A wonder medicated thread in the management of Vagino-Anal Fistula - A Case...

[Full title: A wonder medicated thread in the management of Vagino-Anal Fistula - A Case Report]

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CASE REPORT April 2023 Journal of Ayurveda and Integrated Medical Sciences | April 2023 | Vol. 8 | Issue 4 239 A wonder medicated thread in the management of Vagino-Anal Fistula - A Case Report Pallavi A. Hegde 1 , Mahalaxmi Bilagi 2 1 Professor, Department of PG Studies in Shalya Tantra, BVVS Ayurved Medical College and Hospital, Bagalkot, Karnataka, India. 2 Final Year Post Graduate Scholar, BVVS Ayurved Medical College and Hospital, Bagalkot, Karnataka, India. I NTRODUCTION Anorectal diseases cause great discomfort making one's life miserable. Arsha (Piles), Bhagandara (Fistula in ano) and Parikartika (Fissure in ano) are the common anorectal diseases suffered by the population globally [1] Among them Bhagandara (Fistula-in-ano) is considered as one of the Ashta Mahagaroga (8 major disease) by Acharya Sushruta due to more recurrence rate [2] The word Bhagandara is composed of 2 words Bhaga Address for correspondence: Dr. Mahalaxmi Bilagi Final Year Post Graduate Scholar, BVVS Ayurved Medical College and Hospital, Bagalkot, Karnataka, India. E-mail: mahalaxmibilagi 9845@gmail.com Submission Date: 11/02/2023 Accepted Date: 16/03/2023 Access this article online Quick Response Code Website: www.jaims.in DOI: 10.21760/jaims.8.4.40 and Darana [1] Bhaga word includes all the structures around the Guda (ano-rectal region) including Yoni (vagina) in case of females and Basti (urinary bladder). The word Darana means tear of surface associated with pain. When a Vedanaayukta Shopha (painful swelling) is formed in Gudapradesh within the vicinity of two Angula which becomes Pakwa and causes Daarana in Bhaga, Guda and Vastipradesha. [3] Bhagandara can be correlated with fistula in ano. The word fistula is derived from a Latin word, a reed, pipe or flute. It is an abnormal communication between anal canal and rectum with exterior (perianal skin) is called fistula in ano [4] It usually results from an anorectal abscess which burst spontaneously or opens adequately [5] Treatment for Fistula is a big challenge in front of the medical as well as surgical world due to high recurrence rate and increased likelihood of faecal incontinence [1] Acharya Charaka mentions the line of treatment for Bhagandhara as Virechana (Therapeutic purgation) followed by Paatana (Excision) or if Pakwa, Bhedana by Ksharasutra application [6] Application of A B S T R A C T In Ayurveda, Bhagandara (Fistula-in-ano) is considered as one of the Ashta Mahagaroga (8 major disease) by Acharya Sushruta due to high recurrence rate. In the present era anorectal disorders are increasing, due to sedentary life style and others factors. The word Bhagandara is composed of 2 words Bhaga and Darana. The formation of Pidika leads development of Bhagandara it is characterized by opening around the Guda Pradesha with painful discharge . Acharya Charaka mentions the line of treatment for Bhagandhara as Virechana followed by Paatana (Excision) or if Pakwa, Bhedana by Ksharasutra application. In India the Ksharasutra is having high success rate (96.67%) in the management of Bhagandhara (Anal fistula). A case of 36 years old female patient consulted with complaints of boil in the perianal / vaginal region associated with pain & foul-smelling discharge, was diagnosed as Vagino-Anal Fistula and treated with Ksharasutra therapy, along with some oral medications. Patient recovered well with complete excision of tract within a span of 4 months. Thus, Ksharasutra is very effective in treating this condition, with minimal surgical intervention Key words: Bhagandhara, Ashta Mahagaroga, Ksharasutra, Vagino-Anal Fistula.

