|Year : 2019 | Volume
| Issue : 1 | Page : 51-55
A case report on management of recurrent anal fistula by Nyagrodha Ksheer Sutra
Dhananjay D Deshmukh, Kiran B Khandare, Pooja P Shrivastav
Department of Shalyatantra, MGACH and RC, Wardha, Maharashtra, India
|Date of Web Publication||27-Aug-2019|
Dr. Dhananjay D Deshmukh
Shalyatantra Department, MGACH and RC, Salod (H) Wardha. (MS).
Source of Support: None, Conflict of Interest: None
Background: Fistula in ano is defined as an inflammatory tract lined by unhealthy granulation tissue having its external opening in the perianal region and internal opening in the anal canal or rectum. In Ayurveda, it can be correlated with Bhagandar (fistula in ano). Various surgical as well as para-surgical treatments are in rage to treat anal fistula but have certain limitations and risk of recurrence. Critical recurrent anal fistula is one among the toughest and rare anal fistula to treat and still stand as a challenge in front of surgeons. Materials and Methods: In this case report, critical recurrent anal fistula is managed by Nyagrodha Ksheer (Latex) Sutra (medicated seton) after all the mandatory investigations, and its efficacy was evaluated on the basis of clinical parameters such as pain, itching, pus discharge, and cutting rate. Results: Patient showed significant results in clinical parameters evaluated. Even after 1-month follow-up assessment, there were no signs of recurrence. Conclusion: As seen in many cases, it is very difficult to manage the anal fistula because of its high recurrence rate. In this case also, it was evident that the patient was having the same complaint of recurrence of fistula after multiple surgeries. In order to find out a minimal invasive technique, an attempt was made to treat the critical recurrent fistula with the help of Nyagrodha Ksheer Sutra. From the aforementioned case, it is concluded that Nyagrodha Ksheer Sutra is efficient in treating critical recurrent anal fistula. It also revealed that Nyagrodha Ksheer acts on the basis of its Shodhan (wound cleaning) and Ropan (wound healing) property to heal critical recurrent anal fistula.
Keywords: Bhagandar, fistula in ano, Nyagrodha Ksheer Sutra, recurrent anal fistula, Ropan, Shodhan
|How to cite this article:|
Deshmukh DD, Khandare KB, Shrivastav PP. A case report on management of recurrent anal fistula by Nyagrodha Ksheer Sutra. J Indian Sys Medicine 2019;7:51-5
|How to cite this URL:|
Deshmukh DD, Khandare KB, Shrivastav PP. A case report on management of recurrent anal fistula by Nyagrodha Ksheer Sutra. J Indian Sys Medicine [serial online] 2019 [cited 2019 Nov 17];7:51-5. Available from: http://www.joinsysmed.com/text.asp?2019/7/1/51/265515
| Introduction|| |
Acharya Sushruta, Father of Surgery, included Bhagandar as one among the Ashtamahagad (eight dreadful diseases). This shows the gravity of this disease. At first, it is present as Pidika (boil), and when it becomes Pakwa (suppurated) it forms Bhagandar. It causes Daran (cutting pain) in Bhag (vulva), Guda (anal canal), and Basti Pradesh (pelvic region). It can be correlated to fistula in ano in modern medical sciences. Fistula in ano is an inflammatory tract lined by unhealthy granulation tissue having internal opening in anal canal and rectum and external opening in the perianal region. Most fistulas are thought to arise as a result of crypto-glandular infection with resultant perianal abscess. At present, most common surgical procedures adopted in the treatment of fistula in ano are fistulectomy, fistulotomy, flap advancement, ligation of intersphincteric fistulous tract, glue, and seton. Management of fistula in ano is a daunting task for most of the surgeons due to its two dreadful complications—recurrence and incontinence. Up to 26.5% recurrent rate, 40% of high impaired continence and 5.6% nonhealing of the wound were reported after surgical treatment. In addition to this, there will be severe postoperative pain that persists for many days and required hospitalization for longer duration.
To overcome such problems, surgical field is planned for some alternative technique to treat these cases with minimal operative complications, recurrences, and failure. Here lies the importance of para-surgical methods in Ayurveda. Ayurveda has a unique way of treating fistula in ano. All types of fistula in ano respond well to different types of Kshar (caustic alkali) Sutra as well as Ksheer (Latex) Sutra.Kshar and Ksheer Sutra is a medicated seton. Mechanical action of the thread and chemical action of the drug coated over the thread together do the work of cutting, curetting, scraping, draining, and healing of fistula in ano.
In this case, Nyagrodh Ksheer is used for preparing the Ksheer Sutra, and its efficacy was evaluated on the basis of clinical parameters in recurrent case of fistula in ano.
| Case Report|| |
A 47-year-old male patient came to Shalyatantra outpatient department (OPD) complaining of throbbing pain at perianal region and pus discharge from the boil present at perianal region. History revealed patient was having the aforementioned complaints for 5 years with a history of hypertension for 4 years, and was on regular medication. He was operated for incision and drainage, and fistulectomy for the same before 4 years by different surgeons for two times in a gap of 3 months, but still recurrence took place. He took treatment for the same from various hospitals but got only symptomatic relief, and every time his complaints reoccurred. Therefore he came to Shalyatantra OPD for further management with magnetic resonance imaging (MRI), endo-anal sonography as well as pathological investigation reports in hand.
| Personal History|| |
The patient was a shopkeeper by profession, used to take mixed diet, and was having the habit of occasionally drinking alcohol and chewing tobacco (kharra) for 15 years. Because of his improper lifestyle, he was having complaints of irregular bowel habit for long time.
| Systemic Examination|| |
General condition of the patient was fair and he was well oriented, and his vitals were normal. His blood pressure was under control. The patient’s weight was 60kg and height was 158 cm.
| Ashtavidha Pariksha (Eight-Fold Examination)|| |
Nadi (pulse)—Vatapittapradhan (predominance of vata and pitta)
Mutra (urine)—Samyak (normal)
Shabda (voice)—Spashta (clear)
Sparsh (touch)—Anushna (normal)
Druk (eye)—Samyak (normal)
Akruti (built)—Sthool (obese)
| Local Examination|| |
- (1) External opening was present at 11 O′clock position approximately 4–6cm from anal verge.
