A STUDY ON SIRAJA GRANTHI AND ITS MANAGEMENT WITH ...

A STUDY ON SIRAJA GRANTHI AND ITS MANAGEMENT WITH PUNARNAVADI GUGGULU AND NIMBADI GUGGULU-A

COMPARATIVE STUDY.

By

Dr. NADAF A.N. Dissertation Submitted to the

Rajiv Gandhi University of Health Sciences, Bengaluru, Karnataka

In partial fulfillment of the requirements for the degree of

AYURVEDA DHANWANTARI (MASTER OF SURGERY)

In

SHALYA TANTRA

Under the guidance of

Dr. B.A.VENKATESH BSAM, BAMS, MD (Ayu), FICA

Professor & H.O.D. Dept. Of P.G. Studies in Shalya Tantra

G.A.M.C, Bengaluru - 09

DEPARTMENT OF POST GRADUATE STUDIES

IN SHALYA TANTRA

GOVERNMENT AYURVEDIC MEDICAL COLLEGE

Bengaluru - 560009

2009 - 2010

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A STUDY ON SIRAJA GRANTHI AND ITS MANAGEMENT WITH PUNARNAVADI GUGGULU AND NIMBADI

GUGGULU-A COMPARATIVE STUDY.

By

Dr. NADAF A.N. Dissertation Submitted to the

Rajiv Gandhi University of Health Sciences, Bengaluru,

Karnataka

In partial fulfillment of the requirements for the degree of

AYURVEDA DHANWANTARI (MASTER OF SURGERY)

In

SHALYA TANTRA

Under the guidance of

Dr. B.A.VENKATESH BSAM, BAMS, MD (Ayu), FICA

Professor & H.O.D. Dept. Of P.G. Studies in Shalya Tantra

G.A.M.C, Bengaluru - 09

DEPARTMENT OF POST GRADUATE STUDIES

IN SHALYA TANTRA

GOVERNMENT AYURVEDIC MEDICAL COLLEGE

Bengaluru - 560009

2009 - 10

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

KARNATAKA, BENGALURU

DECLARATION BY THE CANDIDATE

I hereby declare that this dissertation entitled “A study on Siraja granthi and

its management with Punarnavadi guggulu and Nimbadi guggulu – Comparative

study, is a bonafide and genuine research work carried out by me under the guidance

of Dr.B.A.Venkatesh Professor and HOD of Dept of PG studies in Shalya Tantra,

GAMC Bangalore.

Date: Signature of the candidate Place:

Dr.NADAF. A.N

Department of Post Graduate Studies in Shalya Tantra.

Government Ayurvedic Medical College

Bengaluru : 560009

CERTIFICATE BY THE GUIDE

This is to certify that the dissertation entitled “A study on Siraja granthi and


study” is a bonafide and genuine research work carried out by Dr.NADAF.A.N in

partial fulfillment of the requirement for the degree of “AYURVEDA

DHANWANTARI” [Shalya Tantra] – Master of Surgery [Ayu].

I recommend this dissertation for the above degree to the University for assessment

and approval.

Date: Dr.B.A.Venkatesh BSAM,BAMS,M.D (Ayu),FICA

Place: Professor and HOD Dept of PG Studies ShalyaTantra GAMC Bengaluru: 09



Bengaluru: 560009

ENDORSEMENT BY HOD



study” is bonafide research work done by Dr.NADAF.A.N under the guidance of

Dr.B.A.VENKATESH. Professor and HOD, Dept of PG studies in Shalya Tantra.

I recommend this dissertation for the above degree to the University for Assessment

and approval.

Head of the Department Dr.B.A.Venkatesh Professor and HOD Dept of PG Studies in ShalyaTantra GAMC Bengaluru: 09



Bengaluru: 560009

ENDORSEMENT BY PRINCIPAL



study” is a bonafide research work done by Dr. NADAF.A.N under the guidance of

Dr.B.A.VENKATESH. Professor and HOD, Dept of PG studies in Shalya Tantra.

I recommend this dissertation for the above degree to the University for Assessment

and approval.

Principal Govt.Ayurvedic Medical College

Bengaluru

COPYRIGHT

DECLARATION BY THE CANDIDATE

I hereby declare that the Rajiv Gandhi University of Health Sciences,

Bengaluru, Karnataka, shall have the rights to preserve, use and

disseminate this dissertation in print or electronic format for

Academic / research purposes.

Signature of the candidate Dr. NADAF.A.N

@ Rajiv Gandhi University of Health Sciences, Bengaluru

No work is a result of individual effort. It is contributory effort of many

hearts, hands and heads. It gives me immense pleasure to offer my sincere thanks to

all those who have rendered their wholehearted support, guidance and Co-operation in

completing my thesis work.

I place on record my utmost gratitude to my adorable guide and HOD

Dr.B.A.Venkatesh, Professor and Head, Department of P.G.Studies in Shalyatantra

G.A.M.C. Bengaluru, for his incessant, untiring, round the clock guidance with all the

diligence, his sustained fostering and encouragement instilled considerable impetus in

me enabling to achieve this milestone which otherwise would have lacked this

particular finish.

I extend earnest thanks to Dr. H.T.Sreenivas, Principal, G.A.M.C, Bengaluru,

for unstinted help extended whenever solicited.

I express my sincere thanks to, Dr. Vijaya Sarathi .R, Professor,

Dr.R.KHibare, Professor, Dr.Ahalya, Professor and Dr. Narmada., Asst. Professor,

Dr.Sridhar Rao.A, Asst. Professor Dr. Shivu Arekeri, Dr. Srinivas, Dr.Durgesh,

lecturers, Dept. of P.G Studies in Shalya Tantra, G.A.M.C, Bengaluru, for their kind

suggestion and guidance throughout the course of my study.

I am at no words to explain the amount of gratitude and thanks to

Dr.Ravikumar, Gen.Surgeon, KCG Hospital for his dedicated professionalism,

indefatigable efforts and cheerful co-operation.

I sincerely thank my Senior colleagues for their tremendous suggestions and

support through out my work.

I acknowledge my gratitude to all my colleagues, Dr. Vishwanath sharma,

Dr. Ramya bhat, Dr. Veena koppal, Dr. Sweta, Dr. Abhinetri hegde and

Dr.Rajeshwari, who gave me unstinted support and stood solidly beside me

throughout my study.

I also profusely thank my junior colleagues, Jayanth, Laxman, Prashanth,

Manjunath Joshi, Vivek, Naveen, Jayashree and Divya lakshmi for their

continuous support and kind help.

ACKNOWLEDGEMENT

I would like to thank my friend Dr.Naveen, for his support.

I express my sincere gratitude to all the teaching fraternity, Physicians, library

staff, hospital and office staff of G.A.M.C, Bengaluru, for sincere advices and

assistance.

I am very much thankful to my department colleagues and friends for their

needful support to fulfill this task.

It fills joy in my heart to express my sincere gratitude to all my Teachers of

DGM Ayurvedic Medical College, Gadag, who designed my career in Ayurveda. I am

grateful to all the teachers who came in my life and taught me ‘the science of life’.

I sincerely thank Dr.Arun biradar for his utmost support and help during my

study period.

I thank Dr K.P.Suresh, Statistician, without whose help whole of my work

would have looked meaningless

I take this opportunity to appreciate the generous co-operation offered by my

patients by being supportive and compliant during the study period.

I express my thanks to all the persons who have helped me directly &

indirectly with apologies for my ability to identify them individually.

Dr. NADAF.A.N

ABSTRACT

Background: Siraja granthi (varicose veins) is one of the commonest

disorders in surgical practice. Ayurveda has given a great contribution in the

management of this disorder, while describing the management of Vata Vyadhi and

siraja granthi.

In Ayurveda there are various terminology for varicose veins such as Siraja

granthi, Siraakunchan, Sirakutilata and Siragata vata. Research works have been done

with both internal and external medicines along with conservative treatment such as

external application of Sahacharadi Taila, internal Basti and Para surgical procedure

such as Jaloukavacharana and Siravyadha.

A preliminary pilot study was conducted on a selective patient of varicose vein

for a period of 2 months where in selected subject were divided into 2 groups of 5

patients in each group. Group A was administrated with Punarnavadi guggulu vati in

dose of two vati twice daily for a period of 2 months. In-group B, Nimbadi guggulu

two vati twice daily was administered for a period of 2 months.

Objectives of the study:

• To evaluate the efficacy of the Punarnavadi guggulu in Siraja granthi.

• To evaluate the efficacy of the Nimbadi guggulu in Siraja granthi.

• To evaluate the comparative efficacies of Punarnavadi guggulu vati and

Nimbadi guggulu vati in Siraja granthi.

• To assess the management of varicose vein with that of conservative line

of treatment like control study with elastic stockings.

Study design:

This study was undertaken by selecting 20 patients in each group.

Group A- Internal administration of Punarnavadi guggulu in a dose of 2 vati, twice a

day.

Group B- Internal administration of Nimbadi guggulu in a dose of 2 vati, twice a day.

Group C-The management of varicose vein with conservative line of treatment i.e,

control study with Elastic stockings.

Ankle oedema, Skin changes and Tortuous dilated veins were taken as

objective parameters whereas itching was taken as subjective parameter.

In-Group A out of 20 patients, Mild improvement was observed in the 14

patients, Moderate Improvement was present in 3 patients.

In group B out of 20 patients, Mild Improvement was observed in 8 patients,

Moderate improvement was observed in 5 patients and Marker Improvement was

found in 2 patients.

In Group C out of 20 patients, Mild Improvement was observed in 9 patient

and Moderate Improvement was observed in 4 patients.

Key Words: Siraja granthi, Varicose vein, Elastic stockings, Punarnavadi guggulu

vati, Nimbadi guggulu vati.

List of Abbreviations

• Su.Su. – Sushruta Samhita Sutrasthana

• Su.Sha. - Sushruta Samhita Sharirasthana

• Su.U. - Sushruta Samhita Uttarasthana

• Su.Chi. - Sushruta Samhita Chikitsasthana

• Ch.Su. – Charaka Samhita Sutrasthana

• Ch.Vi. – Charaka Samhita Vimanasthana

• Ch.Chi. – Charaka Samhita Chikitsasthana

• A.Hr.Su. – Astanga Hrudyam Sutrasthana

• A.S.Su. – Astanga Sangraha Sutrasthana

• L.S.V. – Long Saphenous Vein

• S.S.V. – Short Shaphenous Vein

• B.P . – Bhavaprakasha

• A.T. – After Treatment

• B.T. – Before Treatment

• M.Ni – Madhava nidana

• B.R – Bhaishajya Ratnavali

• B B R – Bharatha Bhaishajya Ratnavali

CONTENTS

1. Introduction 1-2

2. Objectives 3

3. Review of Literature 4-55

• Disease review 4-47

• Drug review 48-55

4. Materials and Methods 56-60

5. Observation and Results 61-86

6. Discussion 87-93

7. Conclusion 94-95

8. Summary 96-98

9. References 99-101

10. Bibliography 102-104

List of Tables

Sl.No

Titles

Page.No

1. Study design 57

2. Grading of Itching 58

3. Grading of Ankle oedema 58

4. Grading of Skin changes 58

5. Grading of Tortuous dilated vein 59

6. Age wise Distribution of 60 patients of Siraja granthi 60

7. Sex wise Distribution of 60 patients of Siraja granthi 62

8. Distribution of Patients According to Occupation 62

9. Habitat-wise Distribution of 60 patients of Siraja granthi 63

10. Distribution of the Patients According to Agni 63

11. Distribution of Patients According to Involvement of Leg 64

12. Distribution of Patients According to Involvement of Vein 64 – 65

13. Distribution of Patients According to Site of Perforators 65

14 Incidence of Lakshanas in Trail groups 66

15. Effect of Punarnavadi guggulu vati on Itching 67

16. Effect of Nimbadi guggulu vati on Itching 68

17. Effect of the Elastic stocking on Itching 68

18. Effect of the Punarnavadi guggulu vati on the Ankle oedema. 69

19. Effect of the Nimbadi guggulu vati on the Ankle oedema 70

20. Effect of the Elastic stocking on the Ankle oedema 70

21. Effect of the Punarnavadi guggulu vati on the Skin changes 71

22. Effect of the Nimbadi guggulu vati on the Skin changes 72

23. Effect of the Elastic stocking on the Skin changes 73

24. Effect of Punarnavadi guggulu vati on Tortuous dilated vein 73

25. Effect of Nimbadi guggulu vati on the Tortuous dilated vein 74

26. Effect of Elastic stocking on the Tortuous dilated vein 74

27. Therapeutic effect of all the groups on Itching 75

28. Therapeutic effect of all the groups on Ankle oedema 75

29. Therapeutic effect of all the groups on Skin changes 76

30. Therapeutic effect of all the groups on Tortuous dilated vein 76

31 Overall response of the therapies on Siraja granthi 77

32. Co relation between Siraja granthi and varicose vein 88

List of Charts

Sl.No

Titles

Page

No.

1. Classification of the Granthi roga 42

2. Ingredients of Punarnavadi Guggulu. 48

3. General Properties of the Punarnavadi guggulu 48 – 49

4. Karma, Amayika prayoga and Chemical composition of

Punarnavadi guggulu.

49 – 50

5. Ingredients of the Nimbadi guggulu 50

6. General properties of Nimbadi guggulu 50 – 51

7. Karma, Amayika prayoga and Chemical composition of Nimbadi

guggulu.

51 - 52

List of Figure

Sl.No. Title Page No.

1 Leonardo’s drawing of superficial Veins of lower limb 4

2 Leonardo’s detailed drawing of L.S.V. 4

3 Communicating Veins of leg 10

4 Valve of vein 11

5 Incompetent Valve 12

6a Normal vein 16

6b Varicose vein caused by deformed valve 16

7 Communicating vein incompetence 17

8 Thigh and calf perforators 23

9 Crepe bandage 32

10 Ingredients of Punarnavadi guggulu 54

11 Ingredients of Nimbadi guggulu 55

12 Punarnavadi guggulu vati 60

13 Nimbadi guggulu vati 60

14 Elastic stocking 60

15 Photo showing effect of Punarnavadi guggulu 85

16 Photo showing effect of Nimbadi guggulu 85

17 Photo showing effect of Elastic stocking 86

List of Diagrams

Sl.No. Title Page No.

1 Age wise Distribution 78

2 Sex wise Distribution 78

3 Incidence of Occupational Status 79

4 Incidence of Habitat 79

5 Incidence of Agni 80

6 Incidence of Involved Leg 80

7 Incidence of Involved Veins 81

8 Incidence of Involved Perforators 81

9 Incidence of Lakshanas in Trail groups 82

10 Effect on Itching 82

11 Effect on Ankle oedema 83

12 Effect on Skin changes 83

13 Effect of all groups on tortuous dilated vein 84

14 Overall Response of therapies 84

Introduction _______________________________________________________

_____________________________________________________________________

INTRODUCTION

Siraja granthi (varicose veins) is one of the commonest disease in surgical

practice. It occurs in people who are habitual to standing for long periods.

