FISTULA IN ANO AND ITS AYURVEDIC TREATMENT

FISTULA IN ANO AND ITS AYURVEDIC TREATMENT

INTRODUCTION

The anal fistula is a notorious disease due to its recurrence rate. Bhagandara is varyingly defined as a tear, ulcer or boil at Bhaga (Perianal region) within 2 finger circumference of it, causing painful abscess when opened is called Bhagandara. The Sanskrit word 'Bhagandara' has got two components-Bhaga and Darana. Bhaga means perianal region and Darana means to tear. The ancient Surgeon Sushruta has advocated various types of operations in Sushruta Samhita. He has advocated Kshara Sutra treatment due to probability of recurrence after surgery. Sushruta describes many kind of kshara like Apamarga, Palasa, Kadali. Fistula in ano and anorectal sepsis is along established condition described in “Corpus Hippocratum” in a treatise named “ON- Fistula”. Centuries have passed but the basic principles of management of anorectal sepsis remained the same which revolves around resolution of anorectal sepsis and treatment of fistula without hampering continence. Acharya Sushruta defined bhagandara as below:

“Guda bhaga basti pradesha daaranaat bhagandaraha”

PATHOPHYSIOLOGY OF FISTULA IN ANO

Understanding the pathophysiology is one of the pivots in management of Anorectal sepsis. Widely accepted cryptoglandular theory leading to abscess formation and fistula development needs to be well understood as this is the pathology responsible for almost 90% of the perineal sepsis and anal fistulas. The obstruction of anal crypt gland with inspisitted debris leads to infection in these glands, which penetrate, into the anal complex in varying degrees and suppuration follows the path of least resistance. Anorectal abscess is an acute manifestation of the crypto-glandular infection and fistula is chronic sequelae of this infection. Almost one third of the patients who undergo drainage of the Anorectal abscess develop the anal fistula.

EPIDEMIOLOGY

1.      Develop from anal abscess in 25-40% cases

2.      Male to female ratio 2:1

3.      Mean age: 38-45 years

CLASSIFICATION OF FISTULA IN ANO

They are usually classified based on relation to the analsphincter complex. Milligan & Morgan in 1934 classified the fistulas into high fistulas-those in which the internal opening lies above the anorectal ring and low fistulas-those in which the internal opening lies below the anorectal ring.

Park Classified the Fistulas

Anal fistulas are classified into the following 4 general types:

1.      Intersphincteric - Through the dentate line to the anal verge, tracking along the intersphincteric plane, ending in the perianal skin

2.      Transsphincteric - Through the external sphincter into the ischiorectal fossa, encompassing a portion of the internal and external sphincter, ending in the skin overlying buttocks

3.      Suprasphincteric - Through the anal crypt and encircling the entire sphincter, ending in the ischiorectal fossa

4.      Extrasphincteric - Starting high in the anal canal, encompassing the entire sphincter and ending in the skin overlying the buttocks

DIAGNOSIS

On examination, a tender, fluctuant mass is usually present with perianal and ischiorectal abscesses. Patients with intersphincteric or supralevator abscess may have no external findings, with only pelvic or rectal tenderness with fluctuance on digital rectal exam. Careful inspection and palpation may detect the presence of other anorectal pathology or an external opening or tract suggestive of fistula. Anoscopy may be performed to attempt to visualize the internal opening of a fistula or other mucosal abnormalities. Laboratory evaluation is generally not necessary with the exception of patients with systemic symptoms such as fever, serious underlying medical problems, or an unclear diagnosis.

RADIOLOGICAL EXAMINATION

1.      Fistulography: inject contrast through internal opening, followed by radiological imaging to delineate the fistulous tract

2.      MRI is recommended for complex and recurrent lesions and has a high concordance rate with operative findings

3.      CT scan is more efficient in detecting fistula associated with perirectal disease, but requires contrast and provides poor delineation of relationship of fistula with muscle

Types of Fistula in ano in Ayurveda (Bhagandara):-

Based upon the type of the tract formed and dosha involved, Bhagandara is classified into 5 types as below:

(1) Shataponaka – dominance of Vata dosha

(2) Ushtragreeva – dominance of Pitta dosha

(3) Parisraavi – dominance of Kapha dosha

(4) Shambookavarta – dominance of all the three doshas

(5) Unmargi – Due to injury/external causes

Formulations used in Fistula in ano:-

While treatnig the patients of Bhagandara following formulations are taken help:

1) Triphala guggulu

2) Gandhaka rasayana

3) Chiruvilwadi kwatha

4) Kaishora guggulu

5) Chandraprabha vati

6) Gokshuradi guggulu

7)Swayambhuva guggulu

8) Madhusnuhi rasayana

9) Chirabilvadi kashaya

10) Guggulupanchapala choornam etc

AYURVEDIC MANAGEMENT FISTULA IN ANO

Kshara Sutra Management

"Kshar Sutra"  is a sanskrit phrase in which Kshar refers to anything that is corrosive or caustic; while Sutra means a thread. It is described by many Ayurvedic texts  which originated and flourished in India. It is one among popular Ayurvedic treatment modality in the branch of Salyatantra followed by Susruta.The Ksharsutra was first mentioned by the "Father of Surgery" Sushruta in his text named SUSHRUT - SAMHITA for the treatment of Nadi Vrana(sinus), Bhagandara (fistula- in - ano), arbuda(excision of small benign tumour) etc..Although Brihattrayi- the chief three texts of Ayurveda mention the use of kshara sutra, there is no description of their preparation properly. It was Chakrapani Dutta in late eleventh century in his book Chakradatta, first mentioned the method of preparation with a clear-cut indication of its use inbhagandara and arsha(haemorrhoid). In his book Chakradutta explains the method that by smearing a sutra (thread) repeatedly in the latex of snuhi (Euphorbia neriifolia) and haridra(turmeric) powder makes the kshara sutra. Later authors like Bhavamishra, Bhaisajyaratnavali etc. also mention the same method. But because of brevity of preparation and inadequate explanation of procedure of application, it lost its popularity among Ayurvedic surgeons. Later in Rasatarangini a better preparation procedure was introduced still the credit of making it practically in use goes to Prof. P.J.Deshpande, his research officer Dr. S.R. Gupta and his coworkers. They rediscovered and standardized the ksharasutra in the present era . The Dept. of Shalya- Shalakya, Faculty of Ayurveda, IMS, BHU should be credited for the abundant use and popularization of this technique

Preparation of Kshar Sutra:

Requirements:

1.         Thread : Surgical Linen thread of size 20.

2.         Latex of Euphorbia neriifolia

3.         Haridra (Curcuma longa)

4.         Apamarg Kshar (Achyranthus aspera)

Method of Preparation:

For the preparation of thread, surgical linen thread gauge number 20 was manually coated eleven times with the latex of Euphorbia neriifolia, followed by seven coatings of the latex and the alkaline powder of Achyranthus aspera alternatively, and dried. In the final phase, three coatings of latex and powder of Curcuma longa were given alternatively.The thread thus prepared was sterilized by ultra violet radiation and placed in a polythene bag or glass tube.

Mode of Action of Kshar Sutra:

1.         The cut through of fistulous tract is affected by the pressure exerted on anorectal tissue by the moderately tight Kshar Sutra tied in the fistulous tract.

2.         The presence of Kshar Sutra in the fistulous tract does not allow the cavity to close down from either ends and there is a continuous drainage of pus along the Kshar Sutra itself.

3.         The Kshar Sutra slowly and gradually cuts through the fistulous tract from apex to the periphery. There is an ideal simultaneous cutting and healing of the tract and no pocket of pus is allowed to stay back.

4.         The Kshara (Caustics) applied on the thread are anti-inflammatory, antislough agents and in addition, have property of chemical curetting. The Kshar Sutra remains in direct contact of the tract and therefore, it chemically curettes out the tract and sloughs out the epithelial lining, thereby allowing the fistulous tract to collapse and heal.

5.         The Kshar Sutra, due to its antibacterial property, does not allow bacteria to multiply in its presence.

6.         The pH of Kshar Sutra was towards the alkaline side and therefore it did not allow rectal pathogens to invade the cavity.

Post Kshar Sutra Therapy Instructions:

1.         Patients are allowed to take orally only liquid diet before six hours of operation.

2.         From next morning, warm Nimba patra Kwath sitz bath are advised to take at least thrice a day adding 5gm Sphatikadi yog for a minimum period of 3 weeks.

3.         Semi solid diet is allowed after 3-4 hours of the procedure.

4.       Suitable Medicines according to condition...................

General Advices after Kshar Sutra Therapy:

Patients are advised strictly:-

1.         To be ambulated (stay active like walking) during the period of treatment.

2.         To take normal food daily and avoid irritant spicy food.

3.         To take fibre containing diet & vegetables with plenty of water.

4.         To avoid such types of foods which cause constipation.

5.         To keep the bowel clear regularly by taking suitable and mild laxatives.

6.         To avoid prolonged sitting as well as standing during the treatment.

7.         To avoid long distance travelling and driving.

8.         To keep the anal region clean and do proper dressing

Benefits of the Ksharsutra Therapy:

1.         It is an Out Patient Treatment.

2.         Only 30 minutes is required for the procedure

3.         Hospital stay is usually minimum(5-6 hrs).

4.         Minimal bed rest is required after the procedure.

5.         Patient can resume his / her daily routine within 3 to 5 days.

6.         The recurrence rate is very less after Ksharsutra ligation procedure

7.         Most important benefit of Kshar Sutra Therapy over Modern Surgeries is that the muscles that supports the Anus and helps in controlling the bowel movements are not dissected and hence the possibility of Anal Incontinence (loss of power to hold stools) is not there.

Mode of action of Kshara sutra:

Kshara sutra works by pressure necrosis, chemical cauterization by kshar (alkali) and sloughing of the tissue of the walls of the fistulous track along with adequate drainage. It leads to an easy debridement of unhealthy tissue and pus etc. and thus providing a cleaner base for the wound healing of the fistulous track. The Kshara-sutra is changed weekly so that an average pace of cutting of about 0.5 - 1 cm/week is maintained along with healing from behind. Finally the whole track is cut through and the fistula gets healed up with minimal scarring and without any other major complication.

CONCLLUSION

Fistula is an abnormal communication between the anus and the Peri-Anal Skin, which may be with or without Abscess. In treatment f Fistula in Ano Ksharsutra is used it’s a type of thread / medicated setone prepared by coating and recoating the thread 15 to 21 times with different drugs of plant origin. The mechanical action of the treads and the chemical action of the drugs coated on the thread, together do the work of cutting, curetting, draining, and cleaning the fistulous track, thus promoting healing of the track/ wound.