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Pallavi A. Hegde et al. A wonder medicated thread in the management of Vagino-Anal Fistula ISSN: 2456-3110 CASE REPORT April 2023 Journal of Ayurveda and Integrated Medical Sciences | April 2023 | Vol. 8 | Issue 4 240 Ksharasutra in anorectal disease has become more popular due to its easy approach and low rate of recurrence. Acharya Sushruta has described about Ksharasutra in Nadivrana Chikitsa. [7] The present form of Ksharasutra therapy was initiated by Dr. P.S Shankaran and subsequently established by Prof. P.J Deshpande through many researches and development in department of Shalya Tantra at Banaras Hindu University [8] Ksharakarma is more important among Shastra and Anushastra Karma, Kshara having the Chedana, Bhedana, Lekhana also Tridoshaghna properties [9] Ksharasutra is capable to perform excision slowly by virtue of its mechanical pressure and chemical action in Bhagandara. So, for this study Ksharasutra therapy along with some internal medications are used to analyse the therapeutic effect in the management of Vagino-anal-fistula. C ASE R EPORT A 36 years old female patient came to Shalya Tantra OPD, with complaints of painful boil in the perianal/vaginal region since 15 days, foul smelling pus discharge from external opening since 8 days. Associated Complaints Patient also complaints of passing of hard stools since more than 2 years. History of Present Illness Patient was apparently normal 15 days back, and then gradually developed with boil in the perianal region, in the lower part of left labia majora, which was associated with pain and foul-smelling pus discharge. Pain was severe, continuous and throbbing in nature. For this she consulted a doctor near to her home and advised with oral medications, but didn’t get relief, then the doctor had advised her to consult our hospital, so she approached our hospital for further management. Past History Patient had an H/O recurrent perianal abscess at the same place in the year 2015 & 2017 and had undergone incision & drainage twice. Patient is not known case of HTN/DM-2 and other medical disorders General Examination ▪ Pulse - 82 bpm ▪ Blood pressure - 120/70 mm of Hg ▪ RR - 18 /min ▪ Pallor, Icterus, Cyanosis - Absent Astasthana Pariksha 1 Nadi : 82 /min, Vatapittaja 2 Mala : Kathinamala , once/ day with straining 3 Mutra : Prakruta , 4 – 5 times/day 4 Jihva : Ishatliptata 5 Shabda : Prakruta 6 Sparsha : Anushnasheeta 7 Drik : Prakruta 8 Aakruti : Madhyama Systemic Examination ▪ CNS - Conscious, alert, well oriented to time, place and person. ▪ CVS - S 1 S 2 heard, no added sounds ▪ RS - B/L AE+, NVBS - heard ▪ P/A - Soft, Non-tender, no organomegaly Local Examination Inspection ▪ Site: An external opening at lower part of left labia majora 4.5 cm away from the anal verge. ▪ Number: Single ▪ Colour: Pinkish red ▪ Discharge: Present ▪ Odour: Foul smell Palpation ▪ Tenderness: Present ▪ P/R: Sphincter tone was normal, tender dimpling at 1’O clock positio n

