“AYURVEDA VACHASPATI”

“A CLINICAL STUDY OF YASHTIMADHU GHRITHA PICHU IN THE

MANAGEMENT OF PARIKARTIKA w. s. r. to FISSURE-IN-ANO ”

BY

DR.VEERESH .B. SATTIGERI

Dissertation submitted to

Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore

In partial fulfillment Of the requirements for the degree of

“AYURVEDA VACHASPATI”

(M.S. AYURVEDA)

In

SHALYA TANTRA

Under the Guidance of

DR. CHETAN KARDALE

M.S (AYU)

READER OF P G STUDIES IN SHALYA TANTRA

DEPARTMENT OF POST GRADUATE STUDIES IN SHALYA TANTRA RAJIV GANDHI EDUCATION SOCIETY’S AYURVEDIC MEDICAL COLLEGE, HOSPITAL; P.G.STUDIES

AND RESEARCH CENTER, RON-5822O9 DIST:-GADAG (KARNATAKA-582114)

2014-2015

CERTIFICATE BY THE GUIDE

This is to certify that the Dissertation entitled “A CLINICAL

STUDY OF YASHTIMADHU GHRITHA PICHU IN THE MANAGEMENT OF

PARIKARTIKA w. s. r. to FISSURE-IN-ANO ” is a bona fide research work done by

Dr.VEERESH SATTIGERI in partial fulfilment for the degree of Ayurveda

Vachaspati, Master of Surgery (Ayurveda) in Shalya tantra of the Rajiv Gandhi

University of Health Sciences, Bengaluru.

I recommend this dissertation for the above degree to the

University for Assessment and approval.

Signature of the Guide

Dr .CHETAN CARDALE

M S (Ayu)

Reader

Department of Post Graduate Studies in Shalya tantra

Rajivgandhi educational societies’s Ayurvedic medical

College & pg research centre, ron - 582209

Date :

Place :

ENDORSEMENT BY THE HOD,

PRINCIPAL/HEAD OF THE INSTITUTION

This is to certify that the Dissertation entitled “A CLINICAL STUDY OF

YASHTIMADHU GHRITHA PICHU IN THE MANAGEMENT OF PARIKARTIKA

w. s. r. to FISSURE-IN-ANO” is a bona fide research work done by Dr. VEERESH

SATTIGERI under the guidance of Dr.CHETAN CARDALE Reader Department

of Postgraduate Studies in Shalya tantra, RAJIVGANDHI EDUCATIONAL

SOCIETIES’S AYURVEDIC MEDICAL COLLEGE & PG RESEARCH CENTRE,

RON - 582209

Signature of the Guide

Dr.CHETAN KARDALE (Ayu) Reader Department of Post Graduate Studies in Shalya tantra Rajiv Gandhi educational societies’ ayurvedic medical

College & pg research centre, Ron - 582209

Signature of the Principal

RAJIVGANDHI EDUCATIONAL SOCIETIES’S

AYURVEDIC MEDICAL COLLEGE & PG RESEARCH

CENTRE, RON - 582209

Date: Date:

COPYRIGHT

Declaration by the candidate

I hereby declare that the Rajiv Gandhi University of health Sciences,

Karnataka shall have the rights to preserve, use and disseminate this dissertation in

print or electronic format for academic/ research purpose.

Signature of the candidate

Dr. VEERESH .B .SATTIGERI

Date: Place:

© Rajiv Gandhi University of Health Sciences, Karnataka

LIST OF ABBREVIATIONS USED

SYMBOLES USED IN MASTER CHART

AT AFTER TREATMENT

BT BEFORE TREATMENT

P PROBABILITY

SD STANDERD DEVIATION

T T TEST

> MORE THEN

< LESS THEN

0,1,2,3 GRADE OF SEVERITY

AB -ASTANGA SANGRAHA BP -BHAVA PRAKASHA BR -BAISHAJA RATNAVALI CS -CHARAKA SAMHITA CD -CHAKRA DATTA SU -SUTRA STHANA CHI -CHIKISTASTHANA NI -NIDANA STHANA SH -SHAREERA STHANA CK -CHAKRAPANI DL -DALANA HS -HARITA SAMHITHA GN -GADANIGRAHA

ACKNOWLEDGEMENT

It is because of God’s grace that the work could be completed as per my expectation. I

bow my head to Lord Ganesh and Lord Dhanvantari for his divine inspiration and

support.

Words are not enough to express my gratitude and indebt to the sacrifices of my

beloved Late Shri Veerupakshappa & Smt. Iramma and respected parents Shri

Basavraj Smt. Neelamma, my family members Shri Ashok sattigeri (Advocate) ,

smt surekha and other family members for supporting, blessing, praying and standing

by me in all situations of my life.

It is my inexplicable pleasure to offer my salutations to Shri . G S PATIL ,m l a govt

of Karnataka founder of this institution for his blessings, which made me to complete

my thesis without any hurdles High on the list to which I owe my indebtedness, it

gives me immense pleasure and proudness to offer profound gratitude to my beloved

principal Dr.Iranna kotturashetter for his love, motherly care, benevolent guidance

and encouragement ensured the successful completion of the work.

I am extremely thankful to Prof. Dr.Ravikumar Arahunasi dept of

kayachikista Research Studies, R G E A M C H Ron for his valuable suggestions and

timely guidance. Mere words would not be enough for the deep sense of gratitude and

respect I hold for my esteemed tanks to Dr.Ravikumar Arahunasi their inspiration,

guidance, encouragement and expertise throughout my career.

I would like to express my deep sense of gratitude to DR.Subbaraju , Professor &

H.O.D., Dept. of P.G. studies in Shalya Tantra, R G E A M C H Ron, who became a

source of light and provided necessary fuel for my innovative thoughts I am deeply

indebted for his blessings, guidance, advice, broadmindedness and encouragement

placed me where I am today.

The inspiring force throughout this research work was my guide Dr.Chetan kardale

Reader., Department of P.G.Studies in Shalya TantraR G E A M C H Ron , for his

scholarly guidance and suggestions to complete this work.I extend my thanks to

DR.KUMAR for their co-operation encouragement and timely suggestions provided

to me. Nevertheless I am grateful to each one of them I cannot forget the guidance of

Dr. M R Hunagundi and Dr.Shivakumar patil.. which gave me confidence to get

along my work. I am thankful to my classmates, seniors & juniors Co-operation and

support It would be invidious to name a few friends, when many have helped me

DR.VEERESH SATTIGERI

ABSTRACT


MANAGEMENT OF PARIKARTIKA w. s. r. to FISSURE-IN-ANO ”

The research work was aimed to evaluate the efficacy of Yashtimadu Ghrita picchu

and Yashtimadu-Ghrita picchu and Abhayarista,Gandaka rasayana in the management

of Parikartika (Fissure – In -Ano).

It was comparative clinical study .The age limitation was 20 – 60 years. 40 patients

were taken for the study, 20 patients in each group A & B. Both the groups were

advised strict fiber rich diet, exercise and plenty of fluid intakes.

The study period was 7 days and follow up for 2 months Observations were recorded

in the concerned proforma on every month Observations were statistically analyzed

with pairedt- test. Group A showed statistically highly significant result as in both the

Group B also have same effect.but there is no significant result of constipation This

study concludes that in Parikartika (Fissure – in - ano), Yashtimadu Ghrita appears to

be effective in reducing signs & symptoms in both Groups And is cost effective, easy

to prepare and without any adverse effect.

Key words: - Yashtimadu Ghrita picchu,Abhayarista,Gandaka rasayana , Parikartika

TABLE OF CONTENTS SL NO CONTENTS PAGE NO

1 INTRODUCTION 01 to 03

2 OBJECTIVES 04

3 REVIEW OF LITERATURE 05 to 67

4 DRUG REVIEW 68 to 85

5 MATERIALS & METHODS 86 to 92

6 OBSERVATIONS & RESULTS 93 to 122

7 DISCUSSION 123 to 136

8 CONCLUSION 137 to 139

9 SUMMARY 140 to 143

10 REFERENCES AND BIBLIOGRAPHY 156 to 167

11 ANNEXURE( CASE SHEET PERFORMA) 144 to 155

LIST OF TABLES

SL

NO

LIST OF TITAL PAGE NO

1 Relation of Anal canal 5 to 14

2 Chemical composition of wet 100gms Yashtimadu contains 71

3 Pharmacological properties & Action of Yashtimadu 71 to 72

4 Pharmacological properties & Action of Gruthamurchana drugs 73 to 79

5 Pharmacological properties & Action of Go-gritha 79 to 81

6 Age wise distribution 93 to 94

7 Sex wise distribution 94 to 95

8 Socio economic status wise distribution 96

9 Diet wise distribution

97

10 Religion wise distribution 98

11 Occupation wise distribution 99 to 100

12 Incidence of Habitat 101

13 Distribution of patients in relation to Previous Surgery 101 to 102

14 Bleeding per rectum wise distribution 103

15 Constipation wise distribution 103 to 104

16 Pain wise distribution 105

17 Burning sensation wise distribution 106 to 107

18 Size of the ulcer in anal region wise distribution 108

19 Sphincter spasm wise distribution 109

20 Proctitis wise distribution 110

21 Distribution of patients in relation to Associated Lesions 106 to 107

22 Distribution of patients in position of fissure in ano. 107

Group A

23 Assessment of Sign & symptom before treatment & after

treatment

108 to 109

24 Assessment of Sign & symptom before treatment & after fallow up

110 to 101

Group B

25 Assessment of Sign & symptom before treatment & after treatment

112

26 Assessment of Sign & symptom before treatment & after

fallow up

115

27 Evaluation of pain between two groups 115 to 116

28 Evaluation of bleeding between two groups 117 to 118

29 Evaluation of burning sensation between two groups 119 to 119

30 Evaluation of constipation between two groups 120

31 Evaluation of ulcer between two groups 121

32 Evaluation of sphincter spasm between two groups 122

33 Evaluation of proctitis between two groups 122

LIST OF GRAPHS

LIST OF FIGURES

Sl no Tital of page Page no

1 Guda Valli and Spaces 37

2 Interior of anal canal 38

3 Musculature of anal canal 38

4 C.S. Rectum and anal canal 41

5 Blood supply 42

6 Venous supply 43

7 Before treatment 84

8 After treatment 85

Sl no Title page Page no

1 Age wise distribution 94

2 Sex wise distribution 95

3 Diet wise distribution 96

4 Occupation wise distribution 97

5 Religion wise distribution 100

6 Habitat wise distribution 101

7 Distribution of patients in relation to Previous Surgery 102

8 Bleeding per rectum wise distribution 103

9 Pain wise distribution 105

10 Burning sensation wise distribution 106

11 Constipation wise distribution 104

12 Size of Ulcer in anal region wise distribution 107

13 Sphincter spasm wise distribution 108

14 Proctitis wise distribution 109

15 Distribution of patients in position of fissure in ano 107

16 Overall effect of therapy wise distribution 116 to 122

Introduction.

A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 1

INTRODUCTION

Health is a precious possession. Wisdom and art, strength and wealth are of no use if

health is lacking. The surgeon must therefore strive to maintain or to restore his

patient’s health. Experience is of the utmost value but limits are imposed upon

medical skill. The best surgeon is who can distinguish the possible from the

impossible and avoid surgery. In the era of fast food, there is change or irregularity in

diet and diet timings and alsosedentary life style. In addition to change in diet and life

style, one is always under tremendous mental stress. All these causes disturb in

digestive system which results in to many diseases amongst them ano-rectal disorder

constitute an important group.

On the basis of the clinical symptoms the disease fissure-in-ano has been

classified into two varieties; viz. acute fissure-in-ano and chronic fissure-in ano.

Either acute or chronic, pain or bleeding is the two main symptoms of this condition;

pain is sometimes intolerable. In long standing cases it may be associated with

haemorrhoids or a sentinel tag. Pruritis ani may be another symptom of this condition.

On the basis of symptoms, the disease fissure-in-ano can be compared to the disease

Parikartika according to Ayurveda, Parikartika / Fissure in ano is very common and

painfulcondition.

Acharaya Dalhana has described the term Parikartika as a condition of Guda

in which there is cutting pain and tearing pain. Similarly Jejjata and Todara have

clearlydescribed Parikartika as a condition which causes cutting pain in anorectum.

Introduction.


The factors responsible for causation of Parikartika as found in various texts are

Vamana- Virechana-Vyapat, Bastikarma Vyapat, Atisara, Grahani, Arsha, Udavarta

etc. In the similar manner it has been described of three type’s viz. Vata, Pitta and

Kapha. Sushruta while describing the symptoms of the disease speaks of the features

like; cutting or burning pain in anus, penis, umbilical region and neck of urinary

bladder with cessation of flatus. Whereas Charaka has described the features like:

pricking pain in groins and sacral area, scanty constipated stools and frothy bleeding

per rectum.

Fissure-in-ano occurs most commonly in midline posteriorly. In males, usually

occur in midline posteriorly – 90%, and less common anteriorly – 10%. In females in

Midline posteriorly - 60% and anteriorly – 40%An alarming rise in the incidence of

the disease fissure-in-ano and no known satisfactory remedies evolved so far has

given an impetus to find out a suitable solution, with altogether better effects, from

amongst the treatments advocated by the classics. This is the reason that sufficient

work is going on in this direction in many institutes throughout the country.

According to Ayurvedic literature, there are several methods of treatment i.e.

Bhaişaja – Kshara – Śhastra Karma etc. Among them Bhaişaja Karma – medicinal

treatment is the first line of treatment. Now a day, various topical remedies are

available for local application for wound healing in the market including for fissure-

in-ano. In the present study, an effort was made to derive a standard and easily

accessible treatment for fissure-in-ano from classical resources.

Introduction.


Yashtimadu Ghŗita is having ingredients with Vraņa Śodhana and Ropaņa

properties which can help the Vraņa (wound) to heal rapidly (BR. Su.36/16). Its base

is yashtimadu which itself is having Samskara Anuvarti and healing properties.

Yashtimadu Ghŗita is economic by virtue of less number of easily available

ingredients and a time tested classical formulation. Hence, it was selected for the

clinical evaluation in the present study.

Aims and objectives.


AIMS

To evaluvate effect of yeastimadu grith picchu in the management of

parikartika

OBJECTIVES

To review the literature of parikartika in Ayurvedic classics.

To review about fissure in ano in modern literature.

To evaluate efficacy of yashtimadhu ghritha pichu in parikartika.

. Review of literature


REVIEW OF AYURVEDIC LITERATURE

Ayurveda deals with the maintenance of health and relief from the diseases.

Sushruta defines the healthy state1 as one who’s Dosha; Agni and functions of Dhatu

and Malas are in the state of equilibrium and who has cheerful mind, intellect and

sense organs is termed as Svastha (healthy).

World Health Organization (WHO) also supports this definition which shows

the eternity of Ayurvedic description. Charaka has mentioned this in Vimana Sthana

as Dhatusamya.

Ancient literature including Vedas has a rich description of various diseases

and their management, but ‘Parikartika’ is not described in Vedas. Then comes the era

of the Samhitas where Ayurveda, actually developed as a medical science. But even

though there is detailed description about various diseases and their management but

Parikartika is the one that has not been emphasized upon.