The most important factors leading to the development of the varicose veins

includes heredity, prolonged standing, increasing age, heavy lifting, prior superficial

or deep vein clot, female gender, multiple pregnancies, less physical activities, high

blood pressure and obesity has also been linked with the presence of varicose veins in

females.

Ayurveda has given a great contribution in the management of such disorders,

while describing the management of vata vyadhi and Siraja granthi

In Ayurveda, there are many nomenclatures for varicose veins such as Siraja

granthi, Siraakunchana, Sirakutilata and SiragataVata. Research works have been

done including conservative treatment such as external application of Sahacharadi

Taila, internal Basti and Para surgical procedure such as Jaloukavacharana and

Siravyadha, by using animal Shringa as Sushruta had indicated cow’s horn for Vata

Dushita Rakta1 .

It is commonly assumed that, if varicose veins are left untreated they will

continue to enlarge and ‘varicose processes’ will spread to involve other previously

‘normal’ veins. There is evidence that long saphenous vein regress by sclerotherpy.

Other investigators have observed that simple ligation and division of the sapheno-

femoral junction causes regression of distal varices.

The influence of prolonged external elastic compression on the natural history

of varicosity is still not known to our knowledge, but it is interesting to note that

A study on Siraja Granthi and its management with Punarnavadi guggulu and Nimbadi guggulu- A Comparative study 1

Introduction _______________________________________________________

_____________________________________________________________________

many patients with primary varicose veins who have been given elastic stocking to

wear while they await operation, they are so much better that they no longer required

treatment. This is progressive incurable disease that has satisfactorily symptomatic

relief.

It is frequently argued that varicose veins must be treated to prevent the

development of skin changes but little is known about the magnitude of risk that

patients with uncomplicated varicose veins will develop skin changes that may lead to

ulceration.

Based on the clinical experience of physician, Nimbadi guggulu vati and

Punarnavadi guggulu vati was successfully used in the management of varicose vein.

The Punarnavadi guggulu was also used for treating this condition with good result as

per the internet references 2

A preliminary pilot study was conducted on selective patients of varicose vein

for a period of 2 months where in selected subjects were divided into two groups of 5

patients in each group. In Group first, Punarnavadi guggulu vati was given twice a

day for a period of 2 months .In Group second, Nimbadi guggulu vati was given,

twice a day for a period of 2 months.

At the end of the treatment, satisfactory symptomatic improvement was

observed.

This formed basis for selection of these drugs in the management of varicose

vein (Siraja granthi). Hence, this study was undertaken by selecting 60 patients in

three groups

In Group A-Punarnavadi guggulu vati, in Group B- Nimbadi guggulu vati was

administered. In Group C- Patients were advised to wear the elastic stockings.

Hence, the study is undertaken to evaluate the efficacy of the treatment in all groups.


Objectives of the study _______________________________________________________

OBJECTIVES OF THE STUDY

• To evaluate the efficacy of the Punarnavadi guggulu vati in Siraja granthi

• To evaluate the efficacy of the Nimbadi guggulu vati in Siraja granthi

• To evaluate the comparative efficacies of Punarnavadi guggulu vati and

Nimbadi guggulu vati in Siraja granthi.

• To assess the management of varicose vein with that of conservative line

of treatment like Elastic stockings as the control study.

_______________________________________________________ A study on Siraja Granthi and its management with Punarnavadi guggulu and Nimbadi guggulu- A Comparative study 3

Disease review _______________________________________________________

______________________________________________________

VARICOSE VEINS

Historical review

A.D. 130-200

Galen – the beginning of varicose vein surgery:

Galen of Pergamum describes the treatment of ulcer and varicose vein by

Venesection. He noticed that wall of the vein was always much thinner than the wall

of the arteries and that veins contain dark blood. He described the use of silk ligatures

and advised that varicose vein should treated by incision and tearing out with a blunt

hook.

The Anatomy of Veins as Seen by a great artist –

The masterly anatomical drawing of Leonardo da Vinci shows how clearly he

observed the venous system.

Fig-1 Fig-2

Leonardo’s drawing of superficial Leonardo’s detailed drawing of L.S.V

Veins of lower limb

1585:

A drawing of a Valve, at last is believed to be the first recorded drawing of

valve in vein. Saloman Alberti published it in 15853.

200 B.C.

Sushruta Samhita, the main textbook of Indian surgery describes about Siraja

granthi in nidana sthana and chikitsa sthana.


Disease review _______________________________________________________

______________________________________________________

Embryology and Radiographic Anatomy

Development and Congenital anomalies:

Initially the cardinal veins are the main venous drainage system of the

embryo. They consist of the anterior cardinal vein, which drain the cephalic part of

the embryo, and the posterior cardinal veins, which drain the remaining part of the

body of the embryo. The anterior and posterior cardinal vein join before entering the

sinus horn to form the short common cardinal veins. During the 4th week the cardinal

veins form a symmetrical system.

During the 5th to 7th week of embryonic life a number of additional veins are

formed, Subcardinal veins which mainly drain the kidneys; the Sacrocardinal veins

which drain the lower extremities; and the Supracardinal veins which drain the body

wall by the way of intercostal veins, there by taking over the function of the posterior

cardinal veins. Characteristic formation of the vena cava system is the appearance of

anastomosis between left and right so that blood from left is channeled to the right

side.

The anastomosis between the sacrocardial veins is formed by the left common

illiac vein. The right sacrocardinal vein finally becomes the sacrocardinal segment of

inferior vena cava. When the renal segment of the inferior vena cava connects with

the hepatic segment, which is derived from the right vitelline vein, the inferior

venacava is complete. It consists of a hepatic segment, a renal segment and a

sacrocardinal segment4.


Disease review _______________________________________________________

______________________________________________________

Development of the Limb Veins:

The border vein appears in the arm and leg between the 6th and 8th week the

adult venous anatomy being outlined during the next 2 weeks. In the leg, tibial

continuation of primitive border vein disappears while the fibular segment largely

persists.

The long saphenous vein arises separately from the posterior cardinal vein,

gives off the femoral and posterior tibial veins and then incorporates the tibial border

vein at the level of the knee. Distally the border vein develops into the anterior tibial

and saphenous veins.

Structure of Veins:

The walls of the vein like those of the arteries are composed of three coats, the

tunica intima, the tunica media and the tunica adventitia. The main difference between

the wall of arteries and those of vein is that, in the latter, there is a comparative

weakness of the muscular layer and a much smaller proportion of elastic tissue. In

small veins these coats are difficult to distinguish.

Valves:

Unlike arteries, veins possess valves, through which the blood flow towards

the heart. The valves have two leaflets consisting of folds of intima reinforced with an

intervening layer of connective tissue.

There are no valves in the superior and inferior venae cavae but there are

valves in the tributaries from both upper and lower limbs, the number of valves

increasing towards the periphery of each limb. The valves in the lower limb play an

important role in controlling the direction of blood flow.

There are no valves in the sinusoidal veins of the soleal muscles but the

veins arcades that drain the soleal and gastronemius muscles have numerous valves.


Disease review _______________________________________________________

______________________________________________________

All the deep veins of the calf are densely valved with the valves occurring at

approximately 2 cm. intervals.

The popliteal vein usually has two valves in the region of the knee joint;

damage to these valves may result serious consequences on the calf muscle pump.

There is a valve in the femoral vein just distal to its junction with the deep femoral

vein in 90% of all legs and a valve in the upper third of the popliteal vein just distal to

the adductor canal in 96% of the legs. There are eight to ten valves in the long and

short saphenous vein, which is thought to be important in preventing reflux down the

long saphenous vein.

The valves in the communicating vein between the superficial and deep

venous systems of the leg are arranged so that blood flows from the superficial to the

deep vein.

The common femoral and external iliac vein:

The common femoral vein is formed by the confluence of the superficial

femoral and deep femoral veins and becomes the external iliac vein as it passes

beneath the inguinal ligament.

The Common Iliac Veins:

These are short wide vessels, which ascend from the level of the sacroiliac

joints to unit on the right side of the 5th lumbar vertebrae to form the inferior vena

cava. The right common iliac vein and the inferior vena cava run upwards in an

almost straight line where as the left common iliac vein runs transversely to join the

left common iliac vein at right angle. Excessive compression at this site may

predispose to thrombosis.


Disease review _______________________________________________________

______________________________________________________

The superficial veins of the lower limb:

The superficial venous system of the leg consists of two main veins, the long

and short saphenous veins and their tributaries

The Long Saphenous Vein:

The long saphenous vein is formed by the union of the veins from the medial

side of the sole of the foot with the medial dorsal vein. It runs upward in front of the

medial malleolus along the length of the anterior-medial aspect of the limb, gradually

inclining posteriorly to pass behind the medial condyles of the Tibia and Femur. It is

accompanied by the saphenous branches of the femoral nerve, which may be avulsed

if the vein is stripped below the knee in the thigh. The long saphenous vein runs in a

slight curve towards its junction with the femoral vein, the breadth of two fingers

(3cm) below and lateral to the pubic tubercle at the fossa ovalis just before it inter the

fossa, it is joined by superficial circumflex iliac. The superficial inferior epigastric

and superficial external pudendal vein together with as many as seven other

superficial unnamed veins. The long saphenous vein receives several tributaries in its

Course along the lower leg. The medial superficial vein from the sole joins it near its

anatomical origin and the posterior arch vein joints its posterior aspect in the upper

leg. The posterior arch vein is important because it is connected to the deep venous

system by at least two or three major medial ankle communicating veins. The anterior

superficial tibial vein joins the long saphenous vein at about the same level as the

posterior arch vein. There are many variations of anatomy in the region of the fossa

ovalis where the long saphenous joins the common femoral vein.


Disease review _______________________________________________________

______________________________________________________

The Short Saphenous Vein:

The short saphenous vein begins at the outer border of the foot behind the

lateral malleolus as a continuation of the dorsal venous arch. It is joined above the

malleolus by a communicating vein, which may be important when ulcers are present

in this area. It enters the popliteal vein between the heads of the gastronemius muscle.

There are a number of variable connections between long and short saphenous vein in

the region of the knee and these may cause confusion when trying to decide whether

varices are connected to dorsal tributaries of the long saphenous vein or to the

tributaries of the short saphenous vein.

The short saphenous vein usually joins the posterior aspect of the popliteal

vein lateral to the tibial nerve producing a characteristic ‘S’ shaped loop on a

saphenogram. Approximately 60% of all short saphenous veins join the popilteal vein

in the popliteal fossa within 8cm. of the knee joint; 20% join the long saphenous vein

via postero- medial or antero- lateral superficial thigh veins at varying levels in the

thigh and the remainder join the superficial femoral vein, the deep femoral vein, or

even tributaries of the internal iliac veins.

The Communicating Veins:

The deep and superficial venous system of the lower extremities are separated

by fascia and joined by communicating veins with valves, which direct the blood from

superficial to deep venous system. These communicating veins are sometimes called

perforating veins because they pierce the deep fascia. The communicating veins have

been further divided into direct or indirect, when the connection is through one or

more sinusoids in the muscles. Direct communicating veins are generally more

constant in position, larger and haemodyamically more important than the indirect


Disease review _______________________________________________________

______________________________________________________

veins. The largest communicating veins are the termination of the long and short

saphenous veins where they join the deep venous system.

In the lower leg, there are medial and lateral communicating veins. On the

medial side there is one communicating vein just below the medial malleolus and

three or four above the malleolus behind the tibia. The medial lower leg

communicating veins, often called Cockett’s veins, connect the posterior arch vein

with the posterior tibial veins but do not drain directly into the long saphenous vein.

The lowest medial communicating vein is usually found at approximately 7cm, the

middle vein at 12cm, and the upper vein 18cm above the tip of the medial malleolus.

Another communicating vein, which may become incompetent, is situated on the

medial aspect of the calf 10cm below the knee joint. It joins the main trunk of the long

saphenous vein to the posterior tibial veins and is sometimes called Boyd’s vein.

Two more constant communicating veins also joining the short saphenous vein

with the peroneal veins are situated posteriorly approximately 5cm and 12cm above

the os calcis These are the two posterior and mid calf communicating veins which

sometime causes recurrent varicose veins.(Fig- 3)

(a) (b)

Fig.no 3: Communicating Veins of leg (a) medal view, (b) posterior lateral view


Disease review _______________________________________________________

______________________________________________________

In the thigh, there are several connections between the long saphenous vein

and femoral vein. The most important group, sometimes-called Dodd’s veins consist

of one or more veins, which pass through the subsartorial (Hunter’s) canal to join the

long saphenous vein with the superficial femoral vein. These veins are usually, but

not invariably, destroyed when the long saphenous vein is stripped out and so are an

important cause of recurrent varicose veins. After saphenous ligation, without

stripping an incompetent mid thigh communicating vein may be responsible for an

early recurrence of varicose veins on the medial aspect of the leg in the region of the

knee.

Physiology and Functional Anatomy

The Valves:

The direction of venous blood flow is controlled by the valves. Vein valves are

bicuspid. The cusps of the valves of the superficial vein lie with their free edges

parallel to the skin surface. (Fig- 4)

Fig- 4: Valve of vein

Nomenclature of the Valve

The inferior vena cava and common iliac veins have no valves and 75% of

external iliac veins have no valves, but only 25% of common femoral veins are

valveless. It has been suggested that the lack of the valves in the iliac and common.

Femoral vein is the starting point for the development of a progressive

descending valvular incompetence that causes varicose veins (Fig- 5). Below the

inguinal ligament, the number of valves in each segment steadily increases so that the


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calf veins have valves, which are 5cm apart. Valves are present in veins of 1mm

diameter, but not in smaller veins or the venule5.

Fig- 5: Incompetent vein

The Functional Anatomy of the Calf Pump

The Deep Compartment (The Pump Chamber):

The deep compartment below the knee forms the chamber of the calf pump.

The soleal sinuses and gastronemius veins actually lie within the muscle. The

posterior, anterior tibial, and peroneal veins lie between the muscles. The

intermuscular veins are not compressed by muscular contraction as forcefully as the

intramuscular veins, and they also act as the outflow tract for the foot. All the deep

veins of the calf join to form the popliteal vein, which is the calf pump outflow tract.

As this vein continues up the limb, it passes through the ‘thigh’ pump but in a

position, the subsartorial canal, that protects it from much of the compressive forces

generated by thigh muscle contraction. The outflows tract continues through the

abdomen and the thorax where it is subject to the intermittent positive and negative

pressures associated with respiration.

The Superficial Compartment:

The superficial compartment comprises a network of venules and veins in the

skin and subcutaneous tissues that empty into both the deep (pump) chamber and the


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pump outflow tract. The two main superficial veins, the long and short saphenous

veins, drain directly into the outflow tract, but there are many other connections

between the superficial veins and the veins of the deep compartment.