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Pallavi A. Hegde et al. A wonder medicated thread in the management of Vagino-Anal Fistula ISSN: 2456-3110 CASE REPORT April 2023 Journal of Ayurveda and Integrated Medical Sciences | April 2023 | Vol. 8 | Issue 4 241 ▪ On probing through external opening: A single internal opening of fistulous tract was found at 1’O Clock position in the anal canal. Investigations Hematology report: Hb - 12 gm%, WBC - 8000 cells/cumm, DC: P- 65%, L- 33%, E- 02%, M- 06%, B- 00%, CT- 3 min.10 sec, BT- 4 min.35 sec, RVD - Negative, HbsAg- Negative MRI - Fistulogram: An external opening in the left perianal region from which fistulous tract is travelling caudally & posteriorly in the extra sphincteric plane along left side of anal canal, after a length of about 4 cm from external opening fistulous is entering the sphincter & further traversing cranially in the inter sphincteric plane for a length about 1 cm, then coursing posteriorly & having internal opening at 1’O clock position just below the level of levator ani muscle. M ETHODOLOGY Treatment planned was Ksharasutra Therapy along with Oral medications as follows- SN Medicines name Dosage Anupana 1. Tab. Triphala Guggulu 1 TID Ushnodaka 2. Cap. Grab 1 BD Ushnodaka 3. Tab. Anuloma DS 1 HS Ushnodaka 4. Chirabilwadi Kashaya 2 Tsp TID Ushnodaka Apamarga Ksharasutra is prepared using Apamarga Kshara, Arka Ksheera, Haridra & Surgical linen thread no. 20 Procedure of Ksharasutra Therapy Poorva Karma ▪ Informed written consent for procedure and anaesthesia ▪ Part preparation ▪ Inj. T.T 0.5 ml IM, Inj. Xylocaine 2% plain test dose ID ▪ Avagaha Swedana with Panchavalkala Kwatha was given for 15 min. ▪ All the instruments were kept ready for the procedure. Pradhana Karma ▪ Patient was taken in lithotomy position ▪ Under all aseptic precaution painting and draping done ▪ Betadine was pushed from external opening ▪ Under local anaesthesia probing was done through external opening of fistulous tract at 5’ O clock position at lower part of left labia majora & was brought out from internal opening at 1’ O clock position in anal canal with the help of index and middle finger. ▪ Ksharasutra was placed in the tract. ▪ Haemostasis achieved ▪ Dressing and bandaging done. Paschat Karma ▪ Patient was advised for regular Avahaga Sweda with Panchavalkala Kwatha & dressing daily. ▪ Advised to visit every week for assessment and to change Ksharasutra. ▪ Advised to have normal diet, regimen and oral medications mentioned above. ▪ Advised to avoid prolonged sitting and travelling. Figure 1: External opening

[Find the meaning and references behind the names: Mild, Size]

Pallavi A. Hegde et al. A wonder medicated thread in the management of Vagino-Anal Fistula ISSN: 2456-3110 CASE REPORT April 2023 Journal of Ayurveda and Integrated Medical Sciences | April 2023 | Vol. 8 | Issue 4 242 Figure 2: Probing from external opening Figure 3: Ksharasutra application Figure 4: 3 rd sitting of Ksharasutra Figure 5: 6 th sitting of Ksharasutra Figure 6: 8 th sitting of Ksharasutra Figure 7: After Fistulotomy Figure 8: After 1 month Assessment: Sittings Size Pus discharge Pain 1 st 4.5 cm Present Severe 2 nd 4 cm Present Moderate 3 rd 3.5 cm Moderate Moderate 4 th 3 cm Moderate Mild 5 th 2.5 cm Mild Mild