The reason for this may be that, Parikartika was as neglected condition by

doctors and patients both as it is today. Also other strong reason may be that, there

might be a very less incidence of the disease, due to overall well being of the people,

better food quality, less stressful life, and balanced life style.

Acharya of Bruhatrayi has mentioned about this entity ‘Parikartika’ though not

as a separate disease but as a complication of various conditions viz. Vatika Jvara and

Vatika Atisara, as complication of purgatives or enemas. Kashyapa Samhita has given



details of the disease, according to which Parikartika is of three types according to the

predominance of the Dosha and their treatment is to be done accordingly.

Before moving towards better understanding of the disease, it is inevitable to

go through a critical study of the part affected, in its structural and functional aspects

as told by the ancient Acharya. Here Parikartika is studied with special reference to

fissure-in-ano i.e. the one occurring in the Guda. Thus a detailed description of Guda

follows:

GUDA

The term Guda is consequent from, means the organ which excretes the Apana

Vayu and Mala is called as Guda. Here, term Guda can be used to indicate end part of

digestive system. According to Ayurvedic Shabdakosha, the word Guda means, i.e.

the organ which evacuates the Apana Vayu is known as Guda. In various Ayurvedic

texts, the term Guda is used to denote the ano-rectum. Almost all the Acharyas have

used this term to refer to an organ which performs the actual function of defaecation.

They have even described the embryological derivation and development of Guda,

and other body organs in Sharira Sthana.2It shows their ingenuity and depth of study

of the human body and its organs in those days when facilities were lacking.



Synonyms:

Amarkosa: Aapanam, Payu

Jatadharam: Guhyam, Gudavartma

Vijayaraksita: Apanah, Mahatsrotas

Gangadhara: Bradhanam

Vachaspati: Vitmarga

Other words that are mentioned in contact to Guda various Acharyas are

Charaka: Uttaraguda, Adharaguda, Sthulaguda, 3, 4 Gudamukha

Sushruta: Gudamandala, Gudavalaya, Payuvalaya, Gudaustha.

Vagbhatta: Gudamarga

Dalhana : Gudantram

ANATOMY OF GUDA

Guda has been enumerated one among with fifteen Koshtangas (hollow

viscera) of the body by Acharya Charaka and having two parts vis. Uttara Guda and

Adhara Guda5 explains that former is the seat of faecal material collection whereas

later helps in the evacuation.6 This seems to indicate that Charaka has mentioned

Uttara Guda up to pelvic colon at least and Adhara Guda forms the part of anorectum



because no sooner the faecal matter enters in ampula of rectum, the reflexes start

resulting into desire to defecate.

Guda is one among the Praņanayatan.7 It has also been included in

Sadyopraņahara Marma.8 Acharya Sushruta, who was basically a surgeon had

described that Guda is a terminal portion of large intestine (Sthulantra) in vicinity to

Basti (urinary bladder). It excretes the faeces and flatus9, which is also grouped under

Bahya Srotasa (external openings) 10

Origin of Guda:

In Suśhruta Samhita, it has been mentioned that parts like Peshi (muscles),

Rakta (blood), Meda (adipose tissue), Majja (bone marrow), Stana (breast), Nabhi

(navel), Yakŗt (liver), Plihā (spleen), Antra (intestine), Guda (anus) are ‘Matŗja’ in

origin 11,12 According to Acharya Suśhruta, it is Sara of Rakta and Kapha digested by

Pitta along with the active participation of Vayu.13 While Acharya Vagbhatta says that

Guda, Rakta and Mamsa are Maternal in origin.

Relation of Guda:

In the context of anatomy of Basti, Sushruta said that Basti is situated in

between Nabhi, Prushtha, Kati, Muska, Guda, Vankshaņa and Shephas having single

opening downward related to one another with Basti Sira (bladder neck), Paurusha

Granthi (prostate), Vrushana (Testis), Guda (ano-rectum) and placed in

Gudāsthivivara (pelvic cavity). He directed to put a finger into anus during the



operation of vesicle calculus for fixation in perianal region thus quite justified that

Guda is an organ which is terminal part of large intestine situated in pelvic cavity

anterior to Gudasthi (sacrum) and posterior to Basti (bladder).

Parts of Guda:

Acharya Sushruta says that Gudaustha is situated at a distance of half Yava

away from the hair line and one finger interior to the last Vali i.e. Samvarņi.

According to Acharya Charaka, Guda is one of the fifteen organs belonging to

Koshta. Further, he has divided it into two parts viz., Uttar Guda and Adhara Guda.

But according to Ayurvedic text, it is difficult to make a line of demarcation between

the Uttar Guda and Adhar Guda. The words like Sthula Guda and Gudaustha are also

used in Ayurvedic texts. Acharya Charaka has considered Sthula Guda as a root of

Purishvaha Srotasa.14

Measurement of Guda:

Acharya Sushruta and Vagbhatta15, 16 have described that the total length of

Guda is 4½ Angula only. Dalhaņa considered one Angula is maximum width of

thumb. Practically, the width of the thumb may be taken as 2 cm. In this regard, the

length of Guda is about 9 cm (4½ Angula). The total length of anal canal is between 3

–4 cm and the total length of ano-rectal canal from recto sigmoid junction to anal

verge is 16.5 cm. Thus Guda includes anal canal plus distal 5 – 6 cm of rectal segment



that means up to middle houstan valve. Vagbhatta had also told measurement of Guda

as Atmapanitala (palm of hand) 17

Internal Structure of Guda:

Acharya Sushruta and Vagbhaţţa have described the presence of three Valis

(fold, wrinkles) from proximal to distal named as Pravahini, Visarjani and Samvaraņi.

These are situated one over the other inside Guda at a distance of 1½ Angula from

each other and all of them obliquely projectile in one Angula spiral like conch

(Sankhavartanibha) and resembling colour of palate of elephant (Gajatalu) as reddish

black. Gudausţha (anal verge) is situated at a distance of 1½ Yava from Romānta

(hairy margin). The first Vali is at a distance of one Angula from the anal verge18, 19

Dalhaņa while dealing with the above context clarified that three Yavas are equal to

one Angulas length and specified that Gudaustha distance is about 1½ Yava i.e. ½

Angula from Romanta. Now the entire description of Valis can be interpreted in the

light of present day knowledge. Some authors have translated these Valis as

sphincters (Singala et al, 1972). Gaņanathasen has assumed the distal two houstan

valves are Pravahini and Visarjini, the area of external and internal sphincters

collectively as Samvaraņi.

Muscles of Guda:

Acharya Sushruta has described the presence of three muscles in the Guda region20



1) Pravahani is one which compresses and pushes the stool downwards as spiral

movements of middle houstan valve.

2) Visarjani which relaxes and initiating the reflex of defacation in the presence of

rich stretch nerve ending in ampula of rectum and region of ano-rectal junction.

3) Samvarani which is sphincteric continence under the control of reflex mechanism

by presence of external and internal sphincter which is opening and closing in passage

of feces and flatus. Guda has also other functions. It is a place where Vayu can be

controlled easily by its chief site. Charaka and others have advocated the Basti Karma

for amelioration of Vatika disorder.

Guda as a Marma:

Acharya Sushruta has described Guda is one of Sadyopraņahara Marma

(results instantaneous death) which is situated in terminal part of Sthulantra (large

intestine) and categorized under ‘Mamsa Marma.’21 Vagbhatta has mentioned Guda as

Dhamani Marma.22 He has also said that Guda is attached to Sthulantra and functions

as evacuator of faeces and flatus. Injury to this would lead to immediate death.23

Blood Supply of Guda:

Like Sira, Dhamani, Srotasa etc. various words have been described in

Ayurveda which are the Srotasa (channels) carrying Dosha, Dhatu and Mala in the

body and are the essential components of every Avayava (organ). According to the

different commentators, Sira denotes only work of Sarana i.e. presumabling the flow



is maintained slowly. Dhamani denotes work of Sarana with Dhamana i.e. flow

through this channel is maintained with pulsatile movement. Srotasa means the

structure through Sravaņa takes place. There are eight Siras present in middle part of

Shroni (pelvis) which supply to Guda and Medhra24 and two Dhamani are supplying

to Guda in downward direction25 Regarding Srotasa there are two Srotasa which

pertain fecal matter namely, Pakvashaya and Guda, the later one also having external

opening and named as one among Navasrotamsi.26

Importance of Guda:

(1) Marma: Guda is a Mamsa Marma27contradicting to this Vagbhatta includes it in

the Dhamani Marma. Similarly Acharya Sushruta has considered Guda as Udara

Marma28 while Vagbhatta has included it in Koshta Marma.29 Both Acharyas opines

that Guda is a Sadyapraņahara Marma and it is of four Angula size. Injury to it causes

obstruction of Apana Vayu, Mala and loss of moment in Sthulantra (paralytic ileus)

and patient dies instantaneously.

(2) Prananayatan: Praņanayatan are so enlisted because their proper functioning is

very-very important for proper functioning of the body. Guda is one of such

‘Praņanayatan’.

(3) Srotasa: Guda is a Bahirmukha Srotasa. Acharya Charaka has put Sthula Guda as

the root of the Purişhavaha Srotasa and Acharya Sushruta has mention Guda as the

same.30 it is an important ‘Chidra’ of the body and thus a valuable part too.



(4) Karmendriya: While enlisting the Indriyas Guda is categorized under

Karmendriya group and the function designated to it is defecation and releasing of

flatus.

Physiological Function of Guda:

All the ancient authors have mentioned the functions of Guda as to dispose of

excreta from the body. Guda is included among 9 Bahya Srotasa and among 10

Randhras by Sharangadhara. The opening is terminal part of Purishavaha Srotasa and

serves as an excretory channel for excretion of faeces and flatus. According to

Acharya Charaka and Sushruta, Purishavaha Srotasa has two Mula e.g. Pakvashaya

and Guda which serves as a storage and excretion of feces respectively. The presence

of Purishadhara Kala in Koshta serves as to separate Mala from Ahara Rasa. Guda is

also included under Panchakarmendriya and the ancient Acharya expressed these

activities are maintained by Vayu. Vayu has five varieties which are located in their

specific sites and contribute towards integration and maintenance of body by virtues

of their physical as well as mental characteristics. Karma of Guda is chiefly done by

Apana Vayu, and Samana Vayu contributes functions of gastrointestinal tract like

digestion, absorption, separation of nutritional assimilated material from wastage and

finally to move the waste products for excretion.31 When Apana Vayu gets vitiated it

becomes the cause for occurrence of Guda and Basti Roga like Parikartika, Arsha,

Bhagandara etc. On critical analysis, Vayu resembles the activities of nervous system.

The Apana Vayu is one which is responsible for action of defecation and may be



compared as sacral plexus. In Ayurveda, excretory mechanism has been described in a

lucid manner. The three Gudavalis are playing key role in the mechanism of

defecation. As their names:

1) Pravahani is one which compresses and pushes the stool downwards as spiral

movements of middle houstan valve.

2) Visarjani which relaxes and initiating the reflex of defacation in the presence of

rich stretch nerve ending in ampula of rectum and region of ano-rectal junction.

3) Samvarani which is sphincteric continence under the control of reflex mechanism

by presence of external and internal sphincter which is opening and closing in passage

of feces and flatus.32 Guda has also other functions. It is a place where Vayu can be

controlled easily by its chief site. Charaka and others have advocated the Basti Karma

for amelioration of Vatika disorder.

. Nirukti.


PARIKARTIKA

The present study is aimed towards studying of the ailment Parikartika. In

various Ayurvedic literatures, it has been described as a complication of Virechana,

Basti and also Vamana Karma. But the fact that the occurrence of Parikartika as a

sequel of Atisara, Jvara, Garbha etc. was also known to ancient authors may seem

incredible to the modern man.

Definition:

It refers to a condition in which patient experiences a sensation of pain as if

the Guda is being cut around with scissors. It is derived from Sanskŗit word ‘Parikŗ’

which denotes ‘all around’ and ‘Kartanam’. It means that excessive cutting pain

around the anus is seen in Parikartika.

Synonyms:

Kshata Payu and Kshata Guda are the synonyms in this disease. Pain is most

accepted and important clinical symptoms in this disease.

Nirukti:

Acharya Kashyapa says that the one having cutting and tearing pain.33, 34 means

cutting and tearing pain everywhere as said by Dalhana. Jejjata has anticipated about

the condition and opined in a very pin pointed way specific Vatika pain is present all

around in a specific area of Guda, is Parikartika.35

. Nidana


Nidana:

Parikartika though is not that uncommon still has slipped from the due attention of

the Acharyas of Ayurveda. A properly classified documentation of Nidana,

Samprapti, and Rupa etc. of Parikartika is not available at any single place. Even then

many Nidana that may produce Parikartika are described by Acharya which are

scattered in the text. Thus a general assumption can be drown from Sarvaroga Nidana

Adhyaya that those Dosha that are in a Sancaya Avastha get to Prakopa Avastha in

presence of etiological factors and produce the disease.36 In Parikartika, Vata is the

leading or the primary Dosha, this is because of the fact that Guda is actual site of

Vata especially Apana Vayu. Vata vitiation factors are Tikta, Ushņa, Kashaya, Alpa

Bhojana, Vegadharana, Udiraņa, excessive Shodhana therapy; diurnal and seasonal

variations37. The second predominant Dosha that seems to play important part is Pitta.

The factors vitiating it are Katu, Amla, Lavana, Ahara, Krodha; diurnal and seasonal

variations 38 Kapha Dosha, though not predominantly present for triggering the

condition, but still it plays a role many ways. The factors vitiating Kapha are: Swadu,

Amla, Lavana, Adhyasana, Sita, Guru Bhojana, Divaswapna and diurnal and seasonal

variations.39 Other than the three Doshas, Acharya Sushruta has paid utmost attention

to Rakta Dhatu, up to the extent that he says that Rakta is the 4th Dosha. He also says

that as Vayu unites with blood Vrana is formed. In Parikartika, Vrana produced is

mostly Nija in origin and Acharya Charaka in Chikitsasthana Dwivraneeya Adhyaya40

has explained that when Doshas take site in Bahya Roga Marga, they produce Vrana

. Nidana


likewise Prakupita Vata and Pitta especially the causes of Parikartika. As told by

Acharya Sushruta, the Nidana of Parikartika can be divided in to three types.