The superficial tributaries of the saphenous systems collect blood from the

skin and subpapillary dermal plexus and then progressively unite to form the two

main veins. The saphenous veins themselves lie in a deeper layer of the subcutaneous

tissues underneath a thin but quite strong layer of connective tissue. The vein in the

dermal plexus and the subcutaneous fat are well situated for their role in

thermoregulation but are poorly supported against distending forces. The valves

ensure that blood flow into the pump and towards the heart. Blood leaves the

superficial compartment by flowing up the saphenous veins into the femoral or

popliteal veins or directly into the pump through the many communicating veins.

Communication between the Superficial and Deep Compartments:

The superficial compartment has two large constant connections with the

outflow tract, the sapheno-femoral and the sapheno-popliteal junctions. They are

protected by valves that normally prevent reflux from the deep to the superficial

compartments. The common femoral and popliteal veins are not inside the muscle

pumps. They lie relatively unsupported in the loose fatty connective tissue, which

surrounds the femoral and popliteal neurovascular bundles.

The named communicating veins on the medial aspect of the lower leg

connect the superficial veins with the posterior tibial veins. These veins do not

connect the long saphenous vein directly to the deep compartment but drain the whole

superficial system, including the long saphenous vein, into the pump indirectly

through their connection with the posterior arch vein.


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The Physiology of the Calf Pump:

The calf pump has been called the peripheral heart. We have found it helpful

to develop this comparison because the left side of the heart is also a two-chamber

system. The calf pump is equivalent to the left ventricle. The venous outflow tract is

the equivalent of the aorta and its valve. The superficial compartment is equivalent to

left atrium, and the communicating veins are comparable to mitral valve.

The Pump:

Systole:

When calf muscles and the muscles in deep posterior compartment of the

lower leg contract, they raise the pressure in and around all structures contained

within the deep fascia. The muscles generate pressures of 200- 300 mmHg. These

pressures squeeze the blood out of the veins, the valves ensuring that the blood flows

only towards the heart. Flow from the deep to the superficial compartment is

prevented by the valves in the communicating veins.

The large veins within the gastronemius and soleus muscles form the main

chamber of the pump but all the other deep veins participate. The average volume of

the calf is 1500 – 2000 ml, and its contained calf blood volume is 60-70 ml. Normal

walking at 80 steps/min contract each calf 40 times/min so the pump can easily deal

with the high blood flow of exercise hyperemia.

Diastole:

The pump chamber is refilled by the arterial inflow and the flow from the

superficial compartment during diastole. Just as blood flows from the left atrium to

left ventricle during ventricular diastole, so blood flows from the superficial to the

deep compartment when the calf muscles relax.


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Thus, calf pump activity performs two vital functions:

1. It ensures venous return from the lower limbs during exercise.

2. It reduces superficial vein pressure thus removing the damaging effect of the

hydrostatic pressure that is inseparable from men’s upright posture.

The causes of Calf Pump Failure:

The Pump:

Four abnormalities may reduce the efficiency of the pump itself.

Muscle weakness:

Weakness of the calf pump is the equivalent of heart failure. The calf muscle

rapidly waste and weaken with disuse. The absence of calf contractions exacerbates

the venous hypertension and its complications and causes calf muscle disuse atrophy.

A vicious circle develops as valve damage causes skin complications, which cause

pain and walking difficulties, which diminish pump function, which causes further

deterioration of the skin.

Pump Chamber contraction (Reduced End-Diastolic Volume):

Extensive deep vein thrombosis may leave many of the deep veins of the calf,

within and between the muscles, permanently occluded or thick, stiff and narrow with

incompetent valves. They cannot hold all the blood delivered to them during pump

diastole, so that pump vein pressure between calf contractions rises rapidly. The

undamaged patent veins dilate and their valves become incompetent. These secondary

changes, added to the damage caused by the deep vein thrombosis, cause the pump to

fail.


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Pump Chamber Dilatation (Increased End-Diastolic Volume):

Obstruction to the outflow of blood from the pump caused by occlusion of

veins within the pump or in the main outflow tract causes the veins within the pump

to dilate and their valves to become secondarily incompetent. Valvular incompetence

of the intramuscular veins alone may not be particularly important but, if the

communicating veins become incompetent, calf pump efficiency is seriously reduced.

Pump Vein Valve Incompetence:

All veins lying along the axis of the limb need valves to prevent retrograde

flow. Not all the veins within the calf muscles have valves (e.g. the soleal sinuses),

but these particular vessels are U -shaped with both ends emptying towards the heart.

An absence of valves in the deep veins puts additional strain on the valves in the

communicating veins.(fig- 6 )

a b

Fig- 6: (a) -Normal vein. (b) - Varicose vein caused by deformed valve


http://en.wikipedia.org/wiki/File:Varicose_veins.jpg

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Communicating Veins Incompetence:

Their valves form an essential protection between the high pressure that

develop within the pump and the low pressures produced by the pump in the

subcutaneous compartment. If their valves fail, the pump pushes blood into the

superficial veins as well as into the outflow tract during systole. The situation is

analogous to mitral valve incompetence. (Fig- 7)

Varicose vein

Communicating vein

Deep vein

Fig –7: Communicating vein incompetence

The two causes of communicating vein valve incompetence are:-

• Valve cusp destruction by thrombosis and/or valve ring dilatation secondary to

a downstream post-thrombotic venous obstruction.

• The result of the progressive vein dilatation of the primary varicose vein

diathesis.


http://images.google.co.in/imgres?imgurl=http://www.veinsveinsveins.com/app/webroot/img/Image/spider_veins.jpg&imgrefurl=http://www.veinsveinsveins.com/spider_veins.html&usg=__PMAxDsSfBxIccdyZ0ODXy669FBI=&h=278&w=265&sz=39&hl=en&start=62&tbnid=

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Superficial Veins Incompetence:

Superficial vein incompetence is mainly a cosmetic problem. Its only effect on

calf pump function is to increase the volume of blood that has to be pumped out of the

lower leg. Incompetence superficial veins (varicose veins) blood refluxing through

them may be considerable. Eventually, usually after very many years, this added load

can impair calf pump function and cause skin damage6.

Clinical Examination:

History:

Venous disease affects all age groups, though varicose veins in children are

likely to be associated with a congenital rather than an acquired abnormality and deep

vein thrombosis is rare in children. Pain, swelling and unsightliness are the dominant

symptoms. Superficial venous insufficiency causes a dull aching pain, which is

relieved by rest; deep vein thrombosis causes a persistent, more severe pain. Venous

outflow obstruction, whether acute (following a deep vein thrombosis) or chronic,

causes a bursting pain during muscle exercise. A patient with an acute thrombosis is

unlikely to try to walk because the muscles are also painful at rest. Night cramps are

less common.

Swelling of the leg may be localized, or general. General swelling may very

from a little oedema around the ankle to gross swelling of whole limb. There is no

difference between the swelling of deep vein thrombosis and that of chronic venous

insufficiency; it is a low protein oedema caused by the venous obstruction.


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Examination:

Always examine the legs twice, first when the patient is standing and then

when the patient is lying down, except when muscle pain and discomfort are severe.

Inspection:

Three abnormalities may be visible on inspection: dilated superficial veins,

changes in the skin and swelling. Dilated veins may be large incompetence tortuous

subcutaneous veins (i.e. varicose veins) or fine intradermal venules (‘venous stars’).

The position of dilated veins may indicate their anatomical origin and connections.

Veins on the medial side of the thigh are most likely to be connected to the long

saphenous system but below the knee, the position of a varicose vein does not allow

its attribution to any particular system. A varicose vein on the medial side of the calf

may be connected to the long saphenous system but it could be connected to the short

saphenous system or it could be independent of both.

Skin changes range from mild eczema and pigmentation through thickening

and hardening of the skin and fat (lipodermatosclerosis) to weeping eczema and frank

ulceration. Although the majority of these skin changes are found on the lower medial

third of the lower leg, they can occur anywhere. Conversely, other forms of ulceration

more common on other parts of the leg can occur in the ‘gaiter’ area and so it should

never be assumed that skin changes are venous in origin just because of their site. The

presence of skin changes indicates a severe disturbance of calf pump function,

whereas quite large varicose veins may exist with little or no functional abnormality.

The extent of diffuse swelling caused by venous disease usually correlates

with the site and severity of the venous outflow obstruction. Localized swelling is

usually caused by local inflammatory changes (e.g. superficial thrombophlebitis).


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Palpation:

The size and tension of the veins can easily be assessed with the finger tips.

The presence of an expansile cough impulse indicates the absence of functioning

valves between the palpating finger and the thorax. Always examine for this impulse

at the sapheno – femoral junction, whether there be a palpable vein or not, and over

any other visible veins. Veins that cannot be seen, can often be felt, especially in the

thigh. A calf that is the site of a deep vein thrombosis will be warmer than the normal

calf. Recently thrombosed veins are firm, incompressible and tender. The tenderness

fades with the inflammation but the vein gets harder and the overlying skin often

becomes pigmented. The surface of an ulcer is painful if it is infected or necrotic.

Clean, healing chronic venous ulcers are usually neither painful nor very tender. The

oedema of venous obstruction is soft and ‘pits’ easily with firm pressure. The

thickening of lipodermatosclerosis some time looks like oedema but is hard and

incompressible and can even become calcified.

Percussion:

A dilated blood - filled vein will conduct a percussion impulse in the direction

of normal blood flow and retrogradely if the valves are incompetent. Thus tapping on

a vein and feeling downstream should be used as a method for detecting the course

and connections of a dilated vein, whereas tapping and feeling upstream should be

used as a way of testing for incompetent valves in the segment of vein between the

two hands.

Auscultation:

Do not forget to place a stethoscope over large bunches of varicosities,

especially if they are in an abnormal position. On rare occasions there will be a

machinery murmur indicating the presence of an arteriovenous fistula.


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Elevation:

If the veins in a limb are distended when the patient is lying down, slowly

raise the limb until the veins collapse. The height to which the limb has to be raised

corresponds to the pressure in the veins and indicates the severity of the venous

obstruction.

Clinical classification:

C – for Clinical signs.

E – for Etiologic classification.

A – for Anatomical distribution.

P – for Pathophysiological dysfunction.

C: Clinical signs:

Class 0 – No visible or palpable signs of venous disease.

Class 1 – Telangiectases or reticular veins.

Class 2 – Varicose veins.

Class 3 – Edema.

Class 4 – Skin changes ascribed to venous disease (e.g. pigmentation, venous eczema,

and lipodermatosclerosis).

Class 5 – Skin changes as defined above with healed ulceration.

Class 6 – Skin changes as defined above with active ulceration.

E: Aetiology:

Congenital (Ec).

Primary (Ep) – with undetermined cause.

Secondary (Es) – with known cause of

Post thrombotic and Post traumatic

Other.


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P: Pathophysiology:

Reflux (PR).

Obstruction (Po).

Reflux and obstruction (PRo).

A: Anatomy:

Superficial veins (As).

1- Telangiectases/reticular veins.

2- Greater (long) saphenous (GSV) – above knee.

3- Greater (long) saphenous (GSV) – below knee.

4- Lesser (short) saphenous (LSV).

5- Nonsaphenous.

Deep veins (AD)

6- Inferior vena cava.

7- Common iliac.

8- Internal iliac.

9- External iliac.

10- Pelvic- gonadal, broad ligament, other.

11- Common femoral.

12- Deep femoral.

13- Superficial femoral.

14- Popliteal.

15- Crural – anterior tibial, posterior tibial, peroneal (all paired).

16- Muscular- gastronemial, soleal, other.


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17- Perforating veins (Ap) (Fig- 8 )

18- Thigh.

19- Calf

Fig-8: Thigh and calf Perforators

A few tests are performed to know the details of the varicose vein including

the sites of incompetent perforators7.

Brodie – Trendelenburg Test:

This test is performed to determine incompetence of the sapheno-femoral

valve and the other communicating system. This test can be performed in two ways.

In both the methods, the patient is first placed in recumbent position and his legs are

raised to empty the veins. The sapheno-femoral junction is now compressed with the

thumb of the clinician and the patient is asked to stand up quickly.


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(1) In the first method, the pressure is released, if the varices fill very quickly

by a column of blood from above, it indicates incompetency of the sapheno-femoral

valve. This is called a positive Tredelenburg test.

(2) To test the communicating venous system, the pressure is not released but

maintained for about 1 minute. Gradual filling of the veins during the period

indicates incompetency of the communicating veins, mostly situated on the medial

side of the lower half of leg allowing the blood to flow from deep to the superficial

veins. This is also considered as a positive Trendelenburg test.

Tourniquet Test:

It can be called a variant of Trendelenburg test. In this test, the tourniquet is

tied around the thigh or leg at different levels after the superficial veins have been

made empty by raising the leg in recumbent position. The patient is now asked to

stand up. If the veins above the tourniquet fill up and those below it remain collapsed,

it indicates presence of incompetent communicating vein above the tourniquet.

Similarly, if the veins below the tourniquet fill rapidly whereas veins above the

tourniquet remain empty, the incompetent communicating veins must be below the

tourniquet. Thus by moving the tourniquet down the leg in steps one can determine

the position of the incompetent communicating vein.

Pratt’s Test:

This test is performed to know the position of the leg perforators. Firstly, in

Esmarch elastic bandage is applied from toes to the groin. A tourniquet is then applied

at the groin at the upper end of the elastic bandage. This causes emptying of the

varicose veins. The tourniquet is kept in position and the elastic bandage is taken off.

The same elastic bandage is now applied from the groin downwards. At the position


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of the perforator, a ‘blow out’ or a visible varix can be seen. This is marked with a

skin pencil.

Perthes’ Test (Modified):

This test is primarily intended to know whether the deep veins are normal or

not. A tourniquet is tied round the upper part of the thigh tight enough to prevent any

reflux down the vein. The patient is asked to walk quickly with the tourniquet in

place. If the communicating and the deep veins are normal the varicose veins will

shrink whereas if they are blocked the varicose veins will be more distended.

Schwartz Test:

In a long standing case if a tap is made on the long saphenous varicose vein in

the lower part of the leg an impulse can be felt at the saphenous opening with the

other hand.

Morrissey’s Cough Impulse Test:

In this test limb is elevated to empty the veins. The patient is asked to cough

forcibly. An expansile impulse, if felt in the long saphenous varicose vein, it may be

presumed that the sapheno-femoral valve is incompetent. Similarly, if the patient

coughs and the sapheno-femoral junction are incompetent a bruit may be heard on

auscultation.

Fegan’s Method to Indicate the Sites of Perforators:

In the standing position, the places of excessive bulges within the varicosities

are marked with a pencil. The patient now lies down. The affected limb is elevated

and the heel is kept supported. The palpates along the line of the marked varicosities

carefully, so that he can find gap or small pit in the deep fascia which transmits the

incompetent perforator. This is marked with ‘X’ this is the site of the perforator. It

should tally with the skin pencil mark of the venous bulge marked before8.


