff), Juzaam (Leprosy), Za’atuljanab (Pleurisy), Za’atulriya (Pneumonia), Sarsaam (Meningitis), Istisqa’a (Ascites).⁵ If there is no sever pain in the Bawaseer then there is no need to cut it just evacuation of excess Sauda (black bile) is needed. Therefore, drugs like Munzij-e-Sauda and Mushil-e-Sauda should be given. To reduce the quantity of black bile from the vessels, venesection of saphenous vein and vessels present on posterior aspect of ankle is recommended.⁴ Saqalain et al, stated that blood-letting in the form of venesection, leech therapy and cupping with scarification is an essential part of regimental therapy. It has been utilized for preventive as well as therapeutic measures for thousands of years by ancient Unani physicians. Irsale Alaq (leech or Hirudo therapy) is a method of blood-letting which involves the withdrawal of blood in a considerable quantity from the body with the help of leeches. Leeches can ingest an amount of blood almost ten times its own weight and may digest the bout of blood for as long as 12 to 18 months during which time the leech will not bite, leech could suck 5 to 15ml of blood which would then be broken down by the flora of the gut of the parasite.⁶ Mention of medicinal leeches in Australia dates back to 1824 CE.⁷ The aim of Irsale Alaq are Tasqeen-e-Alam (analgesia), Tanqiya-e-Mawad, Jazb-wo-Imala, Taftiyah-Urooq (vasodilation), Iindemaal-e-Qrooh (wound healing), Indefa-e-Afoonat (antiseptic).⁸ There are different treatments according to the degree of haemorrhoid, in third and fourth degree usually surgical treatment is needed, but risk of recurrence or of developing an infection of the wound after the operation is high.^9,10 Hence efforts are being made to avoid operations as much as possible and prefer non-surgical treatments.

CASE REPORT

A 60 years old patient came to the Jarahat OPD of National Institute of Unani Medicine Hospital, Bengaluru, Karnataka on January 2018, with the complaint of something coming out during defecation with occasional bleeding during defecation for 2 years, painful defecation for 3 months and soiling of clothes for 1 month. After careful interrogation we came to know the causative factors behind this condition was non-vegetarian meals and high spicy food intake, straining during passage of stool.

Patient was known case of controlled hypertension already on treatment. There was no history of diabetes mellitus, pulmonary tuberculosis, bronchial asthma, typhoid. There was no history of previous anaesthesia and surgery. He was not allergic to any drug and food.

Examination confirmed three thrombosed masses at 3, 7 and 11 o’clock position. Masses were red and tender on digital examination with sever sphincter spasm present and tenderness. Patient got admitted and conservative Unani treatment was started having properties like Mulaiyenat (laxative), Habiss-uddam (haemostatic), Musakkinat (pain killer) associated with dietary management like consumption of high fibrous diet and plenty of oral fluid.

All basic investigations like complete blood count, viral markers, blood sugar, liver function test, kidney function test and electrocardiography were done which were in normal range. Patient was not willing for haemorrhoidectomy. Hence, Irsale Alaq was offered. After taking consent the procedure was started.

Patient was lying on bed in left lateral position. After cleaning with antiseptic solution two leeches were applied at a time after pricking the mass with sterile needle. Sucking of blood was confirmed by peristaltic movement of leeches which appeared on their surface. Leeches were left for 20 to 25 minutes until they stop sucking blood. After removing the leeches, fresh bleeding started from the site of prick which may be due to the fact that leech saliva contains enzymes which have properties like anti-inflammatory, anticoagulant, antioxidant, antibiotic, platelet anti-aggregating.³ With sterile pad pressure dressing was done and haemostasis achieved. Leeches were again applied on the same site for three consecutive sittings. After blood sucking leeches were forced for Qai (vomiting) by putting their mouth in Haldi (turmeric). Then leeches were preserved in fresh water in a container with hole in its lid for next sitting.

During the whole treatment local examination of the patient was done regularly. Patient was interrogated throughout the treatment about any itching and pain. The patient was followed up monthly for 6 months.

DISCUSSION

In present day practice, Irsale Alaq is found to be a safe, efficacious, less time consuming and cost-effective method for management of thrombosed haemorrhoids on OPD basis. The use of leeches for medicinal purposes dates back to 1500 BC. It was believed that the leeches suck bad blood which later on proved to be a wrong notion, instead the leech is a blood sucking animal which sucks every type of blood.³ Javed, Gupta and Ravishankar et al also reported that leech therapy have significant role in reduction of prolapsed and thrombosed pile mass due to their blood liquefying and blood sucking properties.^11-13

CONCLUSION

Irsale Alaq was found effective in the treatment of thrombosed pile mass within 21 days of application. This case study shows that a combination of Irsale Alaq along with conservative medications, dietary restrictions and life style modifications is effective in treating the pile mass as well as preventing recurrence on a long-term basis. In those cases where immediate surgery is not possible or is contraindicated, Irsale Alaq will be beneficial and can be done on OPD basis.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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