1. Nija Nidana (Endogenous).

2. Nidanarthakari Roga (Complications)

3. Agantuja Nidana (Exogenous).

(1) Nija Nidana:

The Nidana that vitiate Apana Vayu, Rakta are the Nija Nidana41, 42

Consumption of the causative factors for Apana Vikrti are Ruksha Anna and Guru

Anna, holding the natural urges of micturition and defecation, too much of traveling

by vehicles, traveling repeatedly at various places by walking. Sushruta has given few

more reasons of Parikartika. He says that “Due to excessive accumulation of Mala in

Pakvashaya, it obstructs the normal passage of Vayu and produces Vibandha with

cutting like pain. Due to this the Snehamsa (unctuous portion) gets absorbed rapidly

and eliminates dry faeces with pain.43 By excessive intake of astringent, bitter,

pungent and dry articles of diet, by the suppression of natural urge of Mala Pravrutti,

by excessive indulgence in eating and sex, the Apana Vata is provoked in the colon;

growing stronger it causes obstruction in the lower part of the alimentary tract and

produces retention of feaces, flatus and urine and thus produces very serious disorders

of misperistalsis.44Acharya Sushruta has said that due to consumption of Kashaya,

Tikta and Ushna and Ruksha substances Vayu enters into Koshta of a person and

. Nidana


along with abstained urges of defecation, produces Atopa, Shula and Parikartika as

sequel to Vitasanga.45,46

Nidanarthkari Roga Nimittaja.:

Nidanarthkari Roga Nimittaja are such disorders that are produced due to any

pre-existing diseases.47 the chief Roga is Udavarta that produces Parikartika.48,49,50

Acharya Charaka has described this condition as a Lakshana of Atisara.51 ,52

Acharya Charaka and Vagbhatta have mentioned ‘Parikartika’ as a symptom

in Vataja Atisara, who is suffering from Vatik Atisara and has complaints of scanty,

watery or hard rounded motions, soon develops Parikartika53,54

Sushruta while explaining the prodromal features of Arsha, has not mentioned

the word Parikartika but has documented a very similar symptom, 55 the symptom here

is Guda ‘Parikartanam’ i.e. there is cut in the anus and cutting pain. This is nothing

else but Parikartika and it is explained here as a prodromal symptom of Arsha. The

shape of the Vatika Arsha is like ‘arrow’ and is pointed which is similar to sentinel

tag. Acharya Charaka has said that in Sahaja Arsha56 there is severe pain in

Gudavallaya. In Vatika Arsha, the symptoms that he has described57 very much

similar to those found in Parikartika viz. pain in anus, penis, abdomen, umbilcal

region and so on. Also in Kaphaja Arsha he has said that there is Parikartika, nausea

etc.58, 59

. Nidana


(3) Vaidya Nimittaja:

By Pancakarma like Virechana, Basti and Vamana, Parikartika 60 as complication

Virechana Vyapad: Sushruta both have mentioned one important complication

‘Parikartika’, if ingests Tikshna, Ushna and Ruksha drugs for Virechana 61,62 .

Basti Vyapada: If Ruksha Basti containing Tikshna and Lavana drugs is

administered in heavy dose; it may produce Parikartika 63, 64

Basti Netra Vyapada: Due to inappropriate administration of Basti Netra and

defect in Basti Netra it may cause this disease.65

Excessive use of Yapana Basti: It may lead to Parikartika along with other

diseases66

. Rupa....


RUPA

Vikrta Vata gets localized in Guda67 It produces retention of faeces, urine and

flatus, colic pain and flatulence and Śarkara (fecolith).68 Along with these the

prodromal symptoms of Parikartika, in the words of Sushruta, is pain of sharp cutting

nature in Guda.69 Acharya Sushruta has described is absolutely correct because in

modern medicine also for anal fissure same clinical symptoms are described as cutting

or burning pain in anus, pain in umbilical region and radiated pain in penis and thigh

also. Constipation may be habitual or due to disease because patient is apprehensive

to relax the sphincters and defaecate so wind is not passed and constipation develops70

, Further, he has quoted that the symptoms like pricking pain in the sacrum, groins,

below the naval region and passage of scanty stools and constipation are present in

one who is suffering from Parikartika.71

Acharya Vagbhatta has also described same signs and symptoms as described by

Acharya Charaka and Sushruta.72 Vraņa is an essential symptom of Parikartika which

is having Dirghakriti shape or Triputakakrti73 and a Srava may be present.74 The

Vraņa surface appears more Rukşha. Features of Vata Pittaja Vraņa and also Dushta

Vrana like Samvritatwam, Vivitatwam, Kathinya, Mŗduta, etc. can be found 75.

. Samprapthi...


SAMPRAPTI

The structural and functional integrity of the human body is maintained by

Tridoshas in their state of equilibrium. But they are always susceptible to imbalance

and vitiation. If proper Dinacharya and Ritucharya are observed, the vitiation of the

Doshas can be brought to normal limit. When Asatmya Indriyartha Samyoga,

Prajnaparadha and Parinama influence this imbalance of Dosha, a morbidization

process begins and it undergoes six stages known as Kriyakala.

They are Sanchaya, Prakopa, Prasara, Sthanasamsraya, Vyakti and Bheda

during these stages disease is manifested.76The Samprapti of Parikartika and Arsha

shows close similarities. It is evident from the fact that both these conditions are

manifested in the same Srotasa i.e. Purişhavaha Srotasa.

The role of specific etiological factors and site of manifestation of disease

further strengthens this theory. In this disease Vata Prakopa is predominant with

associated Pitta. The localization of Doshas occurs particularly in Guda Pradesh.

As a result of the pathogenesis, Twak becomes Ruksha and shows tendency to

crack. Sushruta and Vagbhatta have clearly stated that similar changes occur in skin

when Vata vitiates from the skin.77 When Ksham and Mridu Koshta person indulges

Ruksha, Tikshna Ahara and Ruksha Aushadha it produces Agnidushti, which in term

leads to Vata- Pitta Prakopa. Due to Daurbalya of Duşhya i.e. Mamsa and Twak,

particularly of Purişavaha Srotasa, Kha-vaiguņya takes place. Because of this Kha-

vaiguņya, Sthana Samşhraya of aggravated Vata and Pitta Dosha takes place in

. Samprapthi...


Purişhavaha Srotasa which leads to Dosha Dushya Sammurcchana. This produces

Twak Māmsa Duşhti specifically in Guda Pradesha. This Twak Mamsa Dushti or

Vrana results in frequent defeacation associated with pain. This ultimately leads to

Parikartika.

The second kind of Samprāpti is that the diseases like Atisara, Grahani etc.

are if not treated properly and patient continues to indulge Aharaja Nidana then

preexisting pathology leads to Guda Vikŗti and later on Parikartika occurs. The third

type of Samprapti is due to Agantuja Nidana where there is wound formation in first

stage and then the Doshas get sited in the Vrana, producing further symptoms. When

the wound is produced simultaneously there is vitiation of Doşa which in term leads

to Parikartika.

. Bheda.


BHEDA:

Acharya Charaka and Sushruta both have described two types of Doshas in

Parikartika viz. Vata and Pitta. In almost all Ayurvedic texts, no detailed descriptions

about classification of disease, its Samprapti and symptomatology have been

specified, but Acharya Kashyapa has described the involvement of all the three

Doshas e.g. Vata, Pitta and Kapha in the Adhyaya of Garbhini Chikitsa while giving

the detailed Chikitsa of the disease Parikartika.79

This classification is chiefly emphasized on the character of pain, shooting,

cutting or pricking pain in Vata predominance, burning pain in Pitta and dull ache

type in Kapha predominance.

Since it is a known fact that Kashyapa Samhita is incomplete work and it

might be possible that he might have considered the Nidana Panchaka of Parikartika

in detail in some of lost portion over a period, but later on given a brief description of

it in relation to a Gravid woman.

. Sadhya Asadhyata.


SADHYA ASADHYATA

Sadhyasadhyata of a disease is decided by considering all the factors which

are likely to influence the curability and incurability of a disease. It is essential to

consider the Sadhyasadhyata before administering any forms of Chikitsa

(treatment).80 any type of Vrana can be cured easily, provided the patient is with good

Satva, Mamsa Dhatu, and Agni and if he is in his younger age.81

Also Vrana occurs in Guda can be cured easily82 if a Vrana is left untreated,

the Sadhyatva, as a consequence may lead to Yapyatva stage and finally leading to

Asadhyatva stage.83

Parikartika which affects the superficial layer of the Twak (analskin) is easily

curable. Therefore it can be included in the Sadhyata group. If it affects the deeper

layers, it shows relectance to heal.

Therefore it can be included in Kŗcchrasadhya group. If it is associated with

Kushta, Vishadushti and Shosha, the healing of Vrana will be delayed.84 If Parikartika

is associated with Sanniruddhaguda, it is considered as Yapya.

. Chikista of parikartika.


CHIKITSA OF PARIKARTIKA

Parikartika as a disease has been considered very briefly by Sushruta and other

successive authors. They have described the treatment of Parikartika in most brief

manner. Kashyapa has mentioned its management according to Doshika

predominance, others have not considered as Doshika type of classification, but it is a

fact that none of them has described surgical management, thereby showing that there

was no need of surgery as the disease was completely cured by the use of medicinal

preparations only, and they were satisfied with management. According to route of

administration the medicines are divided into two categories viz. 1) Sodana and 2)

Shamana

Sodana Chikista:

This local treatment is nothing but only Basti Karma. Basti is prepared in

Ghrita, Taila and milk with the help of other different drugs. Most of the drugs, which

are used in Basti Karma, are VataShamaka, Vraņa Shodhana - Ropaka and

Pittashamaka. There are three types of Bastis described by Sushruta and other

Ayurvedic authors viz.

(i) Anuvasana Basti (ii) Piccha Basti and (iii) Sital Basti. Remedy consists in

employing a Picchā Basti with Yashtimadhu and Sesamum pasted together and

dissolved in clarified butter and honey. And patient should be kept on Anuvasana

Basti, (in cases of Pittapredominance) Basti should be employed with the cream of

clarified butter and in case of Vata predominance with Taila cooked with



Yashtimadhu 85 Charaka has also advocated both types of medicines which have been

advocated by the Sushruta. He says Sheeta Basti consisting of drugs having Madhura

and Kashaya properties (Piccha and Anuvasana Basti) prepared by Madhuyaşti

powder and kwatha should be used.86

Kashyapa has also advised for the Anuvasana Basti. In this type of Basti the

base is milk, oil or Ghŗita87 these are either Vatashmaka or Pittashamaka. In many

compositions so many drugs have been used they have Vata and Pittashamaka

properties and Madhuyasti is many times used. Because it has property of cooling,

Vata- Pitta-Raktashamaka and widely it has been advocated by Sushruta for treatment

of traumatic wounds, Pittaja Vrana, fractures, Bhagandara, Upadansa and ulcer etc.

Both the Acharya Charaka and Sushruta have advocated Piccha Basti with

Madhuyaşti, Madhu and Taila for treatment of Parikartika.

Shamana chikista:

The oral preparation have many-fold objectives some drugs are used to correct

the anorectal disorders other are used as laxative and few more as to correct the

Agniduşhti. They have advised drugs as the Tridoşhashamaka. Sushruta has advised

for cold water bath and milk for oral administration.88

In this disease the main problem is that of constipation and pain only. If one

corrects the constipation part of disease and alleviates the pain the disease may

disappear to a great extent within few days. Pain due to Vata and Pitta vitiation and

constipation due to two reasons 1) Habitual constipation and 2) Due to fear of pain



patient does not go for the defaecation. Acharya Charaka has also written about the

oral treatment in Parikartika and advised for only milk drinking.89

Acharya Charaka has also advised to take Amla Dravya because it has the

property of Vatashamaka and increases the digestive fire. According to Charaka, if

there is Parikartika present with fever, patient should drink the gruel prepared with the

heart shaped leaves of seed, fruits of Kokam, butter tree, sour jujube, then painted

leaved ureria and yellow barried night shade mixed with Beal fruit.90 In Kashyapa

Samhita the treatment has been given according to predominance of Dosha.

1. Vatika Parikartika:

Brihati, Beal and Ananta are used which all have the Vatashamaka property.93

2. Paittika Parikartika:

Such drugs like Madhuyaşti, Hanspatti, Dhaniya, Madhu etc. are useful for

Pittashamana and have also property to correct abdominal trouble with its laxative

effect91

3. Kaphaja Parikartika:

In this he has used the drugs which have the property of Kaphaśhāmaka and

Vatashamaka also as Kantakari, Pippal, Gokshura and salt.95 Further he has given the

treatment for Gravid Stri who is suffering from Parikartika is milk prepared with



drugs which have Madhura Rasa and mixed with Madhu, Sharkara, Tila Taila and

Madhuyaşti in this way, all the treatment is based on following factors.

1. To allevitate the Vata and Pitta.

2. To correct the abdominal trouble because in this disease Vata and Pitta are vitiated.

Most of the patients come with burning type of pain. So keeping these

Modern Anatomical Consideration.


MODERN ANATOMICAL CONSIDERATION

From the surgical point of view organs and structures of the body must be

known by a surgeon as to their anatomy and physiology for complete understanding

and thoroughness including the diagnosis and performing a good job at operation

table. Moreover, the diseases of the ano-rectal area are few of the commonest

pathological conditions of the terminal part of Gastro-intestinal tract and present very

complex conditions, in their management, both from the patients as well as from the

surgeon’s point of view. The basic understanding and knowledge of modern surgical

or applied anatomy of the anal canal and rectum is undoubtedly provided by Milligan

and Morgan (Milligan, 1942; Milligan and Morgan1934, 1937; Morgan, 1936).

Though Thompson (1899) has also dwelt upon the subject in his historic monograph

entitle, “mycology of the pelvic floor”. The former authors actually performed the

various operations and gave their histological findings too.

In fissure–in-ano mainly there is a need for either fissurectomy or

sphincterotomy. Therefore, it is very important that to have a good and thorough

knowledge of its anatomy and recognition of the sphincters, anal canal and rectum.

The ano-rectum, as the term suggest, can be described under two heads; viz. Rectum

and Anal Canal.



DEVELOPMENTAL ANATOMY OF RECTUM AND ANAL CANAL

The development of rectum and anal canal is associated with the growth of the

tail told. Further it is intimately associated with that of the bladder and other elements

of the urogenital system.

ANATOMY OF RECTUM:

The rectum is about 5 inches (13 cm) long and begins in front of the third

sacral vertebra as a continuation of the sigmoid colon. It follows the curvature of

sacrum and coccyx and ends 1 inch (2.5 cm) in front of the tip of the coccyx by

piercing the pelvic diaphragm and becoming continuous with the anal canal. The

lower part of the rectum that lies immediately above the pelvic diaphragm is dilated to

form the rectal ampulla. It develops partly from hindgut and partly from cloaca both

being endometrial in origin.

CURVES OF THE RECTUM:

1. Anteroposterior curves - Sacral flexure and perineal flexure

2. Lateral curves -Upper, middle and lower, lateral curves

PERITONEAL RELATIONS:

The peritoneum covers the anterior and lateral surface of the first third of the

rectum and only the anterior surface of the middle, leaving the lower third devoid of

peritoneum.



VISCERAL RELATIONS:

(a) Anteriorly -

In males the upper 2/3 of the rectum is related to rectovesical pouch with coils

of intestine and sigmoid colon. Where as lower 1/3 of rectum related to the base of

urinary bladder, vas deferens and prostate.

In females the upper 2/3 of rectum is related to recto uterine pouch with coils

of intestine and sigmoid colon and lower 1/3 of rectum is related to the lower part of

vagina.

(b) Posteriorly –

The rectum is in contact with sacrum and coccyx, ano-coccygeal ligament,

piriformis, coccygeus, levator ani, the sacral plexus and the sympathetic trunks.

Mucosal folds:

The mucous membrane of an empty rectum shows two types of folds. They are,

1. Longitudinal folds

2. Transverse or Horizontal folds

1. Longitudinal folds -

These are transitory and are present in the lower part of an empty rectum and

obliterated by distension.