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Varicose Vein:

Definition:

The world health organization (WHO) defines varicose veins as:

Saccular dilatation of the veins which are often tortuous.’

This definition specifically excludes:

• Dilatation of small intradermal subcutaneous veins called ‘venectasis’

• Any tortuous dilated veins that are secondary to previous thrombophlebitis or an

arteriovenous fistula.

The Basle study separated varicose veins into:

1. Dilated saphenous veins (trunk veins)

2. Dilated superficial tributaries (reticular veins)

3. Dilated venules (hyphenwebs).

Epidemiology:

The incidence of this condition is estimated in number of patients in whom the

condition has developed in a specified time period.

The USA National Surveys:

A subsequent survey between 1959 and 1961, of severe chronic disabling

conditions, produced an estimated rate (prevalence) of 2.25 patients with varicose

veins per 100 of the population per year, comprised of 0.8% in men and 3.5% in

women.

The UK Survey:

Showed that 1.41% of men and 3.74% of women had varicose veins.


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The Sickness Survey of Denmark:

This survey of patients attending hospital with varicose veins found an

incidence of 1.7% of males and 2.0% females attending in 1 year.

Aetiology:

Valvular Deficiency:

Anatomical studies on the distribution of venous valves in cadavers have

shown that between 20 and 40% of apparently ‘normal’ individuals have an absent

valve in and above the common femoral vein on one or both sides. These studies

suggested that an absence of ilio-femoral valves exposes the highest valve in the long

saphenous vein to thoraco-abdominal pressures and that on standing upright the

hydrostatic pressure produced by the vertical column of venous blood between the

groin and the heart would be resisted only by a single important saphenous valve.

There are few patients who have a congenital absence of all venous valves

(congenital valve aplasia) who often do develop severe secondary varicose veins.

The complications of Varicose Veins:

The pathology of the complication such as superficial thrombophlebitis, eczema,

pigmentation, lipodermatosclerosis, haemorrhage, ulceration and an increased risk of

deep vein thrombosis9.

Diagnosis of Varicose veins:

Symptoms caused by varicose veins:

• Unsightliness

• Aches and pain

• Cramps

• Mild ankle oedema

• Itching


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• Superficial thrombophlebitis

• Hemorrhage

• Eczema

• Pigmentation

• Lipodermatosclerosis

• Ulceration

Unsightliness:

Many patients with varicose veins complain of the unsightliness produced by

tortuous dilated veins in their lower limbs.Patients concerned with the unsightly

appearance of their varicose veins often complain of discomfort but the severity of

this discomfort is difficult to assess and does not seem to be related to the size of the

varices.

Aches and Pain:

Many patients do however, experience considerable discomfort, which is

sometimes localized to the main varices, but is often a diffuse dull ache felt

throughout the legs, which gets worse as the day passes and is exacerbated by

prolonged standing. Worsening of the pain before a period is characteristic and pain

is sometimes accompanied by a severe ‘itch’ over the veins. Pain that is present at

rest or in bed is unlikely to be caused by varicose veins and another source must be

sought. The typical description of ‘venous’ pain is an ‘ache’ or ‘discomfort’. The

presence of a sharp or acute pain should suggest an alternative diagnosis.

Relief of the discomfort by wearing an elastic stocking provides good

circumstantial evidence that the pain is of venous origin. Elevation of the legs, bed

rest and walking all relieve venous pain, while standing still for prolonged periods

invariably makes it worse.


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A history of a bursting pain during exercise (venous claudication) may

indicate venous outflow obstruction but is a rare symptom in patients with

uncomplicated varicose veins.

Night cramps are a common complaint and appear to be particularly frequent in

patients with varicose veins, especially after a long day of standing without exercise.

Ankle Edema:

Edema is not a common or prominent feature of varicose veins. It is usually

mild and only becomes noticeable at the end of the day. Incompetence of the lower

leg communicating veins in isolation or in association with post-thrombotic damage

of the deep veins can cause moderate oedema of the ankle and lower leg.

Superficial Thrombophlebitis:

This is common complication of varicose veins but must be differentiated

from superficial thromboplebitis caused by other conditions. Thrombophlebitis

usually presents as a tender, hot, red thickening on the course of a varicose vein.

Hemorrhage:

A varicose vein may bleed after injury and can occasionally bleed

spontaneously. Large veins are easily knocked or cut end, if this occurs, they can

bleed profusely for a short time.

Eczema, Pigmentation, Lipodermatosclerosis and Ulceration –

It is important to ask patients if they have ever had a deep vein thrombosis or

leg ulcer and to question them about the duration of skin discoloration or induration

around the ankle.


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Physical signs of varicose veins:

Inspection:

The legs should be examined with the patient standing on a low stool or

platform, suitably undressed to expose the whole of both lower limbs from the groins

to the toes

The presence or absence of the following abnormalities should be recorded.

1. Both limbs must be inspected from all aspects (front, back and side) to ensure

varicosities in the short saphenous territory or abnormal axial veins are not

missed.

2. The presence of a saphena varix.

3. The presence of a capillary naevus.

4. The presence of a dilated intradermal venuls (‘spider veins, or ‘venous stars’)

5. The presence of any angiomatous malformations.

6. The presence of ankle oedema or limb swelling.

7. The presence of an ‘ankle flare’ (corona phlebectatica)

8. The presence of large varicosities, blow-out, over known sites of communicating

veins.

9. The presence of acute and chronic lipodermatosclerosis.

10. The presence of eczema.

11. The presence of ulceration.

12. The presence of atrophic blanche or livedo reticularis.

13. An increase in the length or circumference of the limb.

14. Shortening of the limb or muscle wasting.

15. Evidence of swollen or deformed knee or hip joints

16. Evidence of distended veins in the groin, pubic region or abdominal wall.


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Palpation and Percussion:

Some varicose veins are more easily felt than seen. For example, the upper end

of a dilated long saphenous vein can often be felt along its course in the thigh between

the groin and a lower dilated visible varicose tributary, even when it cannot be seen.

After palpating the terminal segments of the long and short saphenous veins, the hand

should be gently passed over the inner side of the thigh and leg and up the posterior

surface of the calf to detect other sites of venous dilatation that might not have been

detected by inspection. Any difference in the temperature of the two limbs should also

be recorded, and any firm subcutaneous cords, which are usually felt if there have

been past episodes of superficial thrombophlebitis, should be noted.

Auscultation:

A bruit coming from a superficial vein usually indicates the presence of an

arteriovenous fistula10.

TREATMENT

1 Conservative treatment11

• Elastic crepe bandage application from below upwards or use of pressure

stockings to the limb pressure gradiant 30 to 40 mm of hg is provided

• Diosmin therapy increases the venous tone Elevation of the limb to relive

edema

• Unna boots provides nonelastic compressive mechanism. It comprises a gauge

compression dressings that contain zinc oxide , calamine and glycerine.

Pneumatic compression method provide dynamic sequential compression


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Fig-9: Crepe Bandages

STOCKINGS12

Compression stockings: are used to support the venous and lymphatic systems of the

leg. They offer graduated compression where maximum compression is achieved at

the ankle and decreases as you move up the leg. This compression, when combined

with the muscle pump effect of the calf, aids in circulating blood and lymph fluid

through the legs.

Today, compression stockings are available in a wide range of opacities,

colors, styles and sizes, making them virtually indistinguishable from regular hosiery

or socks.

Indications for use:

• Tired, aching legs

• Varicose vein

• Venous insufficiency


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• Oedema

• Lymph oedema

• Burn scar

• Prevention of Deep vein thrombosis (DVT) and the post-thrombotic

syndrome (PTS) following DVT

Compression classes:

Compression stockings are constructed using elastic fibers or rubber. These

fibers help compress the limb, aiding in circulation.

Compression stockings are offered in different levels of compression. The

unit of measure used to classify the pressure of the stockings in different mmHg. They

are often sold in one of the following pressure ranges:

Support - over-the-counter

• 10-15 mmHg

• 15-20 mmHg

With the advice or prescription of a physician or medical professional and

proper size from a trained fitter.

• 20-30 mmHg

• 30-40 mmHg

• 40-50 mmHg

• 50+ mmHg


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Compression levels used by some manufacturers for custom made, flat knitted

products in the US. Also used in Europe.

• 18-21 mmHg

• 23-32 mmHg

• 34-46 mmHg

• >50 mmHg

Styles

• Knee-high (AD)

• Thigh-high (AG)

• Pantyhose (AT)

Commonly used terms for compression stockings:

• Anti-embolism - Worn when non-ambulatory or post-surgical to help prevent

pooling of blood in the legs that could lead to a venous thrombosis.

• Custom - uniquely made for a specific individual.

• Circular Knit - Seamless stockings that offer greater aesthetic appeal.

• Flat Knit - Stockings made with a seam that can be constructed in virtually

any shape or size. Most often used in higher compression classes.

• Silver - Stockings constructed using special silver textile fibers. Silver offers

natural anti-microbial protection.


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• Lymphedema - compression stockings used to manage edema resulting from

the onset of Lymphedema.

• Support - mild compression stockings sold over-the-counter and without a

physician's prescription .

2. Drugs used for varicose vein:13

• Calcium dobisilate 500 mg BD . Improves the lymph flow, macrophage

mediated proteolysis and reduces oedema.

• Doismin 450 mg +Hesperidin50 mg relive the night cramps.

• Toxerutin 500 mg BD or TID Antierothrocytic aggregation agent, which

improves capillary dynamics.

• Benefit of these entire drugs is doubtful.

3. Injection sclerotherapy:14

A detergent injected into the superficial veins, this destroys the lipid

membrane of endothelial cells causing to shed, leading to thrombosis, fibrosis and

obliteration. The commonly used detergent is sodium tetradecyle sulphate.

Fegan stressed to continued compression following sclerosant injections.

Scerotherapy was not found to be effective at eradicating varicosities in the

presence of major saphenous incompetence. It is however, useful for dealing with

minor varicosities and recurrence, especially in calf and lower leg.

Ultra sound guided foam sclerotherapy: 15

Ultra sound guided foam sclerotherpy used treat the main

saphenous trunk. A needle is inserted under duplex ultrasound guidance and

sclerosant made into foam. The top of the saohenous vein should be


Disease review _______________________________________________________

______________________________________________________

compressed by ultrasound probe to prevent the entrance of foam in deep

veins, until spasm in the main trunk develops.

Sclerosants used are16

• Sodium tetradecyle sulphate3%

• Sodium morrhuate

• Sodium oleate

• pilidocanol

Complications of sclerotherapy: 17

• Cutanious ulcerations

• Deep vein thrombosis

• Sever head ache

• Transient blindness

• Stroke

• Death

4. Surgery:

Varicose surgery is performed18

1. To relive symptoms

2. For cosmetic reasons

3. For prophylaxes

4. To reverse skin changes and effect ulcer healing


Disease review _______________________________________________________

______________________________________________________

a. Trendelene burg operation:

It is juxt-femoral flush ligation of long saphenous vein, after ligating

superficial circumflex, superficial external pudendal, superficial epigastric

vien, deep external pudendal vein and unnamed tributaries.

b. Stripping of vein:

Using Myers stripper vein is stripped off. Stripping from below to upwards

is technically easier. Stripping avulses the vein as well as obliterates the

tributaries. Babcock stripper and rigid metal pin stripper can also be used.

Stripping of the short saphenous vein is done from ankle below upwards

after passing stripper from above downwards. It obliterates the mild calf

perforator vein, which is the common reason for recurrence.

c. Subfecial ligation of Cockett and Dodd:

Perforators marked out by fegans method. Perforators are ligated deep to the

deep fascia through the incision in antero medial side of the leg.

d. Ligation of short saphenous vein at saphenopopleteal junction.

e. Removal of superficial varicose vein by hook phleboctomy.

f. Linton’s vertical approach – subfacial ligation of perforators.

g. Subfecial endoscopic perforator ligation surgery(SEPS)

h. Radiofrequency ablation method (RFA);

A catheter is passed into long/short saphenous vein near sapheno femoral or

saphenopopliteal junction under guidance. 850C temperature maintained to

cause endothelial damage collagen denaturation and venous constriction.

Phlebectomy is done while with drawing the catheter. Operation performed

under G.A.


Disease review _______________________________________________________

______________________________________________________

i. Trivex method under subcutaneous illumination and local anesthesia:

A large quantity of fluid is injected percutaniously to identify the superficial

veins. Tumescent anaesthesia causes hydrodissection. Trivex and illuminator are

placed under the skin. Dissector gently extracts veins by suction and morcellation.

Further stages of tumescence flushes all blood and delivers vaso-constriction

solutions. Solution is passed through 18-gauze needle to clear all blood underneath

j. Endo venous laser ablation (EVLA):

Under USG guidance LSV is canulted above the knee and a guide wire is

passed beyond SFJ and 5 French catheter is passed over guide wire and tip is placed 1

cm distal to junction. 200 ml of .1 % lignocaine infiltrated. Laser fiber is inserted up

to the tip of the catheter, it is withdrawn 2 cm, and laser fiber protrudes for 2 cm

.Laser fiber is fired systematically.

Using diode laser, one mm withdrawal in 2-second 7290 to 10000 C heat

produced damages endothelium and leads occlusion of vein.

k. Transilluminated phlebectomy:

Is done by passing transilluminated light under the skin and passing a rotating

blade through another small incision. Veins are grasped by rotating movements.

l. Ambulatory phlebectomy:

This is done through tiny small incision using special phleboctomy instruments.

m. Electrodessication using weak electric current:

In this method, electrical is passed through a fine needle directly into the spider

veins.


Disease review _______________________________________________________

______________________________________________________

Complications of surgery:

• Considerable bruising

• Small aria numbness may be associated with intense tingling pain

(saphenous neuralgia, sural nerve injury).

• Postoperative thrombosis.

• Superficial thrombophlebitis .

• Infection.

• Haematoma formation.

• Recurrence.


Disease review _______________________________________________________

______________________________________________________

Review of Literature in Ayurveda

According to Charaka

Dhamanis are pulsating structures

Srotases are secreting structures

Siras are which allows the flow of blood through them19

SIRA:

Vagbhata says, ‘Those which are blue, yellow or black, warm to touch and

bleed quickly, carry rakta20.’

GRANTHI:

The granthi is so called because of its genuine quality if grathan that is the

property of accumulation or collection. It is as follows according to shabda kalpa

dhruma.

Gradh- Curved or curl in nature. Formation of knot or twist like structure by the

quality if curliness or coiling, rippling in action21

Gradhitam- To twist into ringlets.

Granthi: - Formation of knot like structure by way of accumulation.

It also means swelling and hardening of the vessels.

DEFINITION OR NIRUKTI:

Granthi can be defined as a round mass caused by vitiation of

treedosha,mamsa, meda and sira22

According to Vagbhta, Granthi is a round and huge mass like swelling caused

by vitiation of meda, mamsa and rakta23.