- (2) Pus discharge was present at external opening.
- (3) Previous operative scar was present.
- (1) Induration was present at right side of the perianal region.
- (2) Tenderness was present.
- (3) Local temperature was raised.
Per Rectal Digital and Proctoscopic Examination
- (1) Sphincter tone was normal.
- (2) Internal opening was felt at 12 O′clock position in the anal canal.
- (3) No evidence of any other growth was seen.
| Investigations|| |
Total leukocyte count—4800/cumm
Differential leukocyte count—N = 69%, L = 23%, E = 06%, M = 02%.
Red blood cells—5.28 million
Platelets count—333,000 mm
Bleeding time—1 minute 50 seconds
Clotting time—5 minutes 45 seconds
Random blood sugar—147mg/dL
Kidney function test—within normal limits (WNL)
Liver function test—WNL
| MRI Observation and Impression|| |
The study revealed a fairly well-defined trans-sphincteric fistulous tract in the perineal region with external opening at the right perianal region extending anteriorly and superiorly for a distance of approximately 6.0cm with internal opening in the anal canal at 12 O′clock position.
There was a secondary branching tract seen arising at approximately 3cm from the external opening coursing anteriorly and terminating into the subcutaneous plane.
The maximum width of this sinus tract measured approximately 3mm.
| Ultrasonography Observation|| |
Sign of (S/O) perianal abscess of size about 33mm × 9.1 mm.
It is at 10 O′clock position going upward medially of tract length about 3.4cm.
Opening in anal canal about 1.7cm above anal opening in right lateral wall.
S/O fistulous tract.
| Tuberculosis Gold Result|| |
In between tuberculosis (TB) Gold test was also performed to detect TB, which came negative.
| Method of Preparation of Nyagrodha Ksheer Sutra|| |
Ksheer (latex) was collected in a sterile bottle from the Nyagrodha (Ficus benghalensis) tree by giving slit incision over the bark.
Then every day one coating was made on the thread.
Similarly 11 coatings of Nyagrodha Ksheer were made on thread in 11 days.
Every time fresh Ksheer (latex) will be taken.
It was preserved in Kshar Sutra cabinet under ultraviolet rays for sterilization.
Nyagrodha Ksheer Sutra was applied and the patient was asked to change the thread after every 7 days till cut through. Nyagrodha Ksheer Sutra was applied approximately tight till cut through.
- Under all aseptic precaution under spinal anesthesia, cleaning and draping were carried out in lithotomy position.
- Anal canal was visualized by Sim’s speculum but no any deformity was found.
- Probe was inserted from external opening present at 11 O′clock position approximately 4cm from anal verge and was taken out straight in the anal canal at 12 O′clock position.
- Nyagrodha Ksheer Sutra threading was performed.
- Hemostasis was achieved.
- Betadine jelly pack was inserted.
- Bandaging was carried out.
- The patient was shifted to recovery room under general condition.
- Procedure was uneventful.
Hot sitz bath twice a day, syrup Abhayarishta 20mL twice a day after food, and Panchsakar churna 5g at night with lukewarm water. Follow-up was performed on 30 days after cut through for observing any reoccurrences.
(2) Pus discharge
(4) Unit cutting time
| Observations and Results|| |
Thread was changed after every 7 days till cut through and assessment was conducted to find out the symptoms of the patient such as pain, pus discharge, itching, and cutting rate [Figure 1]. Pain was gradually reduced within 3 months and pus discharge was completely stopped after 2 months. The patient complained of intermittent itching and was treated symptomatically. Total treatment took around 5 months. Unit cutting rate was calculated and found to be approximately 0.34cm per week, which is less than standard Kshar Sutra cutting rate. Follow-up was taken on 30th day after cut through of the tract where no reoccurrence was found [Figure 2].,
| Discussion|| |
Acharya Sushruta included Nyagrodha in Nyagrodhadigana. In Bhagandara Chikitsa (treatment), he explained that Nyagrodhadigana drugs are Bhagandar-nashak (destroyer).Vrana-Shodhak (wound cleaning) property in Nyagrodha helps in the destruction of unhealthy tissue and provides a healthy environment for the healing purpose. Proper drainage is ensured after its application and it prevents the accumulation of pus in the cavities. Nyagrodha also acts on the inherent tissue damage of the area to reduce Shopha (inflammation) to a great extent, which comes under Vrana-ropak (wound healing) properties. So all these properties of Nyagrodha help together to manage a recurrent fistula.
| Conclusion|| |
As seen in many cases, it is very difficult to manage the anal fistula because of its high recurrence rate. In this case also, it was evident that the patient was suffering from the same complaint of recurrence of fistula after multiple surgeries. In order to find out a minimal invasive technique, an attempt is made to treat the critical recurrent fistula with the help of Nyagrodha Ksheer Sutra. From the aforementioned case, it is concluded that Nyagrodha Ksheer Sutra is efficient in treating critical recurrent anal fistula. It also revealed that Nyagrodha Ksheer acts on the basis of its Shodhan and Ropan property to heal critical recurrent anal fistula. Efficacy of Nyagrodh Ksheer Sutra should be evaluated on a large sample size.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]