Varicose veins are nothing but dilated, elongated and tortuous veins mostly found (common sites) in lower limbs either long or short saphenous veins, Varicocele, haemorrhoids and oesophageal varices. It is compared with Sirajgranthi explained under Granthi Vikar. Varicose ulcer is a chronic complication of venous insufficiency marked by delayed wound healing and frequent recurrence. In Ayurveda, such non healing ulcer can be correlated with Raktadushtijanya Dushta Vrana. In Sushrut Sutrasthana 13th adhyaya, Jalaukawcharan is explaind in detail which is the best amongst all anushastras. Jalauka possess sheet guna and it is indicated in mainly Pittaj Vyadhi. In this case study, a 66 years old male with Left leg Varicose vein along with Varicose ulcer over left leg was treated successfully and he got symptomatic relief.

Introduction:

Varicose ulcer represents an advanced stage of chronic venous insufficiency caused by prolonged venous hypertension and incompetency of valves i.e. varicose veins. Common site of these ulcers are over the gaiter area of the lower limb and are associated with pain, edema, pigmentation and impaired healing. Though there is availability of compression therapy and surgical intervention, recurrence and delayed wound healing remain significant clinical challenges. Because of Vataprakopak nidansevan (i.e. causative factors which increases Vata dosha) such as physical exertion, straining, in debilitated persons, the vitiated vata enters the siras (veins) causing Sampeedana (Squeezing). Sankoch (constriction) and Vishoshana (act of drying up) which produces round and protruded Granthi in the Sira (veins), manifesting Sirajgranthi (Varicose veins).[1,2] Ayurvedic text explained chronic, infected and non healing ulcer under Dushta Vrana.  In Sushrut Sutrasthana 13th adhyaya, Jalaukawcharan is explaind in detail which is the best amongst all anushastras.7Jalauka possess sheet guna.There is also description about site from where best quality of jalauka should be collected (Yavan Pradesh/ Pandya/ Sahya/ Pautan) along with their sign of confirm application over affected site i.e. Ashwakhurvadanan) and it is indicated mainly in Pittaj Vyadhi. 3 The main purpose behind this case study is to observe and understand the alleviation of complaints of varicose veins along with varicose ulcer. 

Aims and Objectives: To treat and relieve patient from symptoms.

Case Report:

A 66 year old male presented with non healing ulcer over lateral malleolar region of left leg since 7 months, dragging pain, swelling, sometimes itching and dilated tortouos veins in left leg, came to Shalyatantra OPD of B.S.D.T.’s Ayurved Hospital. There was severe left ankle pain and swelling with difficulty in walking. Symptoms was aggravated by prolong standing, exertion, after heavy work and relieved by leg elevation. He was K/C/O Diabetes mellitus, Hypertension with operated history for left leg varicose veins one year prior. There was history of minor trauma over left lateral malleolar region 7 months back and failed to heal despite of routine wound care. Written, informed consent was obtained before intervention and documentation.

Clinical Findings:

General examination:

Blood Pressure: 140/80 mm of Hg

Pulse rate: 76/min

Temperature: 98.2o F

No pallor, icterus, cyanosis or clubbing

Local examination:

• Site: Lateral aspect of left lower leg, near to lateral malleolus
• Size: 2 x 2 cm
• Shape: oval
• Edges: sloping
• Base: Slough presemt
• Discharge:  seropurulent
• Odor: Foul
• Surrounding skin: Hyperpigmented
• Tenderness: Present
• Peripheral pulses:  palpable

There was tenderness in left foot, ankle and calf region, bluish reticular veins with surrounding hyperpigmented skin along with difficulty in walking. Pain relieved upto some extent after leg elevation.  Mose’s Sign (pain in the calf region on gentle squeeing of calf region) was positive in that patient. The patient was subjected for Jalaukawcharan in left lower limb with oral medicines like Kaishor Guggul and Gandhak rasayan vati (Table-1). Ashtavidha Pariksha was done. Nadi was Vataj type, Mutra, Mala, Jivha, Shabda, Sparsha and drika was found normal. Aakriti pf patient was madhyam. Severity of Varicosity was classified as C4, Ep,As, Pn category using CEAP (Clinical- Etiological-Anatomical-Pathophysiological) Classification.4 (Table 2,3,4 5).

