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ORIGINAL ARTICLE
Year : 2020  |  Volume : 8  |  Issue : 2  |  Page : 109-113

Comparative study of efficacy of Khanduchakka (Ehretia laevis) Ghrit and cow ghee in the management of Parikartika (fissure in ano)


Shalyatantra Department, Mahatma Gandhi Ayurved College Hospital and Research Centre, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, Maharashtra, India

Date of Submission09-Jul-2020
Date of Decision11-Jun-2020
Date of Acceptance17-Jul-2020
Date of Web Publication07-Sep-2020

Correspondence Address:
Dr. Suraj V Tichkule
Shalyatantra Department, Mahatma Gandhi Ayurved College Hospital and Research Centre, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, Maharashtra.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JISM.JISM_31_20

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  Abstract 

Background: Fissure in ano a very common anorectal disorder can be compared with Parikartika as per Ayurveda. Khanduchakka (Ehertia laevis) has Vraņashodhana and Ropaņa (wound-healing) properties that can help to heal the Vraņa (ulcer) rapidly. Its base is ghee, which itself has Samskaranuvarti (i.e., enhancing the properties of a drug) and healing properties. Khanduchakka Ghrita is beneficial by virtue of easily available ingredients and a time-tested classical formulation. Hence, it was compared with cow ghee in this study. Aim: Evaluation of the efficacy of Khanduchakka Ghrita, compared with cow ghee, in the management of Parikartika.Materials and Methods: Diagnosed cases of fissure in ano as per the inclusion and exclusion criteria were selected and divided into two groups. For patients in group A, Khanduchakka Ghrita was applied; and in group B, cow ghee was applied. Assessment of each patient was carried out on 0, 15th, and 30th day and a follow-up on 45th day. Data were collected and a statistical analysis was done using appropriate tests. Results: The present study found that pain, itching, bleeding, and tenderness were significantly reduced and healing was significantly faster in group A (n = 15) compared to group B (n = 15). Conclusions: Based upon the results it can be concluded that Khanduchakka Ghrita is more significant than cow ghee in managing Parikartika.

Keywords: Fissure in ano, Ghrit, Khanduchakka, Parikartika, Samskaranuvarti


How to cite this article:
Tichkule SV, Khandare K, Shrivastav P. Comparative study of efficacy of Khanduchakka (Ehretia laevis) Ghrit and cow ghee in the management of Parikartika (fissure in ano). J Indian Sys Medicine 2020;8:109-13

How to cite this URL:
Tichkule SV, Khandare K, Shrivastav P. Comparative study of efficacy of Khanduchakka (Ehretia laevis) Ghrit and cow ghee in the management of Parikartika (fissure in ano). J Indian Sys Medicine [serial online] 2020 [cited 2020 Sep 23];8:109-13. Available from: http://www.joinsysmed.com/text.asp?2020/8/2/109/294431




  Introduction Top


In Ayurveda, Acharya Sushrut has described the term Parikartika as a condition where cutting and burning pain occurs in anus, penis, umbilical region, and neck of urinary bladder with cessation of flatus.[1] Whereas, Acharya Charaka has described features like pricking pain in groin region and sacral area, scanty hard stools, and frothy per rectum bleeding.[2] The symptoms of Parikartika, according to various texts, are Vamana-Virechana Vyapada (complications), Atisara (diarrhea), Bastikarma Vyapada, Arsha (hemorrhoid), Grahani (irritable bowel syndrome), Udavarta (belching), etc.[3] Further, Acharya Charaka mentioned Parikartika as a complication of Vataj Atisara.[4] In this regard, Acharya Sushrut explained that in a person who is debilitated, with Mrudukoshta (mild digestive power), Mandagni (poor appetite), more intake of food characterized as Ruksha (dry), Ushana (hot), and Lavana (salty), Pitta and Vata are vitiated, leading to the manifestation of the disease.[5]

Parikartika can be correlated with anal fissure, which has been described as an acute superficial break in the continuity of the anal skin. Fissure-in-ano is a very common and painful condition hampering one’s quality of life; it is caused by the passing of hard stools, resulting in a tear in the anus. In males, fissures usually occur in the midline posterior 90%, and much less commonly in anterior 10%. In females, fissures on the midline posteriorly are commoner than anteriorly (60:40).[6]

Various treatment modalities are available for managing anal fissures, including conservative and surgical management. Anal fissure could be either acute or chronic.[6] An acute fissure might respond well to conservative treatment, but when it becomes chronic and gets associated with sentinel tag, it calls for a surgical intervention. Even though there are a number of treatments available for anal fissures, it still remains a challenge in front of a surgical proctologist. Several research works have been undertaken on Khanduchakka to evaluate its chemical constituents and pharmacological actions. No research has yet addressed the management of anal fissure using Khanduchakka. Khanduchakka has analgesic, anti-inflammatory, and anti-bacterial properties which could help the Parikartika (fissure) to heal rapidly.[7]Khanduchakka Ghrita has been previous reported in treating Dushta Vrana (ulcer).[7] Using the available references, Khanduchakka Ghrita was prepared and its efficacy was compared against cow ghee in the management of Parikartika.