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Pallavi A. Hegde et al. A wonder medicated thread in the management of Vagino-Anal Fistula ISSN: 2456-3110 CASE REPORT April 2023 Journal of Ayurveda and Integrated Medical Sciences | April 2023 | Vol. 8 | Issue 4 243 6 th 2 cm Mild After procedure 7 th 1 cm No After procedure 8 th 0.5 cm No After procedure Follow-up and Result ▪ Patient was advised to visit every week for assessment and to change Ksharasutra. ▪ In every sitting, the Ksharasutra length was measured and recorded. ▪ After 8 th setting of Ksharasutra changing 90% of length of the tract was cut and 0.5 cm was remained. ▪ Under local anaesthesia fistulotomy was done & advised dressing with BC 56 Oint. ▪ On 8 th day of follow up wound was healthy & healing. ▪ Wound got healed within a 1 month. DISCUSSION Now a days Ksharasutra is a gold standard method in the treatment of Bhagandhara without any complications & recurrence. Apamarga Kshara is having Chedana, Bhedana, Lekhana, Tridoshagna properties. Apamarga Kshara on Ksharasutra cauterizes the tissue of mass indirectly by its Ksharana Guna . Haridra is having Raktashodhana, Shothahara , Vatahara, Vishaghna Gunas & Vranaropaka Property. The action of turmeric powder provides the effect of bactericidal action with healing properties [8] Arkaksheera is having Shophahara, Vranahara, Kanduhara, Krimihara properties [10] The combined effect of all the ingredients was found effective in cutting & healing of fistulous tract. It cuts unhealthy portion of the tract & provides simultaneous healing due to above properties. Ksharasutra , it facilitates the drainage of infection, promotes healing and cuts the fistula tract naturally. Avagaha Sweda with Panchavalkala Kwatha helped to clean the pus discharge & associated debris from the tract & reduced local congestion, inflammation at perianal region. Panchavalkala Kwatha is having Kashaya Rasa Pradhana dravyas , exhibited Vranashodhana & Ropana properties [11] Oral Medications like Triphala Guggulu is indicated in Bhagandara [12] , Arsha, Vrana Shopha etc, diseases and ingredients of Triphala Guggulu are having Tikta, Kashaya and Madhura rasa, Ushna Virya, Katu Vipaka and properties like Rechana, Deepaniya , Vatashamana , anti-inflammatory, anti-microbial, and analgesic qualities [13] Cap Grab is having Vranapahari Rasa, Triphala Guggulu, Gandhaka Rasayana, Arogyavardhini Vati, Guduchi and Manjista which are having anti-microbial, anti-inflammatory properties, helps in healing of fistulous tract [14] Chirabilwadi Kashaya which is mentioned in Sahasrayoga [15] is indicated in Bhagandara. It is having Ushna Virya, Kapha Pradhana Dravyas, exhibited Deepana, Pachana & Vatanulomana properties [16] Tab. Anuloma DS contains Ajamoda, Jeeraka, Haritaki, Yastimadhu, Shunti , Saindava Lavana and Sonamukhi Dravyas and acts as a laxative [17] BC 56 Ointment is having Yastimadhu, Nimba, Karanja, Sal, Chakramarda, Jasada Bhasma Dravyas, which are having Vranashodhaka and Vranaropaka properties [18] CONCLUSION Thus, Ksharasutra therapy is very effective in the management of Bhagandhara with minimal surgical intervention with high success rate. It is a sphincter saving procedure, prevents recurrence and anal incontinence. Ksharasutra therapy is a gold standard para surgical procedure in the management of Bhagandara. Oral medications used are indicated in Bhagandara, and having Deepana, Rechana, Vatanuloma , antimicrobial and Anti-inflammatory properties, thus effectively helped in the healing of the fistulous tract and management of Bhagandara. REFERENCES 1 Harshitha Kumari, Rasmi Johnson: Bhagandara-Multiple Fistula In Ano- Management By Ksharasutra. International Ayurvedic Medical Journal,2018 {cited