Disease review _______________________________________________________

______________________________________________________

According to and Bhavamisra Granthi is a round mass like swelling caused by

vitiation of mamsa and rakta24

According to Sushruta, a round, knotty, elevated swelling which is caused by

mamsa, rakta, meda25

NIDANA26

The cause for the granthi can be anything, which vitiates all the thridosha at

time, there are some factors as follows which directly result in the vitiation of tridoshs

which in turn form the cause for the granthi.

Diets that of mixed variety, indigestion , improper timing of food, combination

of food stuffs of opposite quality, putrefied water and liquor and flesh, dried

vegetables especial moolaka, residue of oil, clay , too fresh liquor. Improper dieting,

abnormal variations, wind blow from east. Due to the exertion, weakness and

abhighata.

Granthi is also manifests due to exposure to sun and due to excessive smoking

and also due to coming contact with irritants.

CLASSIFICATION (BHEDAS)

The classification is based on the predominant dosha and the site of

manifestation.

Sushruta, Bhavamishra, Yogaratnakara, classified granthi into 5 types, Charaka

said 6 types granthi and Vagbhat explained 9 types granthi rogasa. They are displayed

in the chart.


Disease review _______________________________________________________

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Chart No.01 Classification of Granthi roga

No Types of the

granthi

Sushruta Bhavamishra Yogaratnakara Charaka Vagbhata

1 Vataj granthi + + + + +

2 Pittaja granthi + + + + +

3 Kaphaja

granthi

+ + + + +

4 Medaja granthi + + + + +

5 Siraja granthi + + + + +

6 Mamsaja

granthi

- - + +

7 Raktaja granthi - - - +

8 Asthija granthi - - - - +

9 Vranaja

granthi

- - - - +

SAMPRAPTI OF SIRAJA GRANTHI

All the three dosha are involved in the samprapti. Initially vitiated three

dosha by there own individual causes results in the involment of Mams and Rakta.

The charestrics of granthi is i.e. swelling. The shareerak vruddha dosha invades the


Disease review _______________________________________________________

______________________________________________________

mamsa, rakta and sira. Apart of from this stanika kapha will be greatly involved in the

disease process.

The localized Vata in the diseased area accounts for the dryness, blockage and

accumulation, where as pitta results in the transformation of the entities to increase in

there number. On the other hand, the kapha gives rise to Grathana, consistence and

shape. These mechanisms are being noticed on dooshya like Mamsa, Rakta, Sira,

meda. Thus, granthi that is formed out by above mechanism is no doubt involving all

the three doshas but still the Amshams Kalpana, the Vyadhi sambhava elicits that

Kaph, and Medas will be the dominant factor in most of the granthis.

These granthi normally do not under go the suppuration but may undergo

changes in relation to the Samkshobhaka Niadana and once the change becomes

evidential, growth becomes faster and size increases.

LAKSHANA (Clinical features)

SAMANYA LAKSHANA27

1. Granthi will be round in shape

2. Knotty

3. Elevated

VISHISTA LAKSHANA (Specific features)

According to Sushruta

In persons who are weak, indulging in more of physical exercises, vata

gets aggravated, invades the net work of veins, Squeezes, constricts and dries

up and give rise to an elevated, quick developing and round swelling of veins

(Siraja Granthi).28


Disease review _______________________________________________________

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According to Vagabhata,

foot soldiers immersing themselves suddenly in to the water or other

persons getting exhausted by exertion, Vata getting increased invades Siras,

causing constriction, distortion and dryness in them give rise to granthi, which

is non pulsating and painless. This is Siraja granthi.29

SADHYA ASADHYATA

Vagbhata opines that out of 9 granthi he mentioned, the vataja granthi, pittaja

granthi, kaphaja granthi, raktaja grnthi and medoja granthi are said to be sadhya30

According to sushruta, yogaratnakara, madhavakara, and bhavamishra, are of

the opines that if Saraja granthi is painful and movable, then it is krucchrasadhya.

UPADRAVA31

If this disease is treated properly in initial stage, then there is no occurrence

complication. If not treated in proper time then leads to complication.

1. Weakness.

2. Vruna.

CHIKITSA

This granthi is treated according to the Pittaja granthi chikitsa except Siraja

granthi, remaining other Granthi should be treated surgically. In initial stage,

Sahachara taila should be administer internally. Along with the Vataghna dravya.

Basti karma can be adopted32.

PATHYA33

Ahara sambandhi

Amalaki, fibery fruits, vegetables, whole grains, black and blue berries and

cherries,carrot, lemon peel, onion, brahmi, garlic, ginger, pineapple egg, milk and

meat( not red meat)


Disease review _______________________________________________________

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Vihar sambandhi

Healthy walking, swimming, and cycling.

APATHYA

Alcohol, strong coffee.

SIRAGATAVATA:

Varicose can be correlated with Siragatavata.

In SiragataVata, Sthanasamshraya (localizing the vitiated Dosha and Dhatu)

occurs in Siras of the lower limb; hence, the site of the disease is to be studied well

before the treatment. In the classics, “Siras and Dhamanis” are described separately as

the channels for circulation of blood. The differentiation of Sira and Dhamani can be

understood while the following description as “Sravanat Srotamsi” means through

which blood flows constantly without any pulsation. “Dhamanat Dhamani” means to

pulsate. From this description, it is very clear that Sira is veins and Dhamani is artery.

According to Ayurveda Sira is considered as Srotas, which comes under RasaVaha,

and RaktaVaha Srotas. The occurrence of a disease starts with Doshadushya

Sammurchana, which takes place in Srotas. Srotas can be regarded as the system

through which all the metabolites are transported.

According to Charaka, Dosha, Dhatu and Mala are depended on their

respective Srotas for their formation, conduction and destruction. When Srotas gets

deranged the physiological activity of Dosha, Dhatu and Mala also get deranged. The

derangement of Srotas is called “Kha vaigunya” – Kha means a space or cavity. In the

classics two Moolasthana, have been assigned to each Srotas. If the Moolasthana is

affected then the entire Srotas is deranged. The Moolasthana of Rasa Vaha Srotas is


Disease review _______________________________________________________

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described as Hrudaya and the ten Sthoola Dhamani. The Moolasthana of RaktaVaha

is Yakrit and Pleeha34.

Srotho Vaigunya:

The Samprapti of the disease takes place when the Srotas is deformed

structurally and functionally. If there is only vitiation of Dosha without any deformity

in the Srotas, the Dosha will not find a place for Samoorchana and the disease will not

be manifested35. Hence, along with maintaining of the state of equilibrium of Dosha,

the normal functioning of Srotas is very important for the prevention of diseases. One

can prevent the vitiation of Srotas by avoiding such causes that derange the normal

functioning. Regarding Rasa Vaha Srotas, excessive intake of heavy, cold and fatty

foods and disturbed mental status are the causes of vitiation. The causes of vitiation of

Rakta Vaha Srotas are intake of food material, which causes Vidaha, Snigdha Ahara

and excessive exposure to sun.36

The normal property of Rakta is lost by excessive intake of Guru, Sheeta,

Vidaha and Snigdha Ahara. Charaka has described four general defects of Srotas.

They are Atipravrutti, Sanga, Siragranthi and Vimaraga Gamana37 That means by any

of these one can identify the vitiation of the particular Srotas. In chronic condition,

Vimaraga Gamana or regurgitation is noticed as an important symptom.

The Ashrayasthana of Siragata Vata is the Sira of the lower limbs. The

vitiation of Dosha particularly Vata occurs due to the above said Ahara and Vihara

causing obstruction of the flow of blood in Sira of the lower limb. Adho-Kaya is an

important seat of Vata, where the Kutila Sira is manifested. So Tulya Dosha and

Tulya Desha make the disease Durupakrama i.e., not easily curable and the duration

of the disease becomes prolonged.


Disease review _______________________________________________________

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Rakta moving in their own Sira performs function such as supplying

nutrition to the tissue, colour, tactile sensation and many other functions. When it

aggravates, Rakta accumulates in its own Siras, then many diseases caused by blood

developed in the body38.


Materials and Methods _______________________________________________________


MATERIALS AND METHODS

The present study deals with critical evaluation and analysis of both

Punarnavadi guggulu vati and Nimbadi guggulu vati on Siraja granthi.

Selection of patients

The patients suffering from Siraja granthi were selected from the out-patient

and in-patient department of PG studies in Shalya Tantra, Government Ayurvedic

Medical college and hospital, Bangalore irrespective of their sex, religion, occupation.

Materials

Materials required for the study (Fig 12, 13, 14)

1. Punarnavadi guggulu vati

2. Nimbadi guggulu vati

3. Elastic stockings

Methodology

It is a comparative study, comprising of pre-test and post-test design. For this

study, 60 patients in three different groups were taken up, the signs and symptom

before and after the treatment were observed, and recorded in the clinical proforma,

exclusively designed for study.

Inclusive criteria

• Diagnosed cases presenting lakshanas of tortuous dilated vein, ankle oedema,

skin changes and itching in the lower limb.

• Primary varicose vein confined to veins of lower extremities.



Exclusion criteria

• Varicosity associated with complications like deep vein thrombosis,

calcification, equines deformity, venous ulcer.

STUDY DESIGN

Table No.01: Study design

Group Chikitsa Prayoga

avadi

Nireekshana

Avadi for

changes with

treatment

Follow up

for

recurrence

Group A

Internally two Punarnavadi guggulu vati twice a day each weighing 500 mg

90 days On 30th day, on 60th day and on

90th day

3 months

Group B

Internally two Nimbadi

guggulu vati twice a day

each weighing 500 mg


90th day

3 months

Group C Wearing of Elastic

Stockings during day

time


90th day

3 months

Assessment criteria

Changes with the treatment were observed on 30th ,60th and on 90th day. The

features considered for assessment criteria are



Subjective:

1. Itching

Objective:

1. Ankle oedema.

2. Skin Changes.

3. Tortuous dilated vein.

The above parameters have been graded for statistical evaluation and to express result criteria. Subjective parameters: Table No. 02. Grading of itching

SL.NO

ITCHING GRADINGS

01 Absent 00 02 Present 01

Objective parameters: Table No. 03. Grading of Ankle oedema

SL.NO ANKLE OEDEMA GRADINGS 01 Absent 00 02 Present 01

Table No. 04. Grading of Skin changes

SL.NO

SKIN CHANGES

GRADINGS

01 No color changes 00 02 Patchy hyper pigmentation 01 03 Hyper pigmentation with

eczema 02

04 Hyper pigmentation with lipodermatosclerosis

03



Table No. 05. Grading of Tortuous dilated vein

SL.NO TORTUOUS DILATED VIEN GRADINGS 01 Absent 00 02 Present 01

Result criteria:

The total sum point of all the parameters of assessment before and after treatment

were taken into consideration to assess the total effect of the treatment, it is assessed

as follows:

1. Marked improvement - relief of >60% in clinical parameters

2. Moderate improvement - 40 to 60% relief in clinical parameters.

3. Mild improvement - less than 40% relief in clinical parameters.

4. No change - 0% no relief in clinical parameters.



Fig.no.12: Punarnavadi guggulu Fig.no.13: Nimbadi guggulu

Fig.no.14: Stockings

Observations and Results _______________________________________________________


OBSERVATIONS AND RESULTS

The periodical observation on different aspect of the study was documented

and studied under intervals via 30th day, 60th day and 90th day in all the groups. The

observations have been presented as follows.

• Distribution or surveillance:

A subsequent survey from 2008 – 2009 of all the patients attending OPD and

IPD of Shalya Tantra, incidence of Varicose vein cases was 1.04 % in one year.

• Age wise distribution

The cases of Siraja granthi were maximum in age group of 30-39 years

(36.33%) and minimum i.e. 15% in age group of 60-69 years.(Table No.06) ( Graph

No. 01) .

Table No. 06: Age wise distribution of 60 patients of Siraja granthi

Total Age in years Group A Group B Group C

No. %

30-39 9(45.0%) 8(40.0%) 5(25.0%) 22 36.33

40-49 6(30.0%) 5(25.0%) 4(20.0%) 15 25

50-59 2(10.0%) 2(10.0%) 10(50.0%) 14 23.33

60-69 3(15.0%) 5(25.0%) 1(5.0%) 9 15

Total 20(100.0%) 20(100.0%) 20(100.0%) 60 100



• Sex wise distribution

Out of 60 cases, 20% were female patients and Male patients were 80 %(Table

No. 07) ( Graph No.-2)

Table No. 07: Sex wise Distribution of 60 Patients of Siraja granthi

No. of cases Percentage (%) Sex

Group Group

A

Group

B

Group

C Total

Group

A

Group

B

Groups

C Total

Male 17 14 17 48 85% 70% 85% 80%

Female 3 6 3 12 15% 30% 15% 20%

• Occupational Status:

In the series 36.66% were businesspersons, 6.0% were Labors and 15% were

housewives. Farmers were 11.66%. 26.66% were Social workers (Table No. 08)

(Graph No -3)

Table No. 08: Distribution of Patients According to occupation

Occupation Group A Group B Group C Total

Business 12(60.0%) 8(40.0%) 2(10.0%) 22(36.66%)

House wife 2(10%) 4(20.0%) 3(15.0%) 9(15%)

Labour 1(5.0%) 2(10.0%) 3(15.0%) 6(10%)

Farmer 4(20.0%) 2(10.0%) 1(5.0%) 7(11.66%)

Social

Services

1(5.0%) 4(20.0%) 11(55.0%) 16(26.66%)

Total 20(100.0%) 20(100.0%) 20(100%) 60(100%)



• Habitat wise distribution:

Cases were analyzed in view of their habitat. Out of 60 cases of Siragatavata

maximum i.e. 78.33%, patients were from urban area while 21.66% patients were

reported from rural area (Table. No 09) (Graph No.-4)

Table. No. 09: Habitat wise Distribution of 60 Patients of Siraja granthi

Habitat No. of Cases Percentage

Rural 13 21.66%

Urban 47 78.33%

Total 60 100%

• Distribution of patients according to Agni

The present study showed that maximum 41% of patients had Mandagni,

38% had Samagni and 20% had Vishamagni. (Table No .10) (Graph No.5)

Table. No. 10: Distribution of the Patients According to Agni

Group A Group B Group C Total Agni

No. % No. % No. % No. %

Sama 9 45% 7 35% 7 35% 23 38.33%

Manda 4 20% 12 60% 9 45% 25 41.66%

Vishama 7 35% 1 5% 4 20% 12 20%

Total 20 100 20 100% 20 100% 60 100%



• Involved leg :

The present study showed that 38.33% 0f Right leg varicosity and 28.33%

Left leg varicosity. 33.33% were having bilateral varicosity.(Table No. 11) (Graph

No. 6)

Table. No. 11: Distribution of Patients According to Involvement of Leg

Group A Group B Group C Total Involvement of

Leg No. % No. % No. % No. %

Rt 8 40% 8 40 7 35% 23 38.33% Unilateral

Lt 5 25% 7 35% 5 25% 17 28.33%

Bilateral 7 35% 5 25% 8 40% 20 33.33%

Total 20 100% 20 100% 20 100% 60 100%

• Involvement of Vein.