2. Transverse or Horizontal folds -

(Houston's valves or plica transversalis)

These are permanent and most marked in distended rectum. Folding of

mucous membrane continuing circular and some times longitudinal muscle coats

forms them.

a) The upper fold lies near the upper end of rectum and projects from the right or

the left wall. Sometimes it may encircle and partially constrict the lumen.

b) The middle fold that is largest and most constant lies at the upper end of rectal

ampulla and projects from the anterior and right wall.

c) The lower fold that is inconstant lies 2.5 cms below the middle fold and

projects the left wall.

Supports of the rectum:

Waldeyer's fascia

Denonvillier's fascia

Lateral ligaments of endopelvic fascia

Pelvic floor.

ANATOMY OF ANAL CANAL:

The anal canal is the terminal portion of the intestinal tract; it begins at the

anorectal junction, is 3-4 cms in length and terminates at the anal verge. The

anatomical anal canal extends from the anal verge to dentate line. But the surgical

anal canal, extending from the anal verge to the anorectal ring. It passes downwards



and backwards from the perineal flexure. It has greatest surgical importance both

because of its role in the mechanism of rectal continence and because it is prone to

certain diseases.

In the normal living subject, the anal canal is completely collapsed owing to

the tonic contraction of the anal sphincters, and the anal orifice is represented by an

anteroposterior slit in the anal skin.

Table No. 1

Shows Relations:-

Anterior Posterior Lateral

Both

sexes

Perineal body Ano coccygeal

ligament

Ischiorectal

fossa

Males Membranous

urethra

Bulb of penis

Tip of Coccyx

Female Lower end of

Vagina



Interior of the Anal Canal:

This can be divided into 3 parts,

(a) Upper Part -

It extends from ano-rectal ring to the pectinate line and about 15 mm long. it is

lined by columnar epithelium of endodermal origin. The mucous membrane shows

anal columns of morgagni, anal valves, anal sinuses, anal papillae and pectinate line.

Anal glands are 4-8 in number and each has a direct opening into apex of anal crypt

and occasionally two glands open into same crypt.

(b) Middle Part –

It lies between the pectinate line above and white line of Hilton below and

about 15 mm long. This part of anal canal is lined by a stratified squamous

epithelium, which is thin pale and glossy and is devoid of sweat glands. The Hilton's

white line is situated at the level of interval between the subcutaneous part of anal

sphincter and the lower border of internal anal sphincter.

c) Lower Part –

It is about 8 mm long and is lined by true skin containing the sweat and

sebaceous glands.



Musculature of the Anal Canal:

A. Anal Sphincters:

Internal Sphincter:

It is formed by the thickened (5-8 mm) circular muscle coat and is involuntary

in nature. It lies above the subcutaneous part and deep to the superficial and deep

parts of the external sphincter and ends below at the white line of Hilton.

External Sphincter:

It is made up of striated muscle and is under voluntary control. It surrounds

the whole length of anal canal and consists of three parts.

(a) Subcutaneous Part - Which encircles the lower end of the anal canal and has

no bony attachments.

(b) Superficial Part - Which is attached to the coccyx behind and the perianal

body in front.

(c) Deep Part - Which surrounds the upper part of internal sphincter and is fused

with the puborectalis.

B. Ano-rectal Ring:

The term was coined by Milligan and Morgan to denote the functionally

important ring of muscle which surrounds the junction of rectum and anal canal. This

is composed of the upper borders of the internal and external sphincters, which



completely encircles the junction and on the posterior and lateral aspect, by the strong

puborectalis sling. As a consequence, the ring is stronger posteriorly and laterally than

it is anteriorly, and its definition on the posterior aspect is accentuated by the forward

angulation of the bowel at this level.

Recognition of the anorectal ring is of paramount importance in the treatment

of abscesses and fistula in the anal region, for its complete division inevitably results

in rectal incontinence, while its preservation, despite the sacrifice of all the rest of the

sphincter musculature, at least ensures that there will be no gross lack of control,

though minor degrees of incontinence may result.

FIGURE – 1

GUDA VALI & SPACES

Pravahani

Visarjini

Samvarani

Perianal space

Ischiorectal space

Supralevator space

Submucous space

Intersphincteric space



Surgical Spaces

These are potential spaces surrounding the anorectal canal and are sites for collection

of pus that might result in the formation of abscesses and fistulae.

i. Ischiorectal spaces - There is a fossa situated on both sides of anal canal. It is

situated on the pelvic diaphragm. Its base is towards surface and apex upwards.

Apart from these, there is a thin band of tissue intervening between the

ischiorectal fossa posteriorly, which is still a weaker point and permits entry of

Figure -3 Figure -2

MUSCULATURE OF

ANAL CANAL INTERIOR OF ANAL CANAL



pus from one fossa to the other, there by producing a horseshoe abscess in the

posterior perianal region.

ii. Pelvirectal spaces - It is made up of loose connective tissue above levator ani. It

is divided into anterior and posterior regions of lateral ligament of rectum.

These spaces can hold good account of pus.

iii. Submucous space - It is situated above the white line of Hilton between the

mucous membrane and internal sphincter.

iv. Perianal space - It surrounds the anal canal below the white line. It extends from

white line of Hilton medially to pudendal canal laterally.

v. Retrorectal space - It lies in the forward concavity of the sacrum. It is bounded

anteriorly by rectal wall, posteriorly by prevertebral fascia of sacrum, superiorly

by peritoneal reflexion, inferiorly by pelvic diaphragm, laterally by lateral

ligaments of rectum.

(D) Pelvic Diaphragm

It is formed by levator ani muscle. It is thin sheath of muscle on each side

forming major portion of pelvic diaphragm except anterior part. Each levator ani is

divided into three parts. They are pubococcygeus, puborectalis and iliococcygeus.

Pelvic diaphragm fixes pelvic viscera and acts as support for increased abdominal

pressure during exertion.



BLOOD SUPPLY OF RECTUM AND ANAL CANAL

1. Superior rectal artery -

It is the continuation of inferior mesenteric artery. The left and right

branches of superior rectal artery supply the upper and middle rectum.

2. Middle rectal artery –

It arises at anterior division of iliac artery and supply the lower part of

the rectum and upper part of the anal canal.

3. Inferior rectal artery -It supplies external and internal sphincters below the

pectinate line.

4. Median sacral artery -It supplies to the posterior wall of anorectal junction

and anal canal.

VENOUS SUPPLY OF RECTUM AND ANAL CANAL

1. Superior rectal veins -The upper and middle rectums are drained by superior

rectal veins which enter the portal system via inferior mesenteric vein.

2. Middle rectal veins -It drains the lower rectum and upper anal canal, which

open into the internal iliac veins and then into canal system.

3. Inferior rectal veins -It begins from the external rectal plexus and drains the

lower part of anal canal.

4. Internal rectal venous plexus (Haemorrhoidal Plexus)- It lies in the

submucosa of anal canal and drains mainly into the superior rectal vein, but



communicates freely with the external plexus and thus with middle and

inferior rectal veins.

5. External rectal venous plexus - It lies outside the muscular coat of the

rectum and anal canal and communicates freely with the internal plexus.

6. Anal veins - These are arranged radially around the anal margin. They

communicate with the internal rectal plexus and inferior rectal veins.

FIGURE – 4

C.S. RECTUM & ANAL CANAL



FIGURE – 5

BLOOD SUPPLY



LYMPHATIC SUPPLY OF RECTUM AND ANAL CANAL:

1. Lymphatics from more than the upper half of the rectum pass along the

superior rectal vessels to the inferior mesenteric nodes.

2. Lymphatics from the lower half of the rectum pass along the middle rectal

vessels to the internal iliac nodes.

3. Above the pectinate line, the lymphatics drain with those of the rectum into

the internal iliac nodes.

FIGURE –6

VENOUS SUPPLY



4. Below the pectinate line, the lymphatics drain into the median group of

superficial inguinal nodes.

NERVE SUPPLY OF RECTUM AND ANAL CANAL:

1. The rectum is supplied by both sympathetic (L1, L2) and parasympathetic (S2,

3, 4) nerves through superior rectal and inferior hypogastric plexuses.

2. Above the pectinate line - The anal canal is supplied by autonomic nerves,

both sympathetic (inferior hypogastric Plexus L1,L2) and parasympathetic ( S2,

3, 4).

3. Below the pectinate line - It is supplied by somatic (inferior rectal S3, 4) nerves.

4. Anal Sphincters - The internal sphincter contracts by sympathetic nerves and

relaxes by the parasympathetic nerves. The inferior rectal and perineal branch

of fourth sacral nerve supplies external sphincter.

PHYSIOLOGY OF THE RECTUM AND ANAL CANAL

The junction of the anorectal canal has to store and evacuate the fecal matter.

The interval of the defecation varies from a day to 4-5 days, depending upon the

nature of food taken. In majority of the people, this occurs once in a day. There are

two reflexes which initiate peristalsis.

(1) Orthocolic reflex. - This occurs when a person awakes from sleep assuming the

erect position.



(2) Gastrocolic reflex. –This occurs when the person is moving and taking food and

liquids. The increased intra rectal pressure causes the relaxation of anal sphincters

which is counteracted by voluntary contraction of external sphincter permits the act to

proceed. If the delay is prolonged, a temporary reduction in the intensity of the urge

may occur.

FISSURE –IN –ANO

SYNONYMS:

Anal ulcer

Anal fissure

Ulcer –in –ano

Chronic ulcer

Faecal ulcer

Definition of fissure


DEFINITION:

The term “fissure” generally denotes a crack or a split or a cleft or a groove.

The anal fissure (or fissure-in-ano) has been described as an acute superficial break in

the continuity of the anoderm (anal skin) usually in the posterior midline of the anal

margin. 1. “An anal fissure appears to be a longitudinal crack in the anal skin, but in

reality it is a true ulcer of the skin of the wall of the anal canal” (Nesselrod).

2. “An elongated ulcer in the long axis of the anal canal”96

3. “The squamous mucosa of the lower half of the anal canal is prone to superficial

ulceration, which present clinically as an anal fissure. It is a linear ulcer, usually

situated in the posterior commissure of the canal” (Devis Christopher)

AGE:

It is usually encountered in young or middle aged adults, but sometimes seen

at other ages including infancy and early childhood (Bennet). It is disease mainly of

middle life (R.Madevan). Hamilton says that “Fissure-in-ano is not uncommon in

children, and probably because the condition is not even thought of, in young child

the diagnosis is frequently missed.

SEX:

Definition of fissure


Anterior fissure is more common in women than in men, and accounts for

some 40%of all fissures in that women as contrasted with only 10% in men

(Goligher). Posterior fissure is 90% in men, 60%in women.

LOCATION:

It is mostly found on the midline posteriorly. The next frequent situation is the

mid line anteriorly 97 Page 46 of 163 - 46 -Goligher say that it is nearly always in the

midline of the posterior wall of the anal canal or immediately towards one or other

side of it, occasionally it occurs in middle of the anterior anal wall and exceptionally

it is found elsewhere on the circumference of the anus. Fissures are always single but

rarely two or more fissures co-exist.

Aetiology.


AETIOLOGY:

According to Davis,”main aetiology of anal fissure is anal infection”. Boyd

says that there are only two reasons by which anal fissures occur.

1. Trauma by the passage of a thick column of hard stool and,

2. Loss of elasticity due to chronic infection and fibrosis.

Further he says that at least 95% of these lesions are situated in the posterior

commissure, because the fibres of eternal sphincter which encircle the anus fuse much

more completely in front than behind. So that mucosa of the posterior aspect of anal

canal is less strongly supported and more easily torn. Fissure-in-ano is end result of a

tear of mucous membrane at 6 o’clock position of the anus or of anal valve by a hard

scybala in a constipated patient. Bailey and Love have said that the cause of anal

fissure, particularly the reason why the midline posteriorly is frequently involved is

not completely understood. Probability is that posterior wall of the rectum curves

forwards from hollow of the sacrum to join the anal canal, which turns sharply

backwards. During defaecation the presence of hard faecal mass is mainly on the

posterior anorectal angle in which event the overlying epithelium is greatly stretched

and being relatively unsupported by muscle, is placed in a vulnerable position when a

scabalous mass is being expelled. Possibilities in some cases are due to tearing down

of an anal valve of ball.

Modern classification.


CLASSIFICATION:

For all practical purposes, the fissure can be classified into two groups:

1. Primary or Idiopathic

2. Secondary or such fissures

Which develop in those patients who have undergone anal operation, such as

haemorrhoidectomy or lying open of a low anal fistula, where the resulting wound is

situated anteriolry or posteriorly. Considering the large number of minor anal

operations which are regularly performed the secondary anal fissure are not

uncommon.

TYPES:

1. Acute

2. Chronic.

1. Acute.: This ulcer is often a mere crack in the epithelial surface, but may, never the

less, cause severe pain and spasm.

2. Chronic: This has thickened margin edges, the skin at the lower edges of the fissure

is often odematous, hypertrophied and undermined, producing the so called sentinal

tag. In the base of the ulcer some times see the fibres of the external sphincter

crossing transversely.

Pathology..


PATHOLOGY

This condition is nearly always in the midline of the posterior wall of the anal

canal or immediately left or right side of it, occasionally it occurs in middle of the

anterior anal wall, and of exceptionally it is found elsewhere on the circumference of

the anus. Anterior fissures are more common in woman than in man. Fissures are

always single but rarely two or more fissures are encountered simultaneously. The

situation of the fissure in the vertical axis of anal canal is also a very constant. It lies

in the cutaneous portion of anal lining between the level of the anal valve and the anal

orifice. In this portion it is situated superficial to the lower most quarter or one third

of the internal sphincter muscle. Initially it is separated from the sphincter by the thin

layer of longitudinal muscle spread on the inner

An alternative view advanced by Miles (1919-39) was that pale tissue exposed

by a chronic fissure was not sphincter muscle at all but instead a condensation of

fibrous tissue in the submucous space of the anal canal, forming a ring of fibrosis

which is “Paten band” and which he believed played an important part in the

aetiology of anal fissure. The work of Eisenhammer (1953), Goliher, Leacock and

Brossy (1955) and Thomson (1956) however, leaves no doubt that the tissue

underlying a fissure-in-ano is the internal sphincter muscle that the structure identified

by Miles as the ‘Paten band’ is simply the prominent lower edge of this sphincter, and

that at no stage the external sphincter is in direct contact with an anal fissure.

Pathology..


SECONDARY CHANGES:

In its early stages fissure is a simple slit in the skin of the anal canal but there

soon developed in connection with it certain secondary changes. One of the most

important points is the swelling of the skin at the lower end of the fissure, actually at

the level of the anal orifice, so that it forms a tag like swelling the so-called sentinel

tag. This is due to low grade infection and lymphatic oedema, and after the tag has

undergone very inflammed, tense and oedematous appearance, it may go into fibrosis

later on and persist as a permanent fibrous skin tag even after the fissure has healed.

When the fissure is relatively superficial the sphincter usually undergoes a tight

spasm, but when the fissure deepens and bares sphincter fibres thus becomes even

more pronounced. The external sphincter may also have to some extent in the

contraction of the anal musculature associated with the pain of the fissure, but it does

not undergo the intense persistence contraction and eventual fibrosis seen so often in

the internal sphincter.