  Materials and Methods Top


Material

Patients reporting to OPD and IPD of the Shalyatantra Department and also from peripheral camps were enrolled to this study.

Method

The study was started after obtaining approval from the institutional ethics committee (reference number DMIMS (DU)/IEC/2017–18/6391) on March 30, 2017.

Study design

Randomized comparative clinical trial.

Study type

Interventional study.

Sample size

30 patients

Grouping

Patients were divided into two groups of 15 patients each.

Inclusion Criteria

  1. Subjects aged 18–60 years.


  2. Subjects with clinical features of acute and chronic fissure in anowere included after screening.


Exclusion Criteria

  1. Subjects suffering from systemic disorders like diabetes mellitus, tuberculosis, HIV, and hepatitis were excluded.


  2. Known cases of malignancy, Crohn’s disease, ulcerative colitis were excluded.


  3. Chronic patients with grade IV anal spasm were excluded.


Preparation of Materials

Khanduchakka Ghrita

One part of Kalka Dravya (paste of leaves), four parts of cow ghee, and 16 parts of water were mixed and heated on low digestive fire (Mandagni). When foam disappeared and Ghrita consistency emerged, not to produce any crackling sound on continued heating, the substance was filtered and stored. Mridu (low digestive fire) and Madhyamagni (moderate digestive fire) were used for Sneha Pak. Copper or iron pan or earthen vessel was chosen. Usually wide-mouthed, low-depth copper vessel with tin coating is preferred.

Khanduchakka and Cow Ghee Application

Patients in group A were asked to apply Khanduchakka Ghrita with the help of their finger (gently) twice a day followed by hot sitz bath for 30 days. Patients of group B were asked to apply cow ghee with the help of their finger (gently) twice a day followed by hot sitz bath for 30 days.

Study duration:

45 days

Follow-Up Period

Assessment of each patient was done on 0, 15th, 30th day, and follow-up on 45th day.

Subjective parameters

  1. Pain scale is explained in [Table 1].


  2. Bleeding per rectum scale is explained in [Table 2].


  3. Itching scale is explained in [Table 3].
Table 1: Gradation of pain

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Table 2: Gradation of bleeding

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Table 3: Gradation of itching

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Objective parameters

  1. Tenderness scale is explained in [Table 4].


  2. Healing scale is explained in [Table 5].
Table 4: Gradation of tenderness

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Table 5: Gradation of healing

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Assessment of Overall Clinical Improvement

Maximum improvement: >75% improvement of clinical signs and symptoms

Moderate improvement: 50–75% improvement of clinical signs and symptoms

Poor improvement: 25–50% improvement of clinical signs and symptoms

No improvement: 0–25% improvement of clinical signs and symptoms


  Observations and Results Top


Comparison of Pain in Both Groups

[Table 6] shows mean pain score after treatment of group A was 0.06 ± 0.25 and of group B was 1.40 ± 0.63. By Mann–Whitney U test, statistically significant difference in pain score was found between groups (z = 4.55, P = 0.0001).
Table 6: Comparison of pain in both groups

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Comparison of Bleeding Score in Both Groups

[Table 7] shows the mean bleeding score after treatment of group A was 0.00 ± 0.00 and of group B was 0.33 ± 0.48. By Mann–Whitney U test, statistically significant difference in bleeding score was found between groups (z = 2.40, P = 0.016).
Table 7: Comparison of bleeding score in both groups

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Comparison of Itching Score in Both Groups

[Table 8] shows the mean itching score after treatment of group A was 0.46 ± 0.51 and of group B was 0.86 ± 0.74. By Mann–Whitney U test, statistically significant difference in itching score was found between groups (z = 2.40, P = 0.016).
Table 8: Comparison of itching score in both groups

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Comparison of Tenderness Score in Both Groups

[Table 9] shows the mean tenderness score after treatment of group A was 0.13 ± 0.35 and of group B was 1.13 ± 0.63. By Mann–Whitney U test, statistically significant difference was found in tenderness score between groups (z = 3.95, P = 0.001).
Table 9: Comparison of tenderness score in both groups