In This series out of the 60 patients 55% patient has involvement of L.S.V in

varicose vein. 20% patient had both i.e L.S.V and S.S.V.(Table No. 12) (Graph

No. 7)

Table. No. 12: Distribution of Patients According to Involvement of Vein

Group A Group B Group C Total Involved Vein

No. % No. % No % No. %

L.S.V 11 55% 10 50% 12 60% 33 55%

S.S.V 4 20% 5 25% 6 30% 15 25%



Both 5 25% 5 25% 2 10% 12 20%

Total 20 100 20 100 20 100 60 100

• Site of Perforators

The present study showed maximum 75% of the patients having involvement

of medial groups of perforators , 15% having involvement of Medial and lateral

group of perforators and 10% having involvement of Lateral group of Perforators

.(Table. No.13) (Graph No.8)

Table .No. 13: Distribution of Patients according to Site of Perforators

Group A Group B Group C Total Site of Perforators

No. % No. % No. % No. %

Medial 17 85% 13 65% 15 75% 45 75%

Lateral 1 5% 3 15% 2 10% 6 10%

Both 2 10% 4 20% 3 15% 9 15%

Total 20 100% 20 100% 20 100% 60 100%



• Incidence of lakshanas in Trail groups

In Group A, 60% patients had itching, in Group B-70% patient had itching and

in Group C 70% patient had itching.

In Group A, 80% patients had ankle oedema, in Group B-65% patients had

ankle oedema and in Group C 80% patient had ankle oedema.

In Group A, 95% patients had skin changes, in Group B-65% patients had skin

changes and in Group C-95% patients had skin changes.

In Group A, Group B and Group C-100% patients tortuous dilated vein(Table

No.14) (Graph No. 9)

Table.No. 14 Incidence of Lakshanas in trail groups

Lakshanas Group A Group B Group C

Itching 60% 70% 70%

Ankle oedema 80% 65% 80%

Skin changes 95% 65% 95%

Tortuous

dilated vein

100% 100% 100%



• Effect of Punarnavadi guggulu vati on the Itching

Before the treatment, Itching was 60%, which was reduced to the 45% on the

60th day and at the end of the treatment, it remained 45%. The relief was 15% (P

Value is 0.0186). Thus, the effect of Punarnavadi guggulu vati on the itching was not

significant. (Table No 15).

Table .No. 15: Effect of the Punarnavadi guggulu vati on Itching.

Group A

Before

treatment

30th day 60th day After

treatment

%

change

P

value

Itching

absent

8(40.0%) 8(40.0%) 11(55.0%) 12(60.0%) +20.0%

Itching

present

12(60.0%) 12(60.0%) 9(45.0%) 9(45.0%) -15.0%

Total 20(100.0%) 20(100.0%) 20(100.0%) 20(100.0%) 0

0.186

• Effect of Nimbadi guggulu vati on the itching.

Before the treatment, itching was 70% and after 30th day it reduced to 60%

and at the end of the treatment, it was reduced to 25%. The relief was 45% (P value is

0.021) .Thus, the effect of the Nimbadi guggulu vati on itching was moderately

significant. (Table No 16).



Table .No. 16: Effect of Nimbadi guggulu vati on itching.

Group B

Before

treatment

30th day 60th day After

treatment

%

change

P

value

Itching

absent

6(30.0%) 8(40.0%) 10(50.0%) 15(75.0%) +45.0%

Itching

present

14(70.0%) 12(60.0%) 10(50.0%) 5(25.0%) -45.0%

Total 20(100.0%) 20(100.0%) 20(100.0%) 20(100.0%) 0

0.021*

• Effect of the elastic stocking on itching.

Before the treatment, the itching was 70%, which after the 30th day reduced to 65%,

and at the end of the treatment, it was reduced to 45%. The relief was 25% (P value is

0.112) .Thus the effect of the Elastic stocking on the itching is statistically non-

significant. (Table No. 17).

Table .No. 17: Effect of the elastic stocking on the itching.

Group C

Before

treatment

30th day

60th day

After

treatment

%

change

P

value

Itching

absent

6(30.0%) 7(35.0%) 10(50.0%) 11(55.0%) +25.0%

Itching

present

14(70.0%) 13(65.0%) 10(50.0%) 9(45.0%) +25.0%

Total 20(100.0%) 20(100.0%) 20(100.0%) 20(100.0%) 0

0.112

P value 0.833 1.0000 1.000 0.367 -



• Effect of the Punarnavadi guggulu vati on the Ankle oedema.

Before the treatment, the ankle oedema was 80%, which was after 30th day

reduced to 60% and at the end of the treatment; the oedema was reduced to 20%. The

relief is 60% (P value is 0.0019) .Thus the effect of the Punarnavadi guggulu vati is

statistically strongly significant (Table No. 18)

Table .No. 18: Effect of the Punarnavadi guggulu vati on the Ankle oedema

Group A

Before

treatment

30th day

60th day

After

treatment

%

change

P value

Oedema

absent

4(20.0%) 8(40.0%) 10(50.0%) 16(80.0%) +60.0

%

Oedema

present

16(80.0%) 12(60.0%) 10(50.0%) 4(20.0%) -60.0%

Total 20(100.0

%)

20(100.0%) 20(100.0%) 20(100.0%) 0

0.0019**

• Effect of the Nimbadi guggulu vati on the Ankle oedema.

Before the treatment, the Ankle oedema was 65%, on the 30th day it was

reduced to 50% and at the end of the treatment, it was reduced to 25%. The relief was

40% (P value is 0.0406).

Thus, the effect of the Tab Nimbadi guggulu vati over the Ankle oedema is

statistically moderately significant. (Table No.19).



Table. No. 19: Effect of the Nimbadi guggulu vati on the Ankle oedema.

Group B

Before

treatment

30th day

60th day

After

treatment

%

change

P value

Oedema

absent

7(35.0%) 10(50.0%) 14(70.0%) 15(75.0%) +40.0%

Oedema

present

13(65.0%) 10(50.0%) 6(30.0%) 5(25.0%) +40.0%

Total 20(100.0%) 20(100.0%) 20(100.0%) 20(100.0%) 0

0.0406*

• Effect of the Elastic stocking wearing over the Ankle oedema.

Before wearing Elastic stocking, the Ankle oedema was 80%,and after

wearing it, Ankle oedema was reduced to 30% on the 30th day. At the end of the

treatment, it was reduced to 25%. The relief was 55 %( P value is 0.0035)(Table No.

20).

Table .No. 20: Effect of the Elastic stocking on the Ankle oedema

Group C

Before

treatment

30th day

60th day

After

treatment

%

change

P value

Oedema

absent

4(20.0%) 8(40.0%) 15(75.0%) 15(75.0%) +55.0%

oedema

present

16(80.0%) 12(60.0%) 5(25.0%) 5(25.0%) -55.0%

Total 20(100.0%) 20(100.0%) 20(100.0%) 20(100.0%) 0

0.0035*

P value 0.602 0.720 0.179 1.000 -



• Effect of the Punarnavadi guggulu vati on skin changes.

Before the treatment, the skin changes was 95%, at the end of the treatment it

was reduced to 75%. The relief was 20 % (P value is 0.001).

Thus, the effect of the Punarnavadi guggulu vati is strongly significant. (Table No.

21)

Table .No. 21: Effect of Punarnavadi guggulu vati on the skin changes.

Group A

Before

treatment

30th day

60th day

After

treatment

%

change

No colour changes 1 (5.0%) 1(5.0%) 1(5.0%) 5(25.0%) +20.0%

Patchy

hyperpigmentation

16 (80.0%) 16(80.0%) 19(95.0%) 15(75.0%) -5.0%

Hyperpigmentation

with eczema

3(15.0%) 3(15.0%) 0 0 -15.0

Hyperpigmentation

with

lipodermatosclerosis

0 0 0 0 0

Total 20(100.0%) 20(100.0%) 20(100.0%) 20(100.0%) 0



• Effect of the Nimbadi guggulu vati on the skin changes.

Before the treatment, skin changes was 65%. At the end of the treatment, this

was reduced to the 60%. The relief was 5% (P value is 0.015) .Thus, the effect of the

Nimbadi guggulu vati is moderately significant. (Table No. 22)

Table .No. 22 Effect of the Nimbadi guggulu vati on the skin changes.

Group B

Before

treatment

30th day

60th day

After

treatment

%

change

No colour changes 7(35.0%) 7(35.0%) 7(35.0%) 8(40.0%) +5.0%

Patchy

hyperpigmentation

3(15.0%) 4(20.0%) 6(30.0%) 6(30.0%) +15.0%

Hyperpigmentation

with eczema

7(35.0%) 6(30.0%) 4(20.0%) 4(20.0%) -15.0%

Hyperpigmentation

with


3(15.0%) 3(15.0%) 3(15.0%) 2(10.0%) -5.0%

Total 20(100.0%) 20(100.0%) 20(100.0%) 20(100.0%) 0

• Effect of the Elastic stocking on the skin changes.

Before wearing of the Elastic stockings, the skin changes was 95%. At the

end of the treatment, it was reduced to the 65%. The relief was 30% (P Value is

<0.001). (Table No. 23)

Thus, the effect of the Elastic stocking on the skin changes is strongly

significant.



Table .No. 23 Effect of the Elastic stocking on the skin changes.

Group C

Before

treatment

30th day

60th day

After

treatment

%

change

No colour changes 1(5.0%) 1(5.0%) 7(35.0%) 7(35.0%) +30.0%

Patchy

hyperpigmentation

18(90.0%) 18(90.0%) 12(60.0%) 12(60.0%) -30.0%

Hyperpigmentation

with eczema

0 0 0 0 0

Hyperpigmentation

with


1(5.0%) 1(5.0%) 1(5.0%) 1(5.0%) 0.0

Total 20(100.0%) 20(100.0%) 20(100.0%) 20(100.0%) 0

• Effect of the Punarnavadi guggulu vati on tortuous dilated vein.

Tortuous dilated vein was not changed after the end of the treatment schedule.

Thus, the effect of Group A on tortuous dilated vein is statistically non-significant.

(Table No 24 ).

Table .No. 24: Effect of Punarnavadi guggulu vati on the Tortuous dilated vein.

Group A

Before

treatment

30th day

60th day

After

treatment

%

change

P

value

Absent 0 0 0 0 0

Present 20 (100%) 20 (100%) 20 (100%) 20 (100%) 0

Total 20 (100%) 20 (100%) 20 (100%) 20 (100%) 0

_



• Effect of the Nimbadi guggulu vati on tortuous dilated vein.


Thus, the effect of Group B on tortuous dilated vein is statistically non-significant.

(Table No 25 ).

Table .No. 25: Effect of Nimbadi guggulu vati on the Tortuous dilated vein.

Group B

Before

treatment

30th day

60th day

After

treatment

%

change

P

value

Absent 0 0 0 0 0

Present 20 (100%) 20 (100%) 20 (100%) 20 (100%) 0

Total 20 (100%) 20 (100%) 20 (100%) 20 (100%) 0

_

• Effect of Elastic stockings on tortuous dilated vein.


Thus, the effect of Group C on tortuous dilated vein is statistically non-significant.

(Table No 26 ).

Table .No. 26: Effect of Elastic stockings on the tortuous dilated vein.

Group C

Before

treatment

30th day

60th day

After

treatment

%

change

P

value

Absent 0 0 0 0 0

Present 20 (100%) 20 (100%) 20 (100%) 20 (100%) 0

Total 20 (100%) 20 (100%) 20 (100%) 20 (100%) 0

_



OVERALL RESULTS:

• Therapeutic effect of all the groups on Itching.

Effect of all the groups on Itching, Group A has shown 15% relief; and

Group B shown 45% relief and Group C has shown 25% relief. Thus, Nimbadi

guggulu vati is better than the other remedies in concern with itching. (Table No 27)

(Graph No 10).

Table. No.27: Therapeutic effect of all the groups on Itching.

Groups

Before

treatment

30th day

60th day

After the

treatment

Changes

Group A 12 (60%) 12 (60%) 9 (45%) 9 (45%) 3 (15%)

Group B 14 (70%) 12 (60%) 10 (50%) 5 (25%) 9 (45%)

Group C 14 (70%) 13 (65%) 10 (50%) 9 (45%) 5 (25%)

• Therapeutic effect of all the groups on Ankle oedema.

Effect of all the groups on ankle oedema, Group A has shown 60% relief,

Group B shown 40% relief and Group C has shown 55% relief. Thus, the Punarnavadi

guggulu vati is better than the other remedies in concern with ankle oedema. (Table

No 28) (Graph No 11).

Table. No.28: Therapeutic effect of all the groups on Ankle oedema.

Groups

Before

treatment

30th day

60th day

After the

treatment

Changes

Group A 16 (80%) 12 (60%) 10 (50%) 4 (20%) 12 (60%)

Group B 13 (65%) 10 (50%) 6 (30%) 5 (25%) 8 (40%)

Group C 16 (80%) 12 (60%) 5 (25%) 5 (25%) 11 (55%)



• Therapeutic effect of all the groups on Skin changes.

Effect of all the groups on skin changes, Group A has shown 20% relief,

Group B shown 5% relief and Group C has shown 30% relief. Thus, Wearing of

Elastic stockings is better than the other remedies in concern with skin changes.

(Table No 29) (Graph No 12).

Table .No. 29: Therapeutic effect of all the groups on skin changes.

Skin changes

Before

treatment

30th day

60th day

After

treatment

%

change

Group A 19 (95%) 19 (95%) 19 (95%) 15 (75%) 4 (20%)

Group B 13 (65%) 13 (65%) 13 (65%) 12 (60%) 1 (5%)

Group C 19 (95%) 19 (95%) 13 (65%) 13 (65%) 6 (30%)

• Therapeutic effect of all the groups on Tortuous dilated vein.

There was no change found in tortuous dilated vein. Therefore, the action of the

drugs and Elastic stocking was statistically non-significant. (Table No 30). (Graph No

13)

Table. No. 30: Therapeutic effect of all the groups on Tortuous dilated vein.

Grossly dilated

tortuous Vein

Before

treatment

30th day

60th day

After

treatment

%

change

Group A 20 (100%) 20(100%) 20(100%) 20 (100%) 0.0%

Group B 20 (100%) 20(100%) 20(100%) 20 (100%) 0.0%

Group C 20 (100%) 20(100%) 20(100%) 20 (100%) 0.0%



Overall response of the therapies on Siraja granthi:

• Overall effect of the Punarnavadi guggulu vati on Siraja granthi.

Considering the overall response of the patients to the therapy with

Punarnavadi guggulu vati, 14 patients got mild improvement and 3 patients got

moderate improvement. 3 patients showed no changes.