PATHOGENESIS:

According to Devis (1960) and Nesselrod (1970) has said that chief cause of

anal fissure is anal infection and it occurs in three stages:

Stage 1: The infectious material is trapped or lodged in one or more of the anal crypts

and is carried to the anal glands via the anal ducts. Thus, the crypts serve as funnels

Pathology..


through which the infectious material from the intestinal tract is directed into the anal

ducts and glands.

Stage 2: The second stage of anal infection is initiated by the so-called invasion of the

surrounding tissues by the infectious material. This can occur directly due to breaks in

the continuity of gland or duct.

Stage 3: If the infectious material localieses itself superficially in the subcutaneous

tissue of the anal wall, usually the posterior one, a dissolution of the anal skin results

in the formation of an ulcer of the anal skin, more commonly known as an anal

fissure.

CLINICAL FEATURES.

Pain:

The story of the condition is very much suggestive in cases of active anal

fissure. Acute anal pain is associated with and following stool. The pain starts with

the act of defaecation and is described as a sharp/ cutting or tearing; which

subsequently continues as a burning or gnawing discomfort for several hours (3 to 4

hours) following stool. To some patients the pain is so agonizing that they tend to

become constipated rather than go through the agony of defaecation. The reason of

pain following stool can be understood on the basis of pathophysiology of nervous

involvement of anorectal region. During defaecation the anal tissues are stretched and

the margins of the anal ulcer are separated. The first victim of anal fissure is the anal

integument /skin of the anal canal. The anal skin has somatic sensory nerve- supply

Pathology..


further the sensitive nerve conveys its influence from the surface of the ulcer to the

spinal marrow, and the motor branch conveys the motor power from the spinal

marrow to the sphincter muscle thus the irritation engenderaed at the ulcer is

conveyed to the spinal marrow, thereby producing reflected effects upon the sphincter

muscle, leading to painful contraction, which continues until the muscle becomes

fatigued and at that time the patient feels relief. Hence the spasm of the muscle results

in pain, whereas, the fatigue results in relief.

Bleeding:

Bleeding may be present or may not be present. Usually the bleeding is quite

slight and amounts to little more than a streaking of the motion.

Swelling:

A large sentinal tag at the anus and may complain of having painful external

piles.

Discharge and Purities:

If there is much discharge this may lead to soiling of the underclothes, and to

increase moisture of the peri-anal skin with resulting pruritis around the anus.

Urinary symptoms:

Some times patients have developed disturbances of micturation by reflex

mechanism and C/O either dysuria and retention or increased frequency.

Pathology..


Bowel habit:

The patient can quickly make out that is either initiated or aggravated by

defecation. So there is tendency to defer going to stool, thereby the normal bowel

habit is gradually taken over by the constipation.

Nervous Manifestation:

In stable individuals there may be no systemic reaction. Where as in less stable

persons there may be abdominal discomfort, digestive disturbances, headache,

irritability and extreme nervousness. There may be marked changes in the personality.

Differential Diagnosis..


DIFFERENTIAL DIAGNOSIS:

Most of the conditions presenting with anal pain, swelling, bleeding can be

easily differentiated by examination. Thus haematoma, prolapsed haemorrhoids,

various types of abscesses in the anal region can be easily identified. However a few

ulcerative lesions which produce fissures in the anal skin such as carcinoma,

ulcerative colitis, Crohn’s disease, syphilitic ulcers, gonorrhoea requires more careful

discrimination.

ANAL ABRASION AND PRURITUS WITH SUPERFICIAL

CRACKS:

Anal abrasion is caused by passage of hard stools and it is usually found in

infants and children. These are superficial cracks which heal easily under proper anal

hygiene. In pruritus-ani several superficial cracks extending radially from anus are

found. Both these conditions are limited to superficial layer of skin and the

characteristic features of fissure in ano such as tenderness, spasm of internal sphincter

etc are absent. Thus these conditions can be differentiated from fissure in ano.

ULCERATIVE COLITIS:

Fissure-in-ano can be found in some types of ulcerative colitis in which

ulcerative lesions are a prominent feature. In this disease ulcers occur in large

intestine. Fissure-in-ano is a rectal manifestation of this disease and they are

extremely painful and become broad deep and very septic so that they readily lead to



abscess and fistula formation. They are often situated in the midline and may be

multiple in numbers. When ulcerative colitis involves the greater part of large

intestine, the diarrhoea and some constitutional symptoms are also manifested. If

proctocolitis is confined to the rectum and lower part of the sigmoid colon then the

patient may develop mild diarrhoea and little general disturbances with painful

fissures. Usually these fissures are inflamed.

Crohn’s disease:

Anal fissures can be found in Crohn’s disease affecting the large or small

intestine. The fissure appears grosser than idiopathic fissures and more similar to that

seen in ulcerative colitis. But it is more extensive than the latter. Histological

examination of the tissue obtained by biopsy confirms the disease. Sigmoidoscopy

may reveal disease in the rectum, but rarely rectal mucosa appears normal when the

intestinal lesion is situated at a higher level in the bowel.

Associated with carcinoma:

A > Squamous cell carcinoma of the anus.

b > Adenocarcinoma of rectum.

In both these conditions, the anal skin is involved and shows fissures

resembling chronic idiopathic fissures. There will be more induration than a simple

fissure. In chronic cases, these fissures form the lower most part of the more extensive

lesion of anal canal or rectum. These will be severe pain on defaecation. The inguinal



glands may become hard and enlarged. Histological examination of the tissue

obtained by biopsy confirms the diagnosis.

Phiranga Roga Anubandha (Associated with syphilis)

This infectious disease was more prevalent in Phiranga Desha hence the

disease was named as Phiranga. The mode of spreading is through contact with the

infected patient. Therefore it is considered as an aquired disease. There are three types

(1)Bahya (external) (2)Abhyantara (internal) (3) Bahyabhyantara (mixed).

Bahyabhyantara is characterized by painless ulcers. Triponema pallidium is the

causative organism. Fissures due to syphilis may either be primary chancre or

condylomas (secondary). A classic primary chancre is typically a single painless

papule which quickly erodes to from an ulcer with smooth base and firm raised

borders. These ulcers are usually painless. But there may be rectal pain, tenesmus, and

difficulty during defaecation and rectal discharge. The presence of symmentrical

lesions in either side of the anal canal will raise suspection. Anal condyloma affects

anal orifice as well as perianal skin. The anal region is moist and pruritic. The

presence of multiple superficial ulcers should raise the possibility of syphilis.

Secondary lesions and mucous patches are also present in the mouth. Dark ground

illumination of the sample of the discharge from the ulcer for spirochetes can confirm

the diagnosis. TPHA test and VDRL test are also used to diagnose the disease.



Tuberculosis:

Yakshma or Tuberculosis is an infectious communicable bacterial disease

caused by Mycobacterium tuberculosis. Rarely tuberculous ulcers can occur in anal

region. Early stages of this disease may present with a simple fissure and later shows

the characteristic undermined edge. Histological examination of the tissue obtained

from the ulcer edge will confirm the diagnosis.

HIV Infection:

With emerge of HIV infection it becomes an essential step to differentiate and

identify this condition, as it poses diagnostic and therapeutic problems. Recent studies

show that there is clear association between HIV seroposativity and ulcerative lesions.

Immuno compromised patients are susceptible to a wider range of diseases caused by

human immunodeficiency virus or other organisms such as bacteria, fungus, virus,

protozoa etc. ELISA test and western blot tests are the available tests to detect HIV

infection. Latest report says that it is possible to isolate the organism from the

materials obtained from the ulcerative lesions. In the HIV positive patient, benign

fissure and idiopathic AIDS ulcers are distinct processes. Ano-receptive intercourse

and diarrhoeal; illnesses predisposes the HIV positive homosexual to the development

of anal fissures which are typical in appearance and response to treatment. Idiopathic

anal ulcers are characterized by persistent gnawing pain, location above the dentate

line, a broad base, deep invasion, a patulous anus and AIDS. Debridement, excision

with mucosal advancement and Depo-Medrol injection has been successful.



AGRANULOCYTIC ANGINA:

The anal lesions of agranulocytic angina may appear first to resemble a typical

anal fissure. Usually this lesion fails to respond to normal treatment and then a

differential blood study show decreased leucocyte count and a low percentage of

granulocyte. Similar lesions can be found in mouth and throat. Thus the condition can

be differentiated from idiopathic benign fissure.

Associated with Gonorrhoea:

Pooyameha or Gonorrhoea is an infection caused by Neisseria Gonorrhoea.

Catteral in described a patient with a slightly erethematous rectal mucosa and small

ulceration at the anorectal junction. Lebedeff DA, Hochmann EB in described

superficial ulcerations and fissures in rectal gonorrhoea. However, high proportions of

rectal gonococcal infections are asymptomatic or produce mild symptoms including

constipation anorecatal discomfort, tenesmus or a mucopurulent discharge. A

diagnosis can be made by gram stain of rectal exudates obtained through anoscope

and culture of material obtained from biopsy.

Chancroid:

Chancroid is a genital ulcerative disease caused by Haemophillus ducreyi. The

anorectal manifestations of the disease have been described by carman. M.L.in 1984.

An errythematous tender papule develops at the site of inoculation and within a few

days it becomes pustular and develops into a painful ulcer. These ulcers have poorly



demarcated borders and a characteristic necrotic irregular base covered by

mucopurulent exudates. This is no surrounding erythema or induration, but there may

be associatd painful inguinal lymphadenopathy. Culture of material obtained from an

enlarged lymphnode for the H. ducreyi suggests a diagnosis.

Lymphogranuloma vernerum:

L. G.V. is caused by chalamydia trachomatis unilateral tender erythematous

lymphadenopathy will develop 2-3 weeks of the skin lesions. Fever malaise, hepatitis,

meningitis and conjunctivitis are the systematic disturbances manifested at this stage

of disease. Rectal involvement is manifested by rectal discharge and peri-rectal

fistulae or abscess cryptitis. Progressive stricture can cause sanniruddha guda / rectal

stricture in the absence of these symptoms in untreated cases. Culture of the organism

from the lesions and enlarged lymph nodes confirms the diagnosis.

Proctalgia fugax:

The characteristic feature of this disease is the intermittent attack of cramp like

severe pain in the rectum unrelated with organic disease. Pain often occurs at night

when the patient is in bed, usually lasts only a few minutes and disappears

spontaneously. The pain may be due to the segmental cramp of puborectalis muscle.

Ectropion:

Ectropion in reference to Ano- Rectal terminology means growth of rectal

mucosa distal to the former level of the dentate margin, where a portion of the wall of



the canal becomes lined by rectal mucous membrane instead of the anal skin. Careful

examination will reveal the smooth, velvety appearance of mucosa, no pain or spasm.

But constant mucoid discharge resulting in a soggy, macerated anal and perianal skin.

Pruritus ani with superficial cracks of anal skin:

Many cases of anal fissure develop pruritus ani due to irretation of perianal

skin by the discharge. In case of primary pruritus the skin shows superficial cracks

extending radially from the anus. There is no true anal spasm or tenderness in

thesecases.

Coccydynia:

The complaint of the patient is severe pain during defaecation. There is a history of

injury or fracture of the coccyax, which causes the contraction of levator ani, whiles

various movements. Whereas in some cases there is no history of fracture or injury

and such a condition is known as “COCCYDYNIA” of unknown aetiology. Rectal

examination reveals local tenderness and occasionally deformity.

COMPLICATIONS

Main complications are:

1. Abscess and fistula.

2. Sentinel tag.

3. Enlarged papilla



4. Anal contracture.

Treatment..


TREATMENT

Most of the superficial fissure heals spontaneously often in 3 or 4 weeks, which have

short history of pain. On the other hand chronic fissures do not heal on the

conservative line of treatment. They may produce less symptoms but trouble may

recur frequently. To avoid trouble to the patient one should be anxious for a quick

judgment whether there is need of conservative line of treatment or surgical

intervention. Thus there could be two types of treatment for fissure-in-ano.

1. Medical or Conservative Treatment.

2. Surgical Treatment.

1. Medical Treatment:

(i) Palliative

(ii) Injection treatment

Palliative:

In this treatment warm sit bath, hot packs, careful cleaning of the anal outlet

following the passage of stools. (Anal Hygiene) and application of ointment and use

of laxative is common. In this treatment the laxatives play a major role to some extent.

Avoidance of Constipation:

This is most important point in the medical treatment for fissure-in ano.

Fric.L. has suggested for olive oil enema to avoid the constipation. John Wilson has

Treatment..


advised to regularization of bowel habits with mineral oils or other stool softness and

Senna suppositories twice daily. If fissure is healed, care should be taken for

regularizing the bowel habits and constipation must be avoided. If this care is not

taken by the patient, there are more chances to recurrence of fissure.

Nitric oxide - has been identified as the chemical messenger of the intrinsic

nonadrenergic, non- cholinergic pathway mediating relaxation of the internal anal

sphincter. Topical application of nitroglycerin, a nitric oxide donor, causes a transient

lowering of resting anal pressure and an increase in anodermal blood flow.

Botulinum Toxin: Botulinum toxin has been injected into the external and internal

sphincters and, with short term follow up, healing rates of 80% have been achieved.

This approach is expensive and invasive compared to nitroglycerin.

Injection of long acting local anaesthetics: Sensory nerve supply to the skin in the

region of an anal fissure is divided from the inferior rectal nerves, and blocking of

these nerves by long acting anaesthetics injection can give relief from pain of fissure-

in-ano. These anaesthetics are prepared in sterile oily media, the object of which is to

delay the absorption of the anaethetics agents and prolong its local action. Well

known preparation Nupercaine and Proctocaine and so many other preparations are

available in the market now days.

Technique of Injection: Taking proper aseptic care the injection should be injected

producing a wheal of ½% lignocaine in the skin 2.5 cm. Behind the anal verge and

needle being injected at this part, 5-10 ml drug may be injected immediately behind

Treatment..


the anus, deep to the fissure, and skin should be sealed with Tr.Iodine, Second

injection should not be given in less than 3 months, and it is probably unwise for this

treatment to be repeated within period of one year.

Use of the Anaesthetic ointment:

Now a day’s local anaesthetic are used as an ointment for relieving. The pain

and spasm of the fissure very frequently. This treatment is adopted by every

proctologist and every physician; popular preparations are 3% Decicaine

(amethocaine). Percailol or lignocaine 5%. The best time for application is before

defaecation and after defaecation, it can be used by the help of finger or by any

nozzle, but it should not touch the peri-anal skin because it produces local dermatitis

and pruritis (Goligher). Now day’s similar ointments with cortisone are also used.

Use of Anal Dilators:

Goligher suggested producing local anaesthesia by applying the local

anaesthetics and dilatation can be performed digitally.

Method: Under general anaesthesia with the patients in lithotomy position, the

lubricated, gloved index finger is inserted as far as the ano-rectal line and with the

palmer surface against the anal wall the muscle is stretched by firm pressure applied

in a rotatory motion. The index finger of the other hand is then introduced beside the

first, and firm pressure is made in opposite directions about the circumference of the

anus. This procedure should be carried out slowly, several minutes being consumed in

doing so.

Treatment..