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Comparison of Fissure Healing Score in Both Groups

[Table 10] shows the mean fissure healing score after treatment of group A was 0.26±0.454 and of group B was 1.20±0.67. By Mann–Whitney U test, statistically significant difference in fissure healing score was found between groups (z = 3.48, P = 0.0001).
Table 10: Comparison of fissure healing score in both groups

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Comparison of Percentage of Improvement in Both Groups

[Table 11] shows the comparison of percentage of improvement in two groups. In both groups, there was no patient without improvement. There were four patients in group B with mild improvement. There were six patients in group B with moderate improvement. All the patients in group A got maximum improvement, while there were five patients in group B who got maximum improvement.
Table 11: Comparison of percentage of improvement in both groups

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  Discussion Top


Khanduchakka is a traditional tribal medicine. We could not find its reference in Ayurvedic classics, but many authors compared its features with that of Charmavruksha. Its Rasapanchak (five specific features) is not mentioned in classical Ayurvedic texts. In the present case series, Khanduchakka proved to be significant in managing fissure in ano, which reduced pain, itching, bleeding, and promoted healing. It contains botulin, which is anti-inflammatory and antipruritic, thereby promoting differentiation of skin cells (keratinocytes) and wound healing. Its lupeol has wound healing and anti-inflammatory action, and rutin improves blood circulation and wound healing.[8] Owing to all these properties, Khanduchakka was efficient in healing anal fissure. Healing of anal fissure on days 1, 7, 14, and 21 of a representative case is shown in [Figure 1], [Figure 2], [Figure 3] and [Figure 4], respectively.
Figure 1: Day 1 anal fissure

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Figure 2: Day 7 anal fissure

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Figure 3: Day 14 anal fissure

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Figure 4: Day 21 healed anal fissure

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From our clinical assessment of Khanduchakka Ghrita and cow ghee, both the groups showed analgesic activity. When effect of Khanduchakka Ghrita and cow ghee on bleeding was analyzed statistically, results were found significant in the patients of both the groups (on 15th, 30th and 45th day). But Khanduchakka Ghrita was found to be more efficient than cow ghee in stopping bleeding caused due to anal fissures which is also because of its wound healing property. When effect of Khanduchakka Ghrita and cow ghee on Itching was analyzed statistically, the results were found significant in the patients of both the groups (on 15th, 30th and 45th day). It was also found to be more efficient than cow ghee in reducing itching because of its antipruritic property, as well as tenderness because of its anti-inflammatory and wound-healing property.


  Conclusion Top


In this present research work, pain, itching, bleeding, and tenderness improved after Khanduchakka Ghrita use in the management of fissure in ano. Even healing of fissure was also found to be more significant than the control. The study was limited to a population of 30 participants; therefore, to further confirm the efficacy of Khanduchakka Ghrita in the management of anal fissure, it has to be repeated on a large sample size.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Shastri AD. Sushruta Samhita. Vol. I. Chikitsa Sthan 35/32. Varanasi: Chaukhambha Sanskrit Sansthan;2013. p. 155.  Back to cited text no. 1
    
2.
Sharma PV. Sushruta Samhita. Vol II. Chikitsa Sthan 34/16. Varanasi: Chaukhambha Vishwabharti Publishers;2005. p. 595.  Back to cited text no. 2
    
3.
Sharma PV. Caraka Samhita. Vol II. Chikitsa Sthan. Varanasi: Chaukhambaorientalia;2005. p. 879.  Back to cited text no. 3
    
4.
Yadavaji T. Sushrut Samhita. Vol II. Chikitsa Sthan. Varanasi: Chaukhamba Orientalia Publishers;2002. p. 207-8.  Back to cited text no. 4
    
5.
Sharma PH. Kashyapa Samhita. Khilva Sthana. 10/102-5. Varanasi: ChaukhambhaOrientalia Publishers;2013. p. 299.  Back to cited text no. 5
    
6.
Das S. A Concise Text Book of Surgery. 9th ed. Kolkata: Somen Das Publisher; 2016. p.1084.  Back to cited text no. 6
    
7.
Dhenge S, Khandare K. Efficacy of local application of Khanduchakka (Ehretialaevisroxb) Ghrita in Dushtavrana: a case report. Int Ayurvedic Med J 2016;4:3727.  Back to cited text no. 7
    
8.
Thakre R, Bhutada S, Chauragade B. Ethano botanical properties of unexplored plant Khanduchakka (Ehretia laevis roxb.) Int J Ayurved Pharmac Res 2016;4:69-72.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11]



 

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