• Overall effect of the Nimbadi guggulu vati on Siraja granthi.

Considering the overall response of the patients to the therapy with

Nimbadi guggulu vati, 8 patients got mild improvement and 5 patients got

moderate improvement and 2 patients showed marked improvement. No changes

were observed in 5 patients.

• Overall effect of the Elastic stockings on Siraja granthi.

Considering the overall response of the patients to the therapy with Elastic

stockings, 9 patients got mild improvement and 4 patients got moderate improvement.

No changes were observed in 7 patients.

• Hence, Group A was best of all the groups. Group B is better than the Group C.

(Table No. 31) (Graph No.14 )

Table No.31: Overall response of the therapies on Siraja granthi.

Percentage of relief Group A Group B Group C Total

>60% 0 2 0 2

40 to 60 % 3 5 4 12

<40 % 14 8 9 31

No changes 3 5 7 15



Diagram No .01: Age wise Distribution

Age wise distribution of patients

0%

10%

20%

30%

40%

50%

60%

30-39 40-49 50-59 60-69

Group AGroup BGroup C

Diagram No .02: Sex wise Distribution

Sex wise distribution

0

10

20

30

40

50

60

Group A Group B Group C Total

male female



Diagram No .03: Incidence of Occupational Status

0%

10%

20%

30%

40%

50%

60%

70%

Buisiness House wife Labor Farmer Socialworkers

Group AGroup BGroup CTotal

Diagram No .04: Incidence of Habitat

Rural Urban

Incidence of Habitat



Diagram No .05: Incidence of Agni

0% 10% 20% 30% 40% 50% 60% 70%

Group A Ggroup B Group C

SamaMandaVishama

Incidence of Agni

Diagram No .06: Incidence of Involved Leg

0

2

4

6

8

10 12 14

Right Left Bilateral


Incidence of Involved Leg



Diagram No .07: Incidence of Involved Veins.

0% 10% 20% 30% 40% 50% 60% 70%

Group A Group B Group C Total

L.S.VS.S.VBoth

Incidence of Involved Vein

Diagram No. 8: Incidence of Involved Perforators

Site of Perforators

02468

1012141618

Medial Lateral Both

Group AGroup B Group C



Diagram No.9: Incidence of Lakshanas in Trail groups

Incidence of Lakshanas in Trail groups

0%

20%

40%

60%

80%

100%

120%

Itching Ankleoedema

Skinchanges

Tortuousdilated


Diagram No.10: Effect on Itching

0%10% 20% 30% 40% 50% 60% 70% 80%

Before treatment On 30th day On 60th day After the treatment

Group A Group BGroup C

Itching



Diagram No.11: Effect on ankle oedema

Ankle oedema

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

Before treatment On 30th day On 6oth day After thetreatment

Group A

Group B

Group C

Diagram.No.12: Effect on skin changes

Therapeutic effect in three groups on skin changes

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

100%

Before treatment 30th day 60th day After treatment

Group AGroup B GroupC



Diagram No.13: Effect of all groups on tortuous dilated vein

Effect of all groups on Tortuous dilated vein

0 0.2 0.4 0.6 0.8

1 1.2

Before treatment 30th day 60th day After treatment


Diagram No.14: Overall Response of the Therapies

Overall Response of the Therapies

0 2 4 6 8

10 12 14 16

No changes Mild Improvement

ModerateImprovement

MarkedImrovement




Fig 15: Photos showing effect of Punarnavadi guggulu

Before treatment After treatment

Fig 16: Photos showing effect of Nimbadi guggulu




Fig 17: Photos showing effect of Elastic stocking


Discussion _______________________________________________________


DISCUSSION

Discussion constitutes the proper interpretation of different aspects of the

comparative study. A scientific and critical discussion always enriches the sciences by

adding facts to it. In the present study, discussions were made on three main headings

namely:

Discussion on Review of literature

Discussion on Methodology

Discussion on Observation and Results

Discussion on review of literature:

Siraja granthi one among the granthi rogas described in various ayurvedic

classics, denotes a pathological condition characterized by an elevated, quick

developing and round swelling of veins, which are non pulsating and painless. It

would have given a clear-cut picture of the varicose vein if there is a crystal clear

description of its related anatomy and pathology.

To add to the confusion and controversy the various misinterpretations,

additions of new coined recent authors have enumerated terms and new visions,

which are based on present contemporary science. However, it is important to

understand the sciences of Ayurveda based on its basic description of principles.

The disease Siraja granthi is described in the context of Granthi-apachi-arbuda

-galaganda chapter by Sushruta and Vaghbata.

Discussion _______________________________________________________


Siraja granthi

Symptomatologies of Siraja granthi indicate the correlation towards the

Varicose veins. The following points can clarify it.

Table.No.32: Co relation between Siraja granthi and varicose vein

Siraja granthi Varicose vein

Involved

structure

Sira

Vein

Symptoms Sampeedya, Nispuram,

Nirujam.

Diffuse dull ache pain.

Signs Sankochya, Vrutta, Unnata,

Vakrikrutya, Shopham.

Dilated, elongated and tortuous vein,

Superficial thrombophlebitis.

The co-related disorder pattern is equivocal in both Siraja granthi and varicose

vein.

The main aims of the treatment in contemporary science are to strengthen the

veins wall and valves, to achieve the good venous flow from the lower extremities

and to avoid the complications of varicose vein. The treatment principle described in

the Ayurveda like external application of Sahacharadi taila, internal vatahara basti,

and Para surgical procedures such as Jaloukavacharana and Siravyadha serves the

above aim of the treatment.

Discussion _______________________________________________________


Discussion on the Methodology:

Various formulations have been described in Ayurvedic classics for the

management of the Siraja granthi. Handful of researches mainly on external

application of the Sahacharadi taila and internal Administration of the Lashunadi vati

and Para surgical procedures were carried in different centers. It’s the matter of

interest to explore a simple formulation like Punarnavadi guggulu vati or Nimbadi

guggulu vati in the management of the varicose vein supported by Pilot study. Hence,

the study was taken up to see the efficacy of the Punarnavadi guggulu and Nimbadi

guggulu. Both being the Drug trail groups, it was important to have a control group to

compare the results. Hence, a control group in the form of the conservative line of

treatment, through application of Elastic stocking was advised.

The selected patients were assigned into 3 groups. Group A and Group B were

prescribed specific drugs for 90 days and Group C was advised to wear the Elastic

stockings

The symptoms and signs were assessed by observational facts, before, during

and after the treatment. The obtained results were statistically analyzed and

interpreted.

Discussion on Observational study:

• Age:

Out of 60 patients, the cases of Siraja granthi were maximum in age group of

30-39 years (36.33%) and minimum in age group of 60-69 years (15%). Age has no

relevance with that of treatment procedures as similar type of manifestation were

elicited in all the age group (Vide on Table No. 06).

Discussion _______________________________________________________


• Sex:

Out of 60 cases, 20% of them were female patients and 80% of them were

male patients. Sex has no relevance with that of treatment procedures as similar

type of manifestation were elicited in all group (Vide on Table No 07).

• Occupational Status:

In the series, 36.66% were businesspersons, 6.0% were Laborers and 15% were

housewives, 11.66% were Farmers, 26.66% were Social workers. Businesspersons are

more prone to have this disease due to the continuous standing work. (Vide on Table

No 08).

• Habitat:

Cases were analyzed in view of their habitat. Out of 60 cases of Siraja granthi

78.33% patients were from urban area while 21.66% patients were reported from rural

area. Habitat has no relevance with that of treatment. (Vide on Table No 09).

• Agni:

The present study showed that maximum 41% of patients had Mandagni,

38% had Samagni and 20% had Vishamagni. Deepana , Pachana drugs were

given to correct the Agni before commencement of the clinical trail Agni . (Vide

On Table No 10).

• Involved leg :

In the present study, 38.33% had Right leg varicosity and 28.33% had

Left leg had varicosity. 33.33% were having bilateral varicosity. Involvement of

limbs is not related to the occurrence of the disease. (Vide on Table No 11).

Discussion _______________________________________________________


• Involved vein:

In this series, out of the 60 patients,55% patient had varicosity of L.S.V ,

20% patient had both i.e. varicosity of L.S.V and S.S.V . This reveals that L.S.V

is most affected by varicosity. (Vide on Table No 12).

• Perforators:

The present study showed maximum 75% of the patients having

involvement of medial groups of perforators, 15% having involvement of Medial

and lateral group of perforators and 10% having involvement of Lateral group of

Perforators. The maximum number of patients (75%) suffered from the medial

group of perforators. (Vide on Table No 13)

• Lakshanas :

With regards to the lakshanas, it is evident that tortuous dilated veins were

present in all the cases while the remaining lakshanas were present between 60% -

80%. However, skin changes were present in all the cases. The response to the

treatment was more conspicuous as far as skin changes are concerned. On the

other hand appreciable changes were seen in other lakshanas like itching and

ankle oedema while no notable changes was seen in the tortuous dilated veins.

(Vide on Table No 14)

• Follow up study:

The patients were advised to attend the OPD after completion of three months.

No changes was reported within three months of follow up period as they had

been instructed not to stand continuously for long periods and advised to keep the

foot elevated while sleeping.

Discussion _______________________________________________________


Discussion on Results

• Probable mode of action of Punarnavadi guggulu vati on Siraja granthi :

By virtue of its Pittakapha shonita nashana, kandu hara, kustha hara,

varnya, Shopha hara, and Anti-inflammatory properties, it effectively reduces the

pigmentation of skin over Siraja granthi pradesha. The skin attains smoothness, looses

the dark pigmentation, itching and vicharchikavat lakshana are reduced. Swelling

around the Ankle joint is reduced which is suggestive of good venous flow.

• Probable mode of action Nimbadi guggulu on the Siraja granthi :

By virtue of its Kapha-pitta hara, Shotha hara, Kustha hara, Udarda

prashamana, Kandoohara, Varnya and Anti-inflammatory properties, it effectively

removes the Kupita dosha from the twacha, which helps in achieving the Prakruta

varna of twacha. It also reduces the eczematous changes and Ankle swelling.

• Probable mode of action of Elastic Stockings on the Siraja granthi : Compression stockings are used to support the veins of the leg. They offer

graduated compression where maximum compression is achieved. This

compression, when combined with the muscle pump effect of the calf, helps in

movement of blood. The External support to the vein reduces the hydrostatic

pressure of the vein lumen. It prevents the venous stasis. By the virtues of these

properties, it helps in the reduction of swelling, itching, and restores the normalcy

of the skin.

Discussion _______________________________________________________


• Over all effects of the treatment in all three groups :

In Group A, Mild improvement was observed in 14 patients, Moderate

improvement was present in 3 patients.

In Group B, Mild Improvement was observed in 8 patients, Moderate

improvement was observed in 5 patients and Marked Improvement was found in 2

patients.

In Group C, Mild Improvement was observed in 9 patients and Moderate

Improvement was observed in 4 patients. (Vide on Table No 31)

Hence,

The Punarnavadi guggulu group was best of all three groups.

The Nimbadi guggulu group was better than Elastic stocking group.

The Punarnavadi guggulu was better than the Nimbadi guggulu group.

Conclusion _______________________________________________________


CONCLUSION

• A subsequent survey from 2008 – 2009 of all the patients attending OPD and

IPD of Shalya Tantra, incidence of Varicose vein cases was 1.04 % in one

year.

• The cases of Siraja granthi were maximum in age group of 30-39 years.

• Incidence of male was more as far as sex distribution is concerned.

• Incidence of varicose veins was more in people belonging to the occupation

that involved standing for longer duration.

• Almost all the lakshanas were present in all patients, predominantly skin

changes.

• Long saphenous vein was predominantly involved in all the cases.

• The Punarnavadi guggulu group was best of all three groups.

• The Nimbadi guggulu group was better than Elastic stocking group.

• The Punarnavadi guggulu was better than the Nimbadi guggulu group.

Scope for further study:

• The administration of the Nimbadi guggulu vati and Punarnavadi guggulu vati

can be studied on large number of cases for observing synergistic benefits of

the treatment

• The administration of the Punarnavadi guggulu with Elastic stocking wear can

be studied in large number of cases.

Conclusion _______________________________________________________


• The administration of the Nimbadi guggulu vati with Elastic stocking wear

can be studied in large number of cases.

• The administration of the Nimbadi guggulu and Punarnavadi guggulu along

with elastic stocking can be studied in large number of cases

• This study can be taken for multi centre study.

Summary _______________________________________________________


SUMMARY

The present study entitled “A study on Siraja granthi and its management with

Punarnavadi guggulu vati and Nimbadi guggulu vati a comparative study” is mainly

based on clinical observation. The dissertation comprises of literary review, clinical

study discussion, conclusion and summary.

The first part deals with the literary aspect of the disease i.e. Siraja Granthi.

After describing Siraja granthi in detail, Siragata vata is also explained briefly and

later the varicose veins described in modern science was also reviewed.

At the outset of the second part named as clinical study, materials and

methods adopted for this study has been explained in detail. There after general

observations were made on 60 patients of Siraja granthi and results recorded in three

groups. Treatments have been presented in tabular form along with brief description

of each finding. The statistical analysis and geographical presentation of the results

also have been presented. The results obtained in the clinical study have been

discussed in the third part of dissertation designated as discussion to draw the logical

conclusion.

1. Study design

Out of 60 patients of Siraja granthi studied in the series, 20 patients were treated

with Punarnavadi guggulu vati under Group A, 20 patients were treated with

Nimbadi guggulu vati under group B and In Group C, 20 patients were advised to

wear the Elastic stockings.

Summary _______________________________________________________


Out of 60 patients of Siraja granthi (Varicose Veins) maximum were belonging to

30-39 years of age group 36.33% because of their occupation , male sex 71.66%,

urban area 78.33%, occupation businessman 31.36%, Mandagni 41.66%, bilateral

varicosity 33.33%.

2. Significant effect of Punarnavadi guggulu vati :

Punarnavadi guggulu vati has provided significant relief in Ankle oedema (60%)

and Skin changes (20%)

3. Significant effect of Nimbadi guggulu vati :

Nimbadi guggulu vati has provided moderately significance in restoring the

normalcy of the affected skin (5%) and reducing the ankle oedema (55%).

4. Significant effect of Elastic Stockings:

The wearing of Elastic stockings has provided strongly significant relief in the

Skin changes (30%), moderately significant in the relief of Ankle oedema (55%).

5. Comparison of Effect of Both the Groups:

The above results have shown the effect of treatment by Punarnavadi guggulu

vati to be more pronounced in reducing the Ankle oedema and Skin changes. Effect

of treatment by Nimbadi guggulu vati showed moderate reduction in Skin changes,

Ankle oedema and Itching. Elastic stockings were strongly significant on the Skin

changes.

Thus, the total effect of Punarnavadi guggulu vati was better than Nimbadi

guggulu vati.

Summary _______________________________________________________


6. Over all effects of the treatment in all three groups:

In Group A, mild improvement was observed in 14 patients, Moderate

Improvement was present in 3 patients.