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Pallavi A. Hegde et al. A wonder medicated thread in the management of Vagino-Anal Fistula ISSN: 2456-3110 CASE REPORT April 2023 Journal of Ayurveda and Integrated Medical Sciences | April 2023 | Vol. 8 | Issue 4 244 January, 2018}, http://www.iamj.in/posts/images/upload/957_961.pdf 2 Kaviraja Ambikadutta Shastri, Hindi commentary on Sushruta Samhita of sushruta. Sutrasthana; Avaraneeyamadhyayam : Chapter 33, Verse 5. Varanasi: Choukhambha Sanskrit Sansthan, 2016: Pg no-163. 3 Kaviraja Ambikadutta Shastri, Hindi commentary on Sushruta Samhita of sushruta. Nidaanasthana; Bhagandharanidanam : Chapter 04, Verse 4. Varanasi: Choukhambha Sanskrit Sansthan, 2016: Pg no-317 4 K Rajgopal Shenoy, Manipal Manual of Surgery, 2 nd edition, Rectum and Anal Canal, Chapter 31, New delhi, India: CBS Publishers & Distributors; 2005, Pg no- 529 5 Dr. Ashok Naikar et al: A Clinical Study of Apamarga Kshara Sutra in the Management of Bhagandara - A Case Study. J Ayurveda Integr Med Sci 2021; 1:352-355. https://jaims.in/jaims/article/view/1235 6 Vaidya Harish Chandra Singh Kushwaha, Hindi commentary on Charaka Samhita of Charaka. Chikitsa Sthana; Swayathuchikitsaadhyaya : Chapter 12, Verse 17. Varanasi: Choukhambha Oerientalia, 2012; Pg no- 306. 7 Kaviraja Ambikadutta Shastri, Hindi commentary on Sushruta Samhita of sushruta. Chikitsasthana; Visarpanadistanarogachikitsaadhyaya : Chapter 17, Verse 30-32. Varanasi: Choukhambha Sanskrit Sansthan, 2016: Pg no- 109. 8 Sah R K, Shah B, Prasad S M Effect of Ksharasutra Application in the Management of Bhagandara (Fistula- In-Ano) - A Case Report. Int. J. AYUSH CaRe. 2019; 3(1): 100-104. https://www.ijacare.in/index.php/ijacare/article/down load/80/57/ 9 Kaviraja Ambikadutta Shastri, Hindi commentary on Sushruta Samhita of Sushruta. Sutrasthana; Ksharapakavidhiadhyaya : Chapter 11, Verse 3. Varanasi: Choukhambha Sanskrit Sansthan, 2016: Pg no- 45. 10 Sri Brahmasankara Misra and Sri Rupalalaji Vaisya, Hindi commentary on Bhavaprakasa Nighantu, 1 st part, 10 th edition, Guduchyadivarga, Verse 69, Varanasi, Chaukhambha Sanskrit Sansthan, 2002: Pg no-303. 11 Sri Brahmasankara Misra and Sri Rupalalaji Vaisya, Hindi commentary on Bhavaprakasa Nighantu, 1 st part, 10 th edition, Vatadivarga , Verse 15-17, Varanasi, Chaukhambha Sanskrit Sansthan, 2002: Pg no-519. 12 Pandit Parasurama Sastri, Vidyasagar, Hindi commentary on Sarngadhara Samhita, Madyamakhanda: Gutikadhyaya: Chapter 7, Verse 82- 82. Varanasi: Chaukambha Orientalia, 2008: Pg no – 204. 13 Neelam Rawat, Shuchi Mitra, Usha Sharma, Khem Chand Sharma. An Overview of Triphala Guggulu and its Ingredients. AYUSHDHARA, 2023;10(Suppl 1): 47-59. https://doi.org/10.47070/ayushdhara.v 10 iSuppl 1.1134 14 https://greenremediesindia.in/product/grab-tablets/ 15 Ramnivas Sharma, Dr, Surendra Sharma, Hindi commentary on Sahasrayogam, Kashayaprakara : Dehli: Chaukhambha Sanskrit Pratisthan, 2009: Pg no – 17. 16 http://heb-nic.in/jrimissues/admin/freePDF/ywg 58898 e 9 iynq 48 evc 4.pdf 17 https://www.ayurmedinfo.com/2016/09/15/anulomads-tablet-uses-ingredients-dose-side-effects/ 18 https://rajved.in/bc-56-cream-20/ ******************************* How to cite this article: Pallavi A. Hegde, Mahalaxmi Bilagi. A wonder medicated thread in the management of Vagino-Anal Fistula - A Case Report. J Ayurveda Integr Med Sci 2023;04:239-244. http://dx.doi.org/10.21760/jaims.8.4.40 Source of Support: Nil, Conflict of Interest: None declared. Copyright © 2023 The Author(s); Published by Maharshi Charaka Ayurveda Organization, Vijayapur (Regd). This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by-nc-sa/4.0), which permits unrestricted use, distribution, and perform the work and make derivative works based on it only for non-commercial purposes, provided the original work is properly cited

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Bhagandara, Ksharasutra, Virechana, Triphalaguggulu, Therapeutic effect, Fistula in ano, Surgical intervention, Anal canal, Internal medication, Acharya Sushruta, Acharya Charaka, Oral medication, Local anaesthesia, Perianal abscess, Panchavalkala Kwatha, Ksharasutra therapy, Ksharasutra application, Perianal region, Fistulous tract, Anal incontinence, Avagaha sweda, Sphincter tone, External opening, Internal opening, Foul-smelling discharge, Anorectal disease.