COMPLICATION OF THE MEDICAL TREATMENT:

The medical treatment is liable for so many complications, that this has gone

into disrepute. Regular use of such ointments cause local dermatitis and retard the

natural healing of the ulcer rather than promoting it,. Similarly in the injection

therapy, there are more chances of abscess formation and subsequent fistulae may

develop.. It may also produce incontinence due to paralysis of the sphincter, because

it has been seen that higher doses of these local anaesthetics definitely produce the

paralysis of anal sphincters by which the relief from pain is achieved. Moreover, in

anal dilatation there is the need of general anaesthesia and during dilatation there may

be profuse bleeding by an enthusiastic surgeon.

OPERATIVE TREATMENT:

There is correction of spasm and contraction of internal sphincter muscle by

stretching or by partial or complete division or excision of the fissure, so as to provide

a wide external wound in which the discharges cannot stagnate.

1. Stretching of the anal sphincter: It is simple operation and there is no need

of many instruments and other surgical accessories. Only by the help of fingers

this operation can be performed. Not only a surgeons but junior staff without

special equipment can also perform it easily. Thus this operation was made

popular by the surgeon for treating the cases of fissure-in-ano.

2. Technique: This operation can be performed even under local anaesthesia, but

it is better done under general anaesthesia preferably with a relaxant. With the

Treatment..


patient in lithotomy or left lateral position, the anus is stretched by the help of

index and middle finger of the both hands. During this the forearms are fully

pronated so as to stretch the posterior wall of the anal canal. Better stretching is

obtained in male patients by using the sagittal rather than the transverse plane as

this avoids the fingers coming in contact, with the ischial tuberosities. This

problem does not arise in woman because of their wider pelvis.

3. Complication: Within few hours of stretching patients developed painful

perianal oedema.

4. Excision of Anal Fissure: Excision of broad triangle of skin of perianal region

along with the main lesion itself very important and provides relief, The advantage

of so doing, was that the apical part of the wound corresponding to the site of the

former fissure was given a chance to epithelization, so that there was little

prospect of being left with an unhealed area of granulation in the posterior wall of

the anal canal, so healing will not be impaired.

5. Excision of anal fissure with immediate Skin Grafting: In this technique

split thickness skin graft to the wound after the excision of the fissure, but there is

problem of Hospitalization and bowels must be confined for 5-6 days.

6. Division of the Internal Sphincter:

This technique is performed under general anaesthesia. By a short

longitudinal incision in the lining of the posterolateral part of canal it can be

obtained.

Treatment..


7. Technique of Open Posterior Internal Sphincterotomy.

This operation can be performed under a local anaesthetic blocker of the

inferior rectum nerves. For the actual operation patient should be turned on his left

lateral side. This technique should be done under general anaesthesia, because this

is much painful condition and after anaesthesia. it will be more convenient to do

operation in lithotomy position and then by the help of No. 7 Bard Parker knife

carrying a small no. 10 blade, this operation should be performed.

Complications:

There may be anal incontinence in the post-operative period another functional

defect is found that is faecal staining of the underclothes. The physiology of the

internal anal sphincter and its disturbance by internal sphincterotomy. It seemed

that faecal matter and flatus could leak down by this groove. The possibility that

lateral sphincterotomy has less prominent furrow on the anal canal than the

posterior sphincterotomy.

Complication:

Faecal Soiling of the underclothes and anal region in mid posterior

sphincterotomy.

Drug review.


DRUG REVIE

Ayurvedic treatises speak about the importance of drugs as ‘Nothing in world exists

which does not have the therapeutic utility.’ Taking this fact into consideration

Ayurvedic physicians have formulated single as well as compound drug for cure as

well as prevention of various ailments.

Selection of Drug:

In the present clinical research work, Yashtimadu gritha102 indicated for treatment of

Parikartika. Ingredients of Yashtimadu gritha also have sulaharaanulomana

,krimignaand Ropaņa properties that can help the wound to heal rapidly. Yashtimadu

Ghŗita is Sneha Kalpana and based on Ghŗita. Property of Ghŗita has been mentioned

as Vata-Pitta Shamaka, Madhura, Sheeta, Vişhahara, Ropaņa103, 104 Ghŗita is having

also soothing properties. It forms a thin layer over the wound and allows early

epithelization, also protects from invasion of any microbes. Ghŗita is also Samskara

Anuvarti 105

Ayurveda discriminates their particular features also and recommends the Go-Ghŗita

(cow Ghee) as best and the Ghŗita of choice for both, food and medicinal purposes and

in Ayurvedic Yoga if not specified, the Ghŗita always applies to Go-Ghŗita (Cow

Ghee).The present study was aimed towards providing easily accessible economic

treatment fo the common ailments fissure-in-ano. Yashtimadu Ghŗita is used for local

application. It is a simplest and easy formula.

Drug review.


To compare the effect of these therapies a control group of patients is

studied. Drug of the control drug is generally used in the patients of fissure-in-ano. As

a result of such for the better option for the standard control group – Yashtimadu Ghrita

and oral medication like abhayarista,gandaka rasayana is selected. Its Vraņa Ropaņa

and Śhodhana properties are well known and unanimously accepted, due to its dramatic

action on Vraņa like conditions. And it is obviously best option because it removes the

accumulated secretion in the fissure bed and also reduces thechances of secondary

infection thus, it reduces the pain. By application of these Ghrita, accelerates the wound

healing process.

YASHTIMADU GHRITA

YASHTI(GLYCYRRHIZA GLABRA LINN):

Glycyrrhiza glabra linn, is commonly known as ‘yashti in Ayurveda. It is also known as

‘liqarice in ’ in English ; ‘mulethi ’ in hindi ; ‘Kannada : Jestamadu,

Madhuka,Jyeshtamadhu longitudinally wrinkled, with occasional small buds and

encircling scale leaves,smoothed transversely, cut surface shows a cambium ring about

one-third of radius from outer surface and a small central pith, root similar without a pith,

fracture, coarsely fibrous in bark andsplintery inwood, odour, faint and characteristic,

taste,sweetish.

Drug review.


Chemical composition of wet 100gms yashtimadu contains.

Table No. 3

Shows Pharmacological properties & Action:-

Special Yogas: yashtimadu churna, yashtimadu Ghrita and Taila.

Glycyrrhizin

Asparagine, Starch

Glycyrrhizic acid

Sugars

Glycyrrhetinic acid,

Resin

Guna - Guru,Singda Rasa - Madhura.

Vipaka - Madhura. Veerya - Sheeta.

Doshagnata - Balya choksusha, Vrana Shodhaka.vrsya

Rakta Shodhaka,Raktaprasadana Ropaka, Varnya ,vatapittajith,

Drug review.


Haritaki:

Haritaki consists of the pericarp of mature fruits of Terminalia chebula Retz.

(Fam.Combretaceae)

Chemical composition:

Tannins, anthraquinones and polyphenolic compounds

Table No. 4

Pharmacological properties & Action:-

Guna -Laghu, Rooksha, Rasa – Madura,amla ,tikta,Katu,kashaya

Vipaka - Madura Veerya - Ushana

Doshagnata - caksusya,hrdya,dipana, Medya,sarvadoshaprasamanna

Pachana,rasayana ,anulomana Rakta Stambhaka.,

Useful parts: - Phala beeja. a)Macroscopic

Intact fruit yellowish-brown, ovoid, 20-35 mm long, 13-25 mm wide, wrinkled and

ribbed longitudinally, pericarp fibrous, 3-4 mm thick, non-adherent to the seed,taste,

astringent.

Drug review.


b) Microscopic

Transverse section of pericarp shows epicarp consisting of one layer of epidermalcells

inner tangential and upper portions of radial wall thick, mesocarp, 2-3 layers

ofcollenchyma, followed by a broad zone of parenchyma in which fibres and

sc1ereids ingroup and vascular bundles scattered, fibres with peg like out growth and

simple pittedwalls, sclereids of various shapes and sizes but mostly elongated, tannins

and raphides inparenchyma, endocarp consists of thick-walled sclereids of various

shapes and sizes, mostly elongated, epidermal surface view reveal polygonal cells,

uniformly thickwalled,several of them divided into two by a thin septa, starch grains

simple rounded or 62 oval in shape, measuring 2-7 µ in diameter, found in plenty in

almost all cells of mesocarp.

BIBITAKI:

Table No. 5


Guna - Laghu, Rooksha Rasa – Kashaya

Vipaka -Madura Veerya - Ushana

Doshagnata - caksusya,kaphapittajit kesya.

Bedaka ,kriminasahara, Kasahara,vibanda ,sarvabeda

Latin Name: Terntinalia belerica Roxb.

Drug review.


DESCRIPTION

a) Macroscopic

Fruit nearly spherical to ovoid, 2.5-4.0 cm in diameter, fresh ripe fruits Slightly

silvery or with whitish shiny pubescent surface, mature fruits grey orgrayish brown

withslightly wrinkled appearance, rind of fruit shows variationin thickness from 3-5

mm, taste, astringent.

b) Microscopic

Transverse section of fruit shows an outer epicarp consisting of a layer of epidermis,

most of epidermal cells elongate to form hair like protuberance with swollen

base,composed of a zone of parenchymatous cells, slightlytangentially elongated and

irregularly arranged, intermingled with stone cells of varying shape and size,elongated

stone cells found towards periphery and spherical in the inner zone of mesocarp in

groups of 3-10, mesocarp traversed in various directions by numerous vascular

strands, bundles collateral, endarch, simple starch grains and some stone cells found

in most of mesocarp cells, few peripheral layers devoid of starch grains, rosettes of

calcium oxalate 33 and stone cells present in parenchymatous cells, endosperm

composed of stone cells running longitudinally as well as transversely.

CONSTITUENTS - Gallic acid, tannic acid and glycosides.

IMPORTANT FORMULATIONS - Triphal churna, Triphaladi Taila,

Lavanagadi Vati.

THERAPEUTIC USES - Chardi, Kasa, K¤miroga, Vibandha, Svarabheda, Netraroga

Drug review.


DOSE - 3-6 g of the drug in powder .

USED PART:Seeds,root ,

AMALAKI:

Table No. 6


Guna - Laghu, Rooksha Rasa – Madura,amla,katu,tikta, Kashaya

Vipaka -Madura Veerya - sheeta

Doshagnata - caksusya,tridoshajit Vrsya,rasayana

Rakthapittanasana,amlapittanashana Rasayana

Amalaki consists of pericarp of dried mature fruits of Emblica officinalis Gaertn.Syn.

Phyllanthus emblica Linn.

DESCRIPTION

a) Macroscopic

Drug consists of curled pieces of pericarp of dried fruit occuring either asseparated

single segment; 1-2 cm long or united as 3 or 4 segments; bulk colourgrey toblack,

pieces showing, a broad, highly shrivelled and wrinkled external convex surface to

somewhat concave, transversely wrinkled lateral surface, external surface show s a

few whitish specks, occasionally some pieces show a portion of stony testa (which

should be removed before processing); texture rough, cartilaginous, tough; taste,

sourand astringent.

Drug review.


IMPORTANT FORMULATIONS – Cyavanaprasa, Dhatri, Lauha, Dhatryadi Ghuta,

Triphala churna.

THERAPEUTIC USES - Raktapitta, Amlapitta, Premeha, Daha.

DOSE - 3-6 g of the drug in powder form.8

MUSTA:

Musta consists of dried rhizome of Cyperus rotundus Linn. (Fam. Cyperaceae)

occurring throughout the country, common in waste grounds, gardens and roadsides,

upto an elevation of 1800 m.

Table No. 7


Guna - Laghu, Rooksha Rasa – katu ,tikta, Kashaya

Vipaka -Katu Veerya - sheeta

Doshagnata -sotahara,dipana pachana Grihi ,krimigna ,vishagna

Pittakaphahara,sthoulyahara Trsnanirgarana ,tvakdoshahara,jvaragna.

DESCRIPTION -

a) Macroscopic

Drug consists of rhizome and stolon having a number of wiry roots, stolon 10-20cm

long having a number of rhizomes, crowded together on the stolons, rhizomes bluntly

conical and vary in size and thickness, crowned with the remains of stem and leaves

Drug review.


forming a scaly covering, dark brown or black externally, creamish-yellow

internally;odour, pleasant.

b) Microscopic:

Rhizome shows single layered epidermis, followed by 2-6 layers,

suberisedsclerenchymatous cells; epidermis and outer sclerenchymatous layers filled

with dark brown content; ground tissue of cortex consists of circular to oval, thin-

walled, parenchymatous cells with small intercellular spaces; a few fibro-vascular

bundles present in this region; endoderm is distinct and surrounding the stele; wide

central zonebeneath endodermis,

CONSTITUENTS - Volatile Oil

IMPORTANT FORMULATIONS –

Musakarista, Mustakadi Kvatha, Ashokarista, Mustakadi churna, Mustakadi Lehyaetc

THERAPEUTIC USES - Agnimandya, Ajerna, Jvara Kasa, Mutrakucchra, Vamana,

Stanyavikara, Sutikaroga,Atisara, Ëmavata, Krimiroga

DOSE - 3-6 g. (Powder).20-30 ml. (Kwatha).

HARIDRA:

Haridra consists of the dried and cured rhizomes of Curcuma longa Linn.

(Fam.Zingiberaceae), a perennial herb extensively cultivated in all parts of the country,

crop is harvested after 9-10 months when lower leaves turn yellow rhizomes carefully

dug up with hand-picks between October-April and cured by boiling and dried.

Drug review.


Table No. 8


Guna - Rooksha Rasa – katu ,tikta,

Vipaka -Katu Veerya - ushna

Doshagnata -krimigna,kushagna Vranya,vishagna

Kaphapitantu Pramehanashaka

DESCRIPTION

a) Macroscopic

Rhizomes ovate, oblong or pyriform (round turmeric) or cylindrical, often short

branched (long turmeric), former about half as broad as long, latter 2-5 cm long and

about 1-1.8 cm thick, externally yellowish to yellowish-brown with root scars and

annulations of leaf bases, fracture horny, fractured surface orange to reddish

brown,central cylinder twice as broad as cortex: odour and taste characteristic.

b) Microscopic

Transverse section of rhizome shows epidermis with thick-walled, cubical cells Of

various dimensions, cortex characterised by the presence of mostly thin-walled

rounded parenchyma cells scattered collateral vascular bundles, a few layers of cork

developed under epidermis and scattered oleo-resin cells with brownish contents;

cork generally composed of 4-6 layers of thin-walled, brick-shaped parenchyma, cells

of ground tissue contain starch grains of 4-15 µ in diameter, oil cell with suberised

Drug review.


walls containing 60.either orange-yellowglobules of volatile oil or amorphous

resinous matter, vessels mainly spirally thickened, a few reticulate and annular.

CONSTITUENTS - Essential oil and a colouring matter (curcumin).

IMPORTANT FORMULATIONS – Haridra Khanda

THERAPEUTIC USES - Pandu, Prameha, Vrana, Visavikara, Kstha, Tvagroga

raktapitta pachana

DOSE - 1-3 g of the drug in powder .

MATULUNGA:

Table No. 9


Guna - Lagu Rasa – Mdura

Vipaka -Madura Veerya - shita

Doshagnata - vata pittanashaka Pidanashaka

Swasa kasahara Amlapittanashaka

GO – GHŖITA

Latin Name: Butyrum departum

Gaņa: Mahasneha (Su. Ca.)

Vernacular Names:

Drug review.


