Abstract :
A varicose ulcer is an open wound that remains unhealed for at least 4 weeks, occurring in presence of varicose veins. Its prevalence increases with age.1 Approximately 1% of population suffers from it at some point in life.1 Although the overall prevalence is relatively low, its refractory nature increases the risk of morbidity and mortality and has a significant impact over quality of life.2 The goals of treatment are to reduce oedema, improve wound healing and prevent recurrence.2 Although various modern treatments are available, have variable effectiveness and limited support data.2 Leech therapy can be an alternative option for patients, who are unfit or afraid of surgery, aged, delicate and poor.3

Leech application improves the blood circulation; it has anti-inflammatory, vaso-dilating, anticoagulant and antibacterial action; it helps in faster and effective healing of varicose ulcer and reduces its recurrence.

One of the many cases treated through leech therapy in our hospital will be presented here. A 65 year-old non-diabetic, Hypertensive female patient, suffering with varicose ulcer and being treated with modern medicines for 3 years, was admitted in our Seth R.V. Ayurved Hospital, Sion for non-healing varicose ulcer. She was treated with Leech therapy. Patient got complete healing after repeated Leech application for 7 times over a period of 2 months.

Keywords : Varicose ulcer, Leech Therapy

Case study report
Type of study :Observational Case Study
Study center : Seth R.V. Ayurved Hsopital, Sion
Name of patient : Mrs. Shashikala Suryavanshi
Age & Sex : 65 yrs Female
Occupation : Housewife

Demographics and chief complaints of the patient :
3rd Aug 2013
1. Non-healing ulcer over left leg’s pre-tibial region.
2. Itching, hyper-pigmentation and oedema over left leg.{fig.1,2}
3. Left leg pain

Investigations :
Arterial and venous color doppler of both lower limbs dated 16th Aug 2012 s/o Long saphenous vein valve incompetency.
Arterial venous doppler study- normal
Blood report- dated 4th Aug 2012
Hb- 10.2 gm%
R.B.C.- 3.5 million/cu.mm
W.B.C.- 9200/cmm
E.S.R.- 50 at the end of one hour(By Westergren’s method)

History of previous medical illness :
Right side hemiparesis 5 yrs back
K/C/O hypertension since past 6 yrs for which taking anti-hypertensive tab. Losar-H.

Brief history of illness :
Female Patient aged 65 years came to Kayachikitsa Out Door Patient Department of Seth R.V.Ayurved Hospital Sion with above mentioned complaints.
She has been taking modern treatment from various doctors since past 3 yrs for the varicose ulcer. {Fig.1,2}
Skin grafting was done 1 yr back but failed and ulcer recurred at same site. {Fig.1,2}
When she realized that there was no relief of her complaints and no satisfactory and complete healing of her ulcer, she decided to try an Ayurvedic approach.

General examination :
Weight - 56 kg
Height - 155cm
Respiration - 18/min
B.P. - 130/80 mm of Hg
Pulse - 82/min
Sleep - 6-7 hrs daily
Dosha - Pitta
Dhatu - Rakta, Maansa, Meda
Strotas dushti - Raktavaha, Maansavaha
Rogmarg - Bahya
Nidan: Ahar hetu - Consumption of excessive oily, spicy and fermented food like dhokla, viruddhahar like milk and khakra together causing pitta-prakop and rakta-dushti
Vihar hetu - Right side hemiparesis leading to less ambulation for six months causing stagnation of blood in the limbs

Examination of wound {Fig.1,2}:

Darshan :
7.5 x 4.3 cm sized wound over left pre-tibial region.
Irregular shaped(~Vishamakaar).
Congestion ++
Purulent discharge ++
Granulation absent
Local oedema ++
Hyper-pigmentation over the left lower leg around the wound

Sparshan :
Kathin (~Hard)
Local tenderness ++
Local oedema ++

Prashna :
Itching over left lower leg
Left leg pain at rest and on walking
Shaman Therapy given from 3rd Aug 2012 – 9th Aug 2012

Shaman Chikitsa/internal medications :
Gandhak Rasayan 250 mg t.d.s
Kaishor guggula 500 mg t.d.s.
Triphala kwath padavagahan twice daily
The above treatment was done for 1 week but there was no significant improvement in the healing of ulcer.
So we decided to go for Shodhan with Jalaukavacharan (~Leech therapy) along with the above Shaman Chikitsa.
Leech therapy was done once a week for continuous 6 weeks starting from 10th August 2012 till 16th September 2012.