In Group B, mild Improvement was observed in 8 patients, Moderate

improvement was observed in 5 patients and Marked Improvement was found in 2

patients.

In Group C, Mild Improvement was observed in 9 patients and Moderate

Improvement was observed in 4 patients.

References _______________________________________________________


REFERENCES

1. Su.Su 13/4

2. Http://google/sin.com varicose-vein-treatment-ayurvedic-and-home-

Remedies

3 Diseases of the veins by Norman L Browse – Chapter -1





8 A Concise text book of Surgery by S. Das Chapter -16



11 SRB’s Manual of Surgery By Sriram Bhat M. 2nd Edition Page No.198

12 http://en.wikipedia. org/ wiki /file ( varicose vein.jpg)


14 Bailey and Love’s Short Practice of Surgery 25th Edition, Chapter 54,

Page No929

15 Bailey and Love’s Short Practice of Surgery 25th Edition, Chapter 54,

Page No 930


17 Atlas of General surgery, compiled by sir David carte. RCG Russel,

Henry pitt. Page No1144.

References _______________________________________________________


18 Atlas of General surgery, compiled by Sir David carte,RCG

Russel,Henry pitt, Page No 1107

19 Ch. Su.30/12

20 A. S. Su. 6/8

21 Shabda Kalpa Druma by Radha kanta deva, 2nd volume, Page No 372

22 M.Ni 37/11

23 A.S.U 34/2

24 B.P. Chikitsa prakarana 9/44/11

25 Su. Ni.11/3

26 Su. Ni. 11/3

27 Su. Ni. 26/3

28 Su. U. 11/34

29 A. S. Ni. 11/8

30 A. S.U.34/3

31 Su. Ni. 11/4

32 A.S.Chi 23/46

33 http://www.varicose vein-help.com/diet-for-varicose-veins-html

34 Ch. Vi.5/8

35 Ch. Vi. 5/6

36 Ch.Vi. 5/14

37 Ch .Vi. 5/24

38 Su. Sha.7/4-5

References _______________________________________________________


39 B R 42/135

40 B B R, vol- 3,Page No 179

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Distributors New Delhi, Second Edition, 2005.

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commentary edited by prof. Siddhi Nandan Mishra. 1st ed. Chaukambha

Surabharati prakashana ; 2005.

Bibliography _______________________________________________________


• Linda.G.Philips, David C. Sabiston (et al), Text Book of Surgery. The

Biological Basis of Modern Surgical Practice, 16th Edition, Volume I,

W.B.Saunders Company Publication.

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Vimala – Madhudhara Hindi commentary By Brahmanand Tripathi, Volume

II Chaukambha Surabharati Prakashana, Varanasi, Reprint 2005

• Norman L. Browse, Kevin G. Burnand, Allan T. Irvine and Nicholas M.

Wilson, Diseases of the Veins, Second Edition 1999

• R.C.G Russells (et al), Bailey & Love’s Short Practice of Surgery, Arnold

International Student edition London, 24th Edition.

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Edition 2004.

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Dalhanacharya. edited by Vaidya Yadavaji Trikamji Acharya, Chaukambha

Surabharati Prakashana, Varanasi, Reprint - 2003

Bibliography _______________________________________________________


• T.N.Patel, A System of Surgical Diagnosis, Jaypee Brothers Publication, Third

Edition, 1997.

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Brahmanand Tripathi, Chaukambha Sanskrit Pratishthana, Varanasi

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Atridev Gupta, Krishnadas Academy Varanasi, reprint 1993

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Shastri, Edited by Bhishagratna Bramhananda Shastri, 7th ed. Varanasi:

Chaukhambha Sanskrit Sansthan; 1999.

RESEARCH PROFORMA

DEPARTMENT OF P. G. STUDIES IN SHALYA TANTRA

GOVERNMENT AYURVEDIC MEDICAL COLLEGE,

BANGALORE – 560 009.

A STUDY ON SIRAJA GRANTHI AND ITS MANAGEMENT WITH PUNARNAVADI GUGGULU AND NIMBADI GUGGULU – A

COMPARATIVE STUDY Guide: Dr. B. A. Venkatesh B.S.A.M., B.A.M.S., M.D(Ayu), FICA Scholar : Dr. Nadaf A. N. Pt. Name Sl. No. & Group

OPD No. Address

IPD No

Age DOA

Sex DOD

Religion Education

Occupation Socio-economic status

Habitat Dietary Habits

Marital Status

A. PRADHANA VEDANA Duration: 01. Swelling in the lower extremities : Duration: 1) Present 2) Absent

If present – Nature of swelling – 1) Pitting 2) Non-Pitting 3) Unilateral 4) Bilateral 02. Skin changes : Duration:

1) Present 2) Absent

specify _ _ _ _ _ _ _ _ _ _

03. Itching : Duration:

1) Present 2) Absent

If pain present – Type of pain

1) Constant 2) Intermittent

B. ANUBANDHI VEDANA

1) Eczema 2) Dermatitis 3) Scaling

4) If other, specify _ _ _ _ _ _ _ _ _ _.

C. PRADHANA VEDANA VRUTTANTA

Onset of the disease in order with chronicity –

D. POORVA VYADHI VRUTTANTA History of similar previous complaints – Present / Absent

1) Hypertension 2) Diabetes 3) Tuberculosis

4) Asthma 5) COPD 6) Vericose ulcer

Give details –

History of other diseases, if any –

E. POORVA CHIKITSA VRUTTANTA Whether patient has taken treatment for present complaints?

Yes / No. If yes, give details _ _ _

History of any surgical procedures – Yes / No.

If Yes, give details –

Give the details of the management of previous similar complaints –

F. KAUTUMBIKA VRUTTANTA

Any history of similar complaints in the family Yes / No.

1) Maternal Family 2) Paternal Family

Details –

H/o of any other disease –

G. VAIYAKTIKA VRUTTANTA

01. Appetite i) Normal ii) Reduced iii) Increased

02. Bowel i) Regular ii) Irregular

04. Micturation i) Normal ii) Nocturia iii) Dysuria

05. Sleep i) Normal ii) Disturbed

06. Ahara i) Vegetarian ii) Non-vegetarian

1) Regular 2) Irregular

3) Proportionate 4) Dis-proportionate

5) Timely 6) Irrespective of time schedule

07. Vyasana – Smoking / Tobacco Chewing / Alcohol / Tea / Coffee/ others

H. GENERAL EXAMINATION

01. Pulse – / Min 02. Blood pressure – / mm of Hg

03. Temperature – 0F / Afrebrile 04. Respiratory rate – / Min

05. Conjunctiva – 06. Tongue –

07. Prakriti – 08. Satwa –

I. SYSTEMIC EXAMINATION

a) Respiratory system –

b) Cardio-vascular system –

c) Per abdomen –

J. LOCAL EXAMINATION

INSPECTION

1. Involvement of leg

2. Involvement of vein

3. Site of tortuous dilated vein

PALPATION

01. Temperature 1) Present 2) Absent

02. Cough impulse Test 1) Present 2) Absent

03. Trendelenburg Test (a) 1) Present 2) Absent

04. Trendelenburg Test (b) 1) Present 2) Absent

05. Perthe’s Test 1) Present 2) Absent

06. homan`s sign 1) Present 2) Absent

07. Tenderness 1) Present 2) Absent

08. Schwartz test 1) Present 2) Absent

K. INVESTIGATIONS

Doppler study (If necessary)

L. FINAL DIAGNOSIS

M. CHIKITSA

Group A : Punarnavadi Guggulu 500 mg Internally Two tablets twice

daily after food.

Group B : Nimbadi Guggulu 500 mg – Internally Two tablets twice

daily after food.

Group C : Advise to wear elastic stockings

SELF GRADE SCORING FOR RESULT ASSESSMENT PARAMETERS

SL. PARAMETER DESCRIPTION GRADEAbsent 0 01. Itching Present 1 Absent 0 02. Ankle Oedema Present 1 No colour changes 0 Patchy hyperpigmentation 1 Complete hyperpigmentation with eczema 2

03. Skin changes

Complete hyperpigmentation with lipodermatosclerosis

3

Absent 0 04. Tortuous dilated veins Present 1

N. ASSESSMENT OF THE THERAPY

During Treatment AT ASSESSMENT PARAMETERS BT 30 60 90 FU1 FU2 FU3

01. Itching 02. Ankle oedema 03. Skin changes

04. Tortuous dilated veins

RESULT

1) No Improvement 2) Mild Improvement 3) Moderate Improvement

4) Marked Improvement

Signature of the guide Signature of the PG Scholar

MASTER CHART

GROUP – A

GROUP – A Observational Data Clinical Data

Subjective Objective

Itching Ankle

Oedema

Skin

Changes TartuousityS. No Name O.P.No Age Sex Occup

BT AT BT AT BT AT BT AT

Follow up

1. N Prasanna 002000 34 M S 1 1 1 0 1 0 1 1 NR

2. Thiru J 000579 31 M B 0 0 1 1 1 1 1 1 NR

3. Kasturi 004072 46 F Hw 0 0 1 0 0 0 1 1 NR

4. Shankara L 000184 46 M S 1 1 1 0 1 1 1 1 NR

5. Lakshmana S 059095 66 M Fa 1 0 1 0 2 1 1 1 NR

6. Tiruvalla H 059184 39 M B 0 0 0 0 1 1 1 1 NR

7. Katta Shrihari 004072 50 M B 1 1 1 0 1 1 1 1 NR

8. Chandru D 024924 34 M Fa 1 0 1 1 2 1 1 1 NR

9. Shamalakshmi 024932 48 F Hw 1 1 1 0 1 0 1 1 NR

10. Ramachandra S 054307 35 M B 1 0 0 1 1 1 1 NR

11. P R Nagaraj 041133 32 M B 1 1 1 0 1 1 1 1 NR

12. Shrinivasa J 000492 32 M La 1 1 1 0 1 1 1 1 NR

13. Ramesh R 011663 40 M B 0 0 0 0 1 1 1 1 NR

14. N Satish 054621 47 M Fa 0 0 1 1 2 1 1 1 NR

15. Majara Mulla 054620 45 M B 1 1 1 0 1 1 1 1 NR

16. Ramadevi M 050298 60 F Hw 1 0 0 0 1 1 1 1 NR

17. Arun B 055034 32 M B 0 0 1 0 1 1 1 1 NR

18. Bharth. A 055032 32 M B 0 0 1 0 1 1 1 1 NR

19. Manimeh G 055103 60 M B 1 1 1 1 1 0 1 1 NR

20. Muniyappa J 014987 50 M Fa 0 0 1 0 1 0 1 1 NR

GROUP - B

Group B Observational Data Clinical Data


Itching Ankle

Oedema

Skin

Changes TartuousityS. No Name O.P.No Age Sex Occup


Follow

up

1. 017752 Chandrakumar E 64 M B 1 0 1 1 3 3 1 1 NR

2. 032376 Shyamaladevi D 48 F Hw 1 1 0 0 0 0 1 1 NR

3. 179273 Kartika 32 M B 1 1 1 0 2 1 1 1 NR

4. 005491 Ramaprasad A 46 M S 1 0 1 0 0 0 1 1 NR

5. 057038 N Sundaraju 41 M Fa 1 1 1 1 0 0 1 1 NR

6. 055076 Ramesh L 38 M B 1 0 1 0 2 2 1 1 NR

7. 016836 Satyanarayana K 61 M S 0 0 0 0 0 0 1 1 NR

8. 036596 Keshava 38 M B 0 0 0 0 2 2 1 1 NR

9. 033712 Keshvacharya C 35 M La 0 0 1 1 1 0 1 1 NR

10. 009433 Ravindra S 51 M La 1 0 0 0 2 1 1 1 NR

11. 034614 Krishnaveni M 34 F Hw 1 0 1 1 2 1 1 1 NR

12. 038074 Gouri G 68 F B 1 0 1 0 3 3 1 1 NR

13. 037439 Mohini B 35 F Hw 1 0 0 0 2 2 1 1 NR

14. 003504 Shobha L 35 F Hw 0 0 1 0 1 1 1 1 NR

15. 004184 Shantakumara 60 M S 1 1 1 0 0 0 1 1 NR

16. 091704 Ajit R 47 M B 1 0 1 0 1 1 1 1 NR

17. 043063 Shrimant A 38 M B 0 0 0 0 3 2 1 1 NR

18. 032944 Ramalinga Reddy 56 M S 1 0 0 0 0 0 1 1 NR

19. 010662 Renuka Acharya L 46 M B 1 1 1 1 0 0 1 1 NR

20. 011065 Shrinivas E 36 M Fa 0 0 1 0 2 1 1 1 NR

GROUP - C

Group C Observational Data Clinical Data


Itching Ankle

Oedema

Skin

Changes TortuousityS. No Name O.P.No Age Sex Occup


Follow up

1. 039663 B C Jain 52 M S 1 0 1 0 1 0 1 1 NR

2. 018376 Raghavendra K 57 M S 1 0 1 0 1 0 1 1 NR

3. 048397 Nityaananda 45 M S 0 0 1 1 1 1 1 1 NR

4. 004563 Thamas L 54 M B 1 1 0 0 1 1 1 1 NR

5. 019810 Mahesh B 56 M B 1 1 1 0 1 1 1 1 NR

6. 003865 Kiran G 45 M S 0 0 1 0 1 1 1 1 NR

7. 019809 Murli S 40 M La 0 0 0 0 1 1 1 1 NR

8. 019809 Mahalinga R 57 M Fa 1 1 1 0 1 1 1 1 NR

9. 014263 Nagesh A 49 M La 0 0 1 0 1 1 1 1 NR

10. 35900 Radha 37 F Hw 1 1 1 1 1 1 1 1 NR

11. 39650 Guruprakash 30 M S 1 0 1 1 1 1 1 1 NR

12. 46658 Savitri 53 F Hw 1 1 1 0 1 0 1 1 NR

13. 11075 D.Vasadeva 50 M S 1 1 0 0 1 1 1 1 NR

14. 475600 Sayed Njira 58 M La 0 0 1 1 0 0 1 1 NR

15. 50404 Shekhara 55 M S 1 1 1 0 1 1 1 1 NR

16. 41027 Siddlingayya 35 M S 1 1 1 0 1 0 1 1 NR

17. 49772 Shalini 38 F Hw 1 1 1 1 3 3 1 1 NR

18. 019865 Shridhara 38 M S 1 0 1 0 1 1 1 1 NR

19. 19815 Ashwatha Nrayana 60 M S 0 0 0 0 1 0 1 1 NR

20. 19825 Govinndappa 52 M S 1 0 1 0 1 0 1 1 NR

M –Male; F – Female; Hw – House wives; La – Labour; B – Businessmen; S – Social service; Fa – Farmer; NR – No Relapses

A STUDY ON SIRAJA GRANTHI AND ITS MANAGEMENT WITH ...

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