Sanskrit: Ghŗita English: Clarified butter

Hindi: Ghee Gujarati: Ghee

Synonyms: Aajya, Havis, Snehottama, Varasneha, Sarpi

Pharmacodynamics:

Rasa: Madhura Guņa: Guru, Snigdha, Mŗidu

Virya: Sheeta Vipaka: Madhura

Doshakarma: Vata- Pittahara

Actions and Uses: Ghee is the clarified butter fats. It promotes Agni, Sukra and

lengthens the life span. Attributes of Ghee i.e. unctuousness and coldness are

antagonistic to those ofVata and Pitta like dryness, lustreless, roughness and heat

respectively. Moreover, boilinwith Kapha antagonist drugs (like pungent, bitter taste),

prepared medicated Ghee caninhibit the action of deranged Kapha due to its

assimilating properties.

According to Bhavapraksha, Suśhruta, Charaka and almost all Acharya Go-Ghrita is

also beneficial for visual acuity by oral as well as local use. It also improves Dhi, Dhŗti

and Smŗti. It is good for complexion, voice and in Kşhatakşhiņa, Visarpa, toxins,

Unmada etc

. (A. H. Su. 5/37-39)

Drug review.


Chemical Constituents:

Go – Ghrita contains carotene in the amount of 3.2 – 7.4 g/g, vitamin A in the amount

of 19 – 34 I.U./g and Tocopherol (vitamin E) in the amount of 26 – 48 g in it. It also

contains vitamin D and K. (Source: Milk products of India by Srinivasan and

Anantakrishnan)

The principal contents are triglycerides or neutral fats. Fatty acid contents in

percentage by weight of different fatty acids is as follows: saturated – c14, below 3.0

palmitic (c10) 29, stearic (c18)21, c20 and above 1.0; monounsaturated – palmitoleic

(c16)3, oleic (c18) 41; polyunsaturated; linoleic (c18: 2)2, arachidonic (c20: 4) and c22

and higher in trace.

(Beaton G. H. McHenry W. E. 1964)

PREPARATION OF YASHTIMADU GHRITA:

Ingredients: - Yashtimadu gritha .

Kalka Dravyas: - 1 part (Amalaki,vibitaki,Haritaki,Hridra,Musta,matulunga swarasa)

Snehana Dravya: Murcchita Ghrita – 1 part ( 4 .1/2 liters)

Drava Dravya - Jala 4parts.

Drug review.


Method of preparation:

Taken 1 part of kalka dravyas,and 1 part of sneha dravyas,4 part of drava

dravyas taken in a big vessel heated on moderate flame till only ghee part remains. after

snehasiddi lakshanas remove preparation from heat. Filter the yashtimadu gritha and

stored in steel container104.

Mode of Action:

Yeashtimadu Ghŗita is having properties like sulahara ,anulomana, dipana,

krimign pachana Shodhana, Vraņa Ropaņa, Shothahara, Thus it removes the

accumulated secretions in the fissure bed; it promotes healing and also reduces probable

secondary infections.

Method of Administration:

Yashtimadu Ghrita Pichu in Guda-Marga

Indication: - Vrana Shodhaka, Vrana Ropaka, Pittaja Vrana, Nadi Vrana and Dust

Vrana. In this study Ghrita preparations were used because Ghrita preparations are said to

be coolantsand Vata Pittaharas. Ghee which is the base for the preparation of yashtimadu

Ghrita It accelerates the process of healing; reduce sphincter spasm of the Vrana when

applied locally.

Drug review.


Drug review.


PREPARATION OF GRITHA

Yastimadu churna Murchitha ghritha

Adding churna to grithaAdding matulunga

swarasa

Heating mixture of all drugs

Pure yeashtimadu gritha

Materials and methods.


MATERIALS AND METHODS:

SOURCE OF DATA

a) LITERARY SOURCE:

The source of parikartika is collected from the various classical texts of Ayurveda &

Modern Science, updated with journals and internet.

b) CLINICAL SOURCE:

Patients suffering from parikartika as per Ayurvedic classics, will be selected from the

OPD and IPD of RGES Ayurvedic Medical College and Hospital, RON

c) Drugs: The trial drug “yastimadhu” is collected from the local area and certified by

the Dravya Guna department.

Preparation of Yashtimadhu ghritha

Yashtimadhu ghritha preparation as per Bhaishajya Kalpana Ayurvedic text12

METHOD OF COLLECTION OF DATA:

The patients who are presenting with the features of Parikartika which can be

correlated with Fissure-in-ano in modern science, symptoms like excruciating pain in

anal region during and after defecation, constipation, bleeding per anum i.e. stools

streaked with blood, burning sensation in anal region, presence of longitudinal tear in

the anal region and sphincter spasm shall be selected for study.



A. INCLUSION CRITERIA:

Patients having classical features of Fissure-in-ano namely excruciating pain in anal

region during and after defecation, bleeding per anum, constipation, burning

sensation, presence of sphincter spasm and with a longitudinal ulcer in the anal region

will be selected.

Acute solitary fissures will be included.

Patients suffering from parikartika as per Ayurvedic classics will be selected.

B. EXCLUSION CRITERIA:

Patients suffering from any other ano rectal diseases.

Patients suffering from systemic disorders like HTN, DM etc

Patient suffering from infectious disease like HIV, tuberculosis etc

DIAGNOSTIC CRITERIA

Signs & Symptoms

Pain in anal region

Constipation

Bleeding per anum i.e. stools streaked with blood

Burning sensation in anal region.

STUDY DESIGN:

A Compairitive clinical study with pre test and post test design.



SAMPLE SIZE:

20 cases of each group (group A and group B) either sex and age group of 20 to 60

years suffering from Parikartika are randomly selected and submitted for clinical

trial.

GROUP-A

(CONTROL GROUP)

Patient treated with Yashtimadhu ghritha pichu

Aabhayarishta (3 tsf, t i d daily ) + Gandhaka

Rasayana(1 tab. t i d daily) and advised sitz bath twice

daily.

GROUP-B

(TRIAL GROUP)

Patient treated with Yashtimadhu ghritha pichu +

DURATION OF TREATMENT: Seven days

FOLLOW UP: - up to 2 months.

SOURCE OF FORMULATION:

Yashtimadhu ghritha will be prepared in the Rasa Shastra & Bhaishajya kalpana

Dept. of R G E S Ayurvedic Medical College, Hospital PG Studies & Research

centre, Ron, according to the classical references.



ASSESSMENT OF RESULTS

Depending upon subjective & objective parameters, assessment of response will be

made based on Gradation Index mentioned below.

Statistical analysis will be made using unpaired‘t’ test.

PARAMETERS OF STUDY:-

The improvement provided by therapy will be assessed on the basis of classical signs

and symptoms. All the signs and symptoms will be assigned with a score depending

upon their severity to assess the effect of the drugs objectively.

CRITERIA FOR ASSESMENT:

Assessment will be done based on the following parameter:-

GRADING FOR THE ASSESSMENT CRITERIA:-

FOR SUBJECTIVE PARAMETERS:

Pain;

No pain - 0

Mild -1

Moderate -2

Severe -3

Constipation:

No constipation - 0

Mild -1

Moderate -2

Severe -3



Bleeding:

No -0

Mild -1

Moderate -2

Severe -3

Burning sensation:

No -0

Mild -1

Moderate -2

Severe -3

b. Objective parameters:

Ulcer healing

Sphincter spasm.

Proctitis

Ulcer healing

Size of the ulcer is measured in mm and filled in the digits.



Sphincter spasm

Symptoms Normal Spasmodic

Grading 0 1

Proctitis:

Proctitis Absent Present

Grading 0 1

7.3) Does the study require any investigations or interventions to be conducted on

Patients or other humans or animals? If so please describe:

Yes

Study will be a human observational study. No animal experimentation will be

conducted.

INVESTIGATIONS:

HB

TC

DC,ESR

HIV, HBsAg

7.4 Has ethical clearance been obtained from your institution in case of 7.3?

YES (Copy Enclosed)

Effect of the therapies .


The efficacy of Yashtimadu Ghrita and control group has been studied in 20

patients of Parikartika (Fissure-In-Ano). These patients were divided into two group’s

viz. Control group internal medication (Abhayarista, gandaka rasayana) and

Yashtimadu Ghritha Pichu Group A and Yashtimadu Ghrita Pichu Group B . Each

group comprises of 20 patients.

All the patients of Parikartika were analyzed for their age, sex, socio-economic status,

religion, diet, etc. The details of these observations were as follows:

Age: The age wise distributions of 20 patients showed that maximum number of

patients i.e. 55% belonged to age group of 20-30 years, followed by 27.5% patients to

31-40 years and 12.5% patients to 41 – 50 years. Lastly 5 % patients belonged to age

Group of 51 - 60 years. (Table-10, Graph No.1)

Table- 10

Age wise distribution of 40 patients of Fissure-in-Ano

Age

Group A Group B Total

No % No. % No. %

20 – 30 12 60% 10 50% 22 55%

31 – 40 04 20% 07 35% 11 27.5%

41 – 50 03 15% 02 10% 05 12.5%

51 – 60 01 5% 01 5% 02 05%



Sex: Among 40 patients, in Group A 75 % were male, 25 % were female.

In Group B 75 % were male, 25 % were female. (Table-11, Graph No2)

Table-11

Sex wise distribution of 40 patients of Fissure-in-Ano

sex


No. % No. % No. %

Female 5 25 % 5 25% 10 25

Male 15 75 % 15 75 % 30 75

0

5

10

15

20

25

No % No. % No. %


Age wise distribution

20 – 30

31 – 40

41 – 50

51 – 60



Socio- Economic Status: Among 40 patients, in Group A 30% patients were in lower

class 65% patients in middle class and 5% patients in high class. In Group B 5 %

patients were in lower class ,90% patients in middle class and 5% patients in high

class (Table-12 graph- 3 )

No. % No. % No. %


525%

525%

10

25

15

75%

15

75%

30

75

Sex wise distributionFemale Male



Table- 12

Socio economic status wise distribution of 30 patients of Fissure-in-Ano

Socio economic

status

Group

A(Control)

Group

B(trail ) Total

No. % No. % No. %

Lower class 06 30 % 1 5% 7 17.5%

Middle class 13 65% 18 90% 31 77.5%

High class 01 5 % 1 5 % 2 5%

0

5

10

15

20

25

30

35

No. % No. % No. %

Group A(Control) Group B(trail ) Total

Socio economic status

Lower class

Middle class

High class



Diet: While observing the nature of diet, in Group A- it was found that mixed diet

patients were majority in number i.e. 100% and vegetarian diet patients were 0%. In

Group B 100 % patients were mixed diet and 0 % patients were vegetarian diet (Table

No 13 Graph No.4)

Table- 13

Diet Habit wise distribution of 40 patients of Fissure-in-Ano

Diet habit


No. % No. % No. %

Vegetarian 0 0 0 0 0 00

Mixed 20 100 20 100 40 100

No. % No. % No. %


0 0 0 0 0 020

100

20

100

40

100

Diet Habit Vegetarian Mixed



Religion: Cases were analysed in view of their religion, out of 40 cases, in Group A

100% were Hindus and 0 % was Muslim. In Group B 95 % patients were Hindu 5%

Muslim (Table No14)

Table-14

Religion wise distribution of 40 patients of Fissure-in-Ano

No. % No. % No. %


20

100

19

95

39

97.5

0 0 1 5 1 2.5

Religion wise Hindu Muslim

Religion


No. % No. % No. %

Hindu 20 100 19 95 39 97.5

Muslim 0 0 1 5 1 2.5



Occupation: Among 40 patients, in Group A 50% patients were in Job holder , 10%

patients students and 20% patients were agriculture 4% house wife. In Group B 30%

patients were in Job holder, 20% patients were Student and 40% patients were

Agriculture 10% House wife(Table-15, Graph No 4

Table-15

Occupation wise distribution of 40 patients

of Fissure-in-Ano

Occupation


No. % No. % No. %

Job holder 10 50 % 06 30% 16 40

Students 2 10 % 04 20 % 6 15

Agricultures

04 20 % 08 40 % 12 30

House wife 4 20% 02 10% 6 15



Habitat: Patients were analyzed in view of their habitat. Out of 40 patients of

Parkirtika in Group A. 80 % patients were reported from rural area and 20 % patients

from urban area. In Group B 40 % patients were reported from rural area and 60 %

patients to urban area. (Table No16)

Table No.16

Incidence of Habitat of 40 patients Of Fissure-in-Ano

Habit


No. % No. % No. %

Rural 16 80 8 40 24 60

Urban 4 20 12 60 16 40

0

5

10

15

20

25

30

35

40

No. % No. % No. %


Occupation wise

Job holder

Students

Agricultures

House wife



Previous surgery: Patients were classified into two groups on the basis of surgical

treatment reported (recurrent) and non-operated (fresh) cases. Out of 40 patients, in

Group A 0 % were reported as operated and 20 % were non-operated. In Group B,

15% patients were reported as operated and 85% patients were non-operated. (Table-

17 Graph No5)

Rural Urban

164

80

208 12

40

60

2416

60

40

Incidence of Habitat Group A No. Group A % Group B No. Group B % Total No. Total %



Table No-17

Distribution of patients in relation to Previous Surgery of

40 patients of Fissure-in-Ano

Surgery


No. % No. % No. %

Operated 0 0 3 15% 3 7.5%

Non-operated 20 100% 17 85% 37 92.5%

Bleeding per rectum: Out of 40 patients, in Group A 50% patients were having

bleeding per rectum,50% patient not having bleeding & in Group B also 60% patients

were having bleeding per rectum.40% patient not having bleeding (Table-18, Graph-

6)

05

10152025303540

No. % No. % No. %


Relation to Previous Surgery

Operated

Non-operated



Table-18

Bleeding per rectum wise distribution of 40 patients of Fissure-in-Ano

Bleeding per rectum


No. % No. % No. %

Present 10 50% 14 70% 24 60%

Absent 10 50% 06 30% 16 40%

Vibandha: Out of 40 patients, in Group A 100 % patients were having Vibandha

00% patients were reported normal stool habit. In Group B 100% % patients were

having Vibandha and (Table-19)

No. % No. % No. %


10

50%

14

70%

24

60%

10

50%

6

30%

16

40%

Bleeding per rectum Present Absent



Table-19

Vibandha (constipation) wise distribution of 40 patients of

Fissure-in-Ano

Vibandha

Group D Group G Total

No. % No. % No. %

Present 20 100% 20 100% 40 100%

Absent 00 00% 00 00% 00 00%

Pain (burning sensation): In Group D, 20% patients were reported having moderate

pain but 80% patients were reported having severe pain. In Group G, 26.7% patients

were reported having moderate pain but 73.3% patients were reported having severe

pain. (Table-16, Graph- 7)

No. % No. % No. %

Group D Group G Total

20

100%

20

100%

40

100%0 0% 0 0% 0 0%

Vibandha (constipation)Present Absent



Table-20

Pain (Burning sensation) wise distribution of


Distribution of patients in relation to Associated Lesions: Out of 40 patients in

both the groups, No case was observed of having any associated disease (Table-17)

0

5

10

15

20

25

30

35

No. % No. % No. %


Pain (Burning sensation)

No pain

Mild

Moderate

Severe

Pain


No. % No. % No. %

No pain 00 0 00 00 00 00

Mild 01 05% 02 10% 03 7.5%

Moderate 16 80% 18 90% 34 85%

Severe 03 15% 00 00% 03 7.5%



Table No. 21

Distribution of patients in relation to Associated Lesions of 40

patients of Fissure-in-Ano

Associated Lesions


No. No. No. %

Piles 0 0 0 0

Sentinel tag 0 0 0 0

Abscess 0 0 0 0

Prolapse 0 0 0 0

Malignancy 0 0 0 0

Total 0 0 0 0

Position of Fissure-in-Ano: In Group A 50 % patients were recorded to have

posterior fissure, 35% patients were recorded to have anterior fissure and 15 %

patients had both anterior & posterior fissure in ano. Whereas in Group B, 45%

Piles Sentinel tag Abscess Prolapse Malignancy Total

0 0 0 0 0 00 0 0 0 0 00 0 0 0 0 00 0 0 0 0 0

Relation to Associated Lesions Group A No. Group B No. Total No. Total %



patients were reported having posterior fissure, 40% patients were reported having

anterior fissure and 15% patients had both anterior & posterior fissure in ano. (Table-

22)

Table No-22

Distribution of patients in position of fissure in ano of


Position


No. % No. % No. %

Posterior 10 50% 09 45% 19 47.5%

Anterior 07 35% 08 40% 15 37.5%

Both 03 15% 03 15% 06 15%%

Posterior Anterior Both

0

107

30 50% 35% 15%0

9 8

30 45% 40% 15%0

19

15

6

Position of Fissure in AnoGroup A Group B Total



EFFECTS OF THE THERAPIES

In thise series 40 patients of Parikartika (Fissure-In-Ano) were treated in 2

groups each comprising of 20 patients. The patients of one group were applied Pichu

of yeashtimadu Ghrita and internal medication(Gandaka rasayana,abhayarista)

(Group A) and patients of other group were applied the Pichu of Yeashtimadu Ghrita

(Group B). The results obtained are being described under the heading of each group.