Investigations:

Hemoglobin: 11.2 g/dl

ESR: 36mm/hr

RBS: 132 mg/dl

Renal parameters and viral markers: Within normal limits

Both legs Venous doppler study:

Left leg- GSV mild dilated with superficial varicosity with few perforators along with edema on medial aspect 5cm above ankle joint.

Right leg- No varicosity or DVT.

Diagnosis:

On the basis of clinical features, the condition was diagnosed as Vam paad Sirajgranthi with Dushta Vrana (Left leg Varicose Veins with Varicose ulcer).

Materials and Methods:

Treatment Protocol:

On the day of admission, internal medication was started using Kaishor Guggul vati 250mg and Gandhak rasayan vati 250mg – both 2 tablets twice daily for 2 months. Four sittings of Jalaukawcharan was planned once in a week for one month. In first sitting, on First day one Leech were applied over varicose ulcer. From next day upto wound healing, local application of Jatyadi taila was done once daily. The overall pain reduction, burning sensation, swelling, tortuosity and skin changes were graded on the basis of patient’s presentation and physician’s observation and it was manually documented (Table 6,7).

Table 1: Key Ingredients of the Formulations used.

Ceap Classification:

Table 2:  Clinical classification (severity)

Table 3: Etiological Classification (cause)

Table 4: Anatomical Classification (Location)

Table 5: Pathophysiological Classification (Mechanism)

Table 6: Subjective Parameters

Table7:  Objective parameters

Procedure of Jalaukawacharan:

1. Poorvakarma (Pre operative procedure):
2. Well informed written consent taken.
3. All pre procedure investigation like RBS, BT, CT was done and they were under normal range.
4. Patient was explained about the procedure
5. All instruments required for procedure were prepared.
6. Jalauka activated.

Pradhankarma: (Main Procedure):

1. 1 Jalauka was applied on left leg over wound at left malleolar  region.
2. Jalauka applied there for approxamately 45 minutes.
3. Proper bandage done to avoid post procedure bleeding.

1. Paschat Karma (post procedure):
2. Haemostasis achieved.
3. Proper vaman of Jalauka done.
4. After vaman, Jalauka stored in it’s container with label of name of patient with date.
5. Patient was advised for proper position of the leg.

Table 8: Weekly relief in subjective and objective parameters

Results:

Table 9:

On the very first day of leech application, patient came in OPD with the support of walking stick and went without it’s support. After first sitting, within 1 week patient got around 50% relief from pain. Visible reduction in edema and slough was seen after the second sitting. The ulcer was healed completely within 3 weeks.  At the end of one month, there was marked improvement in skin colour with reduction of upto 75% hyperpigmentation.

Discussion:

Patient underwent four times jalaukawcharan with internal medicines in first one month and during second month patient was on internal medicines.The assessment was done by weekly interval by assessing the subjective and objective parameters (Table:8).  Symptoms of varicose veins resembles with Sirajagranthi in Ayurveda. Accumulation of rakta and vitiation of vata leads to dilatation and elevation of veins along with tortuosity and pain. In case of involvement of Raktadushti, Raktamokshan (bloodletting) is the most common treatment of choice and Jalaukawcharan is involved in it’s types. In Grathita and Avagadha Rakta (clotted and thick blood), Jalaukawcharan is indicated. Saliva of Leech has analgesic action, blocking certain steps of the regular pain evolving cascade by counteracting cytokines with anti-inflammatory agents.5 Leech saliva contains histamine, serotonin, steroid hormones, enzymes, protease inhibitor and anti-microbial agents along with hirudin. Factor Xa inhibitor destabilize and hyaluronidase which have anticoagulant, thrombolytic, vasodilator, anti-inflammatory effects and also helps to enhance the blood circulation. After leech application, there were no complications observed like bleeding, hematoma etc. Resulting in local hyperaemia, Jalaukawcharan increases cell permeability and also it improves tissue regeneration and blood circulation. Kaishor Guggul acts on both vatadushti & raktadushti. It is also effective in pain relief because of it’s anti-inflammatory action.6 Gandhak Rasayan Vati 9 is traditionally used for skin health, digestion and detoxification. It has Kledaghna (drying of abnormal wound discharge) action on wound. It improves blood circulation which helps in healing of skin ulcer & in reduction of inflammation. After two months treatment and 4 sittings of Jalaukawcharan, there was complete relief in shool(pain), marked improvement in skin colour . Jatyadi tail plays important role in healing of dushta vrana8 .Varicose ulcer healed completely within  3weeks.

Conclusion:

Therefore, combined effect of Jalaukawcharan and oral/systemic ayurvedic medicines are said to be effective in the management of Sirajgranthi (Varicose veins) and Dushta Vrana (Varicose Ulcer). From this case study, it is concluded that when treatment is done on the basis of Ayurveda guidelines, significant improvement can be obtained.  This study should be done in more number of population to observe better  results.

Acknowledgements:

I would like to express my sincere gratitude to Dr. Rashmi Kale madam, My Ph.D.Guide, Professor &HOD, Shalyatantra Department, Sumatibhai Shah Ayurved Mahavidyalaya, Hadapsar, Pune, for their invaluable guidance and support throughout this study. I also thank BSDT’s Ayurved Mahavidyalya, Wagholi, Pune, for providing the necessary facilities and resources. Special thanks to the patient who participated in this case study and consented to share their experience.

Conflict of Interest: No conflict of Interest

1. Dr.Anantram Sharma, Chapter no. 11, Nidansthan, Sushruta Samhita, 2023, Chaukhambha Surbharti Prakashan, Varanasi, Volume I, Page no. 540.
2. Dr.Anantram Sharma, Chapter no. 18, Chikitsasthana, Sushruta Samhita, 2023, Chaukhambha Surbharti Prakashan, Varanasi, Volume II, Page no. 312.
3. Dr.Anantram Sharma, Chapter no. 13, Sutrasthan, Sushruta Samhita, 2023, Chaukhambha Surbharti Prakashan, Varanasi, Volume I, Page no. 94.
4. H.G. Beebe et.al. Classification of Chronic venous disease of the lower limbs: A consensus statement.  Eur J VascEndovasc Surg. 1996;12, Page no.:487-492.
5. Koeppen D, Aurich M, Rampp T, A Narrative review, Medicinal Leech Therapy in Pain Syndromes, Wiener Medizinische Wochenschrift. 1 March 2014; 164 (5-6); Page No. 95-102.
6. Gupta V, Bansal P, Sahu M, Sachdeva K, Ghaiye P, A review, International Journal of Pharmaceutical & Biological Archives, An Ayurvedic Polyherbal Formulation Kaishor Guggulu, 2011; 2(1); Page No. 497-503.
7. Dr. Brahmanand Tripathi, Chapter No.25.Sutrasthan, Charak Samhita,2014, Chaukhambha Surbharti Prakashan, Varanasi, Volume I, Page no. 455.
8. Pt. Parashuram Shastri Vidyasagar, Adhyaya 9, Sarangadhara Samhita by Pandita Sarangadharacharya, Madhyamkhanda, Reprint 1986, Krishnadas Academy, Varanasi, Pg. No. 229.
9. Madduru MH, Prashant GJ. A review on probable mode of action of Gandhaka Rasayana- An ayurvedic herbo-mineral formulation with multifaceted action. Int J Ayur Pharma Res 2024; 12:173-9.
10. Cited Here /Google Scholar.