Observations and conclusion :
When leech therapy had been started for the ulcer, there was gradual improvement in its healing day by day.{Fig.3,4}
At first there was reduction in pus discharge and oozing from the wound.
Then there was reduction in congestion of the wound.
This was followed by reduction in oedema and pain.
Granulation tissue had started one week after the application of first leech which gained speed with repeated application of leech once per week.{Fig.5,6}
This lead to complete healing of the ulcer after seven weeks of leech therapy.

Discussion :
Conditions for jalaukavacharan:
Oedematous, hard, shyam , indurated, congested vrana, Pittaj-rakta dushti & related diseases, Avaghaad/Gambhir or deep-seated Doshas, Localised diseases/conditions.4,5,6
All the above features were present in the ulcer.
Leech has certain enzymes and substances which possess following actions- 7
1. Anti-bacterial action decreases Dushta strava (~pus)
2. Thrombolytic: Removes the Srotorodha
3. Anti-coagulant: stops further Srotorodha
4. Anti-inflammatory: reducing Raktadushti
5. Vasodilating action.
All the above actions eventually improve blood circulation, which increases the oxygenation thereby increasing nutritional supply, which causes increased granulation thus leading to wound/ulcer- healing, reduced edema, congestion, hyperpigmentation, itching and local pain also.
Rakta dhatu does Maansa-pushti as well as Varna prasadan.8 Sira is the Upadhatu of Rakta 9and also develops from Mrudupaak of Meda-dhatu.10 Jalaukavacharan improves the blood circulation by removing the stagnated blood, thus improving Rakta-poshan and Meda-dhatu poshan by Ksirdadhi nyaya leading to improved Sira poshan as well. This improves the elasticity of the Sira. The leech’s saliva contains enzymes and compounds that act as an anticoagulant agent. The most prominent of these anticoagulant agents is hirudin, which binds itself to thrombins, thus, effectively inhibiting coagulation of the blood. Another enzyme, destabilase, breaks up any fibrins that have formed, has thrombolytic effect, which can also dissolve clots of blood that have formed. There are some compounds in the leeches’ saliva that act as a vasodilator agent, and they are the histamine-like substances, the acetylcholine, and the carboxypeptidase-A inhibitors, which widen the vessels, thus causing inflow of blood to the site.11 All this eventually help reducing the recurrence of such varicose ulcers.



* PG Scholar, ** Assistant Professor, *** Associate Professor and HOD, Department of Kayachikitsa, APM’s Ayurved Mahavidyalaya, Sion, Mumbai

References :
1. Management of chronic venous ulcer, a national clinical guideline, www.sign.ac.uk, august 2010
2. Diagnosis and treatment of venous ulcers, American family physicians, aafp.org, april 15,2010
3. Sushruta Samhita Ayurvedtatvasandipika hindi commentary edited by Kaviraj Ambikadutta Shastri,Chaukhamba Sanskrit Pratishthan,1st part, Sutra-sthaan chapter 13, Verse 3, Page 43
4. Sushruta Samhita Ayurvedtatvasandipika hindi commentary edited by Kaviraj Ambikadutta Shastri, Chaukhamba Sanskrit Pratishthan, 2008, 2nd part , Chikitsa-sthaan, Chapter 1, Verses 28,29,30, Page 6
5. Sushruta Samhita Ayurvedtatvasandipika Hindi Commentary edited by Kaviraj Ambikadutta Shastri, Chaukhamba Sanskrit Pratishthan, 1st part, Sutra-sthaan Chapter 13, Verse 4, Page 43
6. Sushruta Samhita Ayurvedtatvasandipika Hindi Commentary edited by Kaviraj Ambikadutta Shastri, Chaukhamba Sanskrit Pratishthan, 2008, 2nd part, Sharir-sthaan, Chapter 8, Verse 25-26, Page 68 7. Hirudo Medicinalis,Wikipedia.com
8. Sushruta Samhita Ayurvedtatvasandipika Hindi Commentary edited by Kaviraj Ambikadutta Shastri, Chaukhamba Sanskrit Pratishthan, 2008, 1st part, Sutra-sthaan Chapter 15, Verse 7, Page 57
9. Charak Samhita Vaidya Manorama Hindi Commentary 2nd part edited by Acharya Vidyadhar Shukla and Prof.Ravi Dutta Tripathi, Chaukhamba Surbharti Prakashan, 2006, 2nd part, Chikitsa-sthaan, Chapter 15, Verse 17, page 361
10. Sushruta Samhita Ayurvedtatvasandipika Hindi Commentary edited by Kaviraj Ambikadutta Shastri, Chaukhamba Sanskrit Pratishthan, 2008, 2nd part, Sharir-Sthaan, Chapter 4, Verse 26, Page 32
11. Leechestherapy.com