EFFECTS OF YASHTIMADU GHRITA PICCHU AND ORAL

MEDICATION

As mentioned above a group of 20 patients suffering from Parikataka was

treated with local application of Pichu dipped in Yashtimadu Ghrita (Group A) two

times a day for 7 days. Its effect on the various signs and symptoms were as follow:

1. Effect of yashtimadu Ghrita and oral medication Treatment for 7 Days:

Guda Shoola: The initial mean score of the symptom Shoola was 3.00 which was

reduced to 1.75 at the end of 7th day. Its statistical analysis shows highly significant

result at <0.001 level.

Rakta Srava: The initial mean score of the symptom Rakta Srava was 2.00. This was

reduced to 1.15 at the end of 7th day. It was statistically highly significant result at

<0.001 level



Viband: The initial mean score of the symptom Vibanda was 3.00. This was reduced

to 1.85 by 38% at the end of 7th day. It was statistically highly significant result at

<0.001 level

Gudadaha(burning sensation): The initial mean score of the symptom gudatapa was

2.0 This was reduced to 1.0 by 50 % at the end 7th day. It was statistically highly

significant result at <0.001 level

Size of Ulcer: The initial mean score of the size of ulcer was 2.00 which was reduced

to 0.80 (60%) at the end of 7th day. Its statistical analysis shows highly significant

result at <0.001 level

Sphincter spasm : The initial mean score of the symptom sphincter spasm was 1.00

which was increased to 0.85 by 15% at the end of 7th day. It shows statistically highly


proctitis : The initial mean score of the symptom proctitis was 1.00 which was

increased to 0.9 by 10% at the end of the 7th day. It shows statistically highly

significant result at <0.001 level.



TABLE-23

ASSESSMENT OF SIGN & SYMPTOMS BEFORE

TREATMENT AND AFTER TREATMENT

Signs & Symptoms

Mean BT

Mean AT

% of Change

SD ()

SE () t* P

Shoola 3.00 1.75 41.66 0.44 0.09 17.61 <0.001

Rakta

Srava 2.00 1.15 42.5 1.13 0.25 4.52 <0.001

Vibanda 3.00 1.85 38.0 0.48 0.10 16.9 <0.001

Gudadaha 2.00 1.00 50 0.56 0.12 15.9 <0.001

Size of

ulcer 2.00 0.80 60 0.52 0.11 6.83 <0.001

Sphincter

spasm

1.0 0.9 10 0.30 0.06 13.0 <0.001

Proctitis 1.0 0.9 10 0.30 0.06 13.0 <0.001

ASSESSMENT OF SIGN & SYMPTOMS BEFORE TREATMENT AND

AFTER FU:

Guda Shoola: The initial mean score of the symptom Shoola was 3.00 which reduced

to 0.1.67 at the end of the follow up. This 44.33% reduction in pain was statistically

highly significant at P<0.001 level.



Raktasrava: The initial mean score of the symptom Rakta Srava was 2.00. This was

reduced to 1.40 by 30% at the end of follow up. It was statistically highly significant



to 1.50 by 50% at the end of follow up. It was statistically highly significant result at

<0.001 level

Gudatapa(burning sensation): The initial mean score of the symptom gudatapa was

2.00. This was reduced to 1.40 by 30% at the end of follow up. It was statistically

highly significant result at <0.001 level


to 1.13 (33.5%) at the end of follow up Its statistical analysis shows highly significant



which was increased to 0.75 by 25 % at the end of follow up. It shows statistically

highly significant result at <0.001 level (Table-23).


increased to 0.75 by 2 5% at the end of follow up. It shows statistically highly

significant result at <0.001 level (Table-23).



TABLE No. 24


TREATMENT AND AFTER FU

Signs & Symptoms

Mean BT Mean AF % of

Change SD ()

SE () t* P

Shoola 3.00 1.67 44.33 0.49 0.13 10.58 <0.001

Rakta

Srava 2.00 1.40 30 0.51 0.13 4.58 <0.001

Vibanda 3.00 1.50 50 0.52 0.13 4.58 <0.001

Gudatapa 2.00 1.40 30 0.51 0.13 4.58 <0.001

Size of

ulcer 2.00 1.13 43.5 0.35 0.09 6.53 <0.01

Sphincter

spasm 1.00 0.75 25 0.26 0.07 9.33 <0.001

Proctitis 1.00 0.75 25 0.26 0.07 10.0 <0.001

EFFECTS OF YASHTIMADU GRITHA

A group of 20 patients suffering from Parikataka was treated with local application of

Pichu dipped in Yashtimadu gritha (Group B) two times a day for 7 days. Its effect

on the various signs and symptoms were as follow:

1. Effect of Yashtimadu gritha Treatment for 7 Days:



Guda Shoola: The initial mean score of the symptom Shoola was 3.00 which were

reduced to 1.8(40%) After treatment. Its statistical analysis show significant result at

<0.001 level.

Raktasrava: The initial mean score of the symptom Rakta Srava was 2.00. This was

reduced to 1.40(30%) after the treatment. It was statistically significant result at <0.01

level


to 0.1 by 96 % at the end of after the treatment. It was statistically highly not

significant result at >0.05 level

Gudatapa(burning sensation): The initial mean score of the symptom gudatapa was

3.00. This was reduced to 1.85 by 38% at the end of after treatment. It was

statistically highly significant result at <0.001 level


to 0.9 (55%) at the end of after the treatment. Its statistical analysis shows highly



which was increased to 0.8 by 20% at the end of after the treatment. It shows



increased to 0.95 by 5% at the end after the treatment. It shows statistically highly

significant result at <0.001 l



TABLE- 25

ASSESSMENT OF SIGN & SYMPTOMS BEFORE TREATMENT AND AFTER TREATMENT

Signs & Symptoms

Mean BT Mean AT % of

Change SD ()

SE () t* P

Shoola 3.00 1.8 40.0 0.49 0.09 19.6 <0.001

Rakta

Srava 2.00 1.40 30 0.88 0.19 7.09 <0.001

Vibanda 3.00 0.1 96.6 0.30 0.06 1.4 >0.05

Gudatapa 2.0 1.00 50 0.36 0.08 22.5 <0.001

Size of

ulcer 2.00 0.9 55 0.55 0.124 7.28 <0.001

Sphincter

spasm

1.0 0.95 5. 0.22 0.05 19.0 <0.001

Proctitis 1.0 0.95 5. 0.22 0.05 19.0 <0.001

ASESSMENT OF SIGN & SYMPTOMS BEFORE TREATMENT AND

AFTER FALLOW UP:

Guda Shoola: The initial mean score of the symptom Shoola was 3.00 which were

reduced to 1.67 (44.33%) at the end of fallow up. Its statistical analysis shows




Rakta-Srava: The initial mean score of the symptom Rakta Srava was 2.00. This was

reduced to 1. 40(30%) at the end of fallow up. It was statistically significant result at

<0.001 level


to 0.1 by 96 % at the end of fallow up. It was statistically not significant result at

>0.05 level

Guda daha (burning sensation): The initial mean score of the symptom gudatapa

was 2.00. This was reduced to 1.40 by 30% at the end of fallow up. It was statistically



to 1.13 (30%) at the end of fallow up. Its statistical analysis shows highly significant



which was reduced to 0.75 by 25% at the end of the fallow up. It shows statistically

highly significant result at <0.001 level (Table-25).

proctitis : The initial mean score of the symptom proctitis was 1.00 which was to

1.75 by reduced 25% at the end of the fallow up. It shows statistically highly

significant result at <0.001 level (Table-26)



TABLE- 26


TREATMENT AND AFTER TREATMENT

Signs & Symptoms

Mean BT Mean AF % of

Change SD ()

SE () t* P

Shoola 3.00 1.67 44.33 0.49 0.13 10.58 <0.001

Rakta

Srava 2.00 1.40 30 0.51 0.13 4.58 <0.001

Vibanda 3.00 0.1 96 0.308 0.069 1.4 >0.05

Gudatapa 2.00 1.40 30 0.51 0.13 4.58 <0.001

Size of ulcer 2.00 1.13 43.5 0.35 0.09 6.53 <0.01

Sphincter

spasm 1.00 0.75 25 0.26 0.07 9.33 <0.001

Proctitis 1.00 0.75 25 0.26 0.07 10.0 <0.001

Overall effect

Evaluation of pain between two groups: Group A showed a Complete relief in pain

during therapy at the end of 7th day 80 % patients got relieved, and at the end of 2

months 90 % patients got relieved which was statistically highly significant at the

level of p <0.001

Group B showed relief in pain during therapy at the end of 7th day 80% patient got

relieved, which was statistically significant and at the end of 2 months 85 % patients

got relieved which was statistically significant at the level of p <0.001



Table- 27

Evaluation of pain between two groups

Evaluation of bleeding between two groups:

Group A showed a Complete relief in bleeding during therapy at the end of 7th

day 95 % patients got relieved, and at the end of 2 months 95 % patients got relieved

which was statistically highly significant at the level of p <0.001

Study

period Group

No.of

patients

Pain (shoola)

P value No

pain Mild Moderate Severe

Before

treatment

Group A 20 00 03 15 02 -

Group B 20 00 01 18 01 -

After

Treatment

Group A 20 16 04 00 00 <0.001

Group B 20 16 04 00 00 <0.001

After

fallow

Up

Group A 20 18 02 00 00 <0.001

Group B 20 17 03 00 00 <0.001

Over all

out come

Group A 20 18 02 00 00 <0.001

Group B 20 17 03 00 00 <0.001



Group B showed relief in bleeding during therapy at the end of 7th day patient

got 90% relieved, which was statistically significant and at the end of 2 months 95 %

patients got relieved which was statistically not significant at the level of p <0.001

Table-28

Evaluation of bleeding between two groups

Evaluation of constipation between two groups: Group A showed a Complete relief

in Constipation during therapy at the end of 7th day 85 % patients got relieved, and at

Study

period Group

No.of

patie

nts

BLEEDING

P value No

bleeding Mild Moderate Severe

Before

treatment

Group A 20 09 01 07 03 -

Group B 20 05 02 13 00 -

After

Treatment

Group A 20 19 01 00 00 >0.001

Group B 20 18 02 00 00 >0.001

After

fallow

Up

Group A 20 19 01 00 00 >0.001

Group B 20 19 01 00 00 >0.001

Over all

out come

Group A 20 19 00 00 00 >0.001

Group B 20 00 00 00 00 >0.001



the end of 2 months 100% patients got relieved which was statistically highly

significant at the level of p <0.001

Group B showed Not relief in Constipation during therapy at the end of 7th day

100% patient got no relieved, which was statistically not significant and at the end of

2 months 100% patients got relieved which was statistically not significant at the

level of p >0.001

Table- 29

Evaluation of CONSTIPATION between two groups

Study

period Group

No.o

f

pati

ents

CONSTIPATION (VIBANDA)

P value No

constipation Mild Moderate Severe

Before

treatment

Group A 20 00 02 16 02 -

Group B 20 00 01 18 01 -

After

Treatment

Group A 20 17 03 00 00 <0.001

Group B 20 00 01 18 01 >0.001

After

fallow

Up

Group A 20 20 00 00 00 <0.001

Group B 20 00 01 18 01 >0.001

Over all

out come

Group A 20 20 00 00 00 <0.001

Group B 20 00 01 18 01 >0.001



Evaluation of Gudadaha(Burning sensation) between two groups: Group A

showed a Complete relief in Burning sensation during therapy at the end of 7th day

95% patients got relieved, and at the end of 2 months day 95 % patients got relieved

which was statistically highly significant at the level of p <0.001

Group B showed relief in Burning sensation during therapy at the end of 7th day

95% patient got relieved, which was statistically significant and at the end of 2

months 95% patients got relieved which was statistically significant at the level of

p <0.001 Table – 30

Evaluation of BURNING SENSATION between two groups

Study

period Group

No.of

patie

nts

BURNING SENSATION

(GUDADAHA)

P value No

burning

sensation

Mild Moderate Severe

Before

treatment

Group A 20 00 01 16 03 -

Group B 20 00 02 18 00 -

After

Treatment

Group A 20 19 01 00 00 <0.001

Group B 20 19 01 00 00 <0.001

After fallow

Up

Group A 20 19 01 00 00 <0.001

Group B 20 19 01 00 00 <0.001

Over all out

come

Group A 20 19 01 00 00 <0.001

Group B 20 19 01 00 00 <0.001



Evaluation of Size of the ulcer between two groups: Group A showed a

Complete relief in Size of Ulcer during therapy at the end of 7th day 70% patients got

relieved, and at the end of 2 months 90 % patients got relieved which was statistically

highly significant at the level of p <0.001

Group B showed relief in Size of Ulcer during therapy at the end of 7th day 70%

patient got relieved, which was statistically significant and at the end of 2 months

85 % patients got relieved which was statistically significant at the level of p <0.001

Table- 31 Evaluation of SIZE OF THE ULCER between two groups

Study

period Group

No.o

f

pati

ents

Size of the ulcer

P

value No

ulcer Mild Moderate Severe

Before

treatme

nt

Group A 20 00 05 14 01 _

Group B 20 00 04 14 02 _

After

Treatme

nt

Group A 20 00 20 00 00 <0.01

Group B 20 00 20 00 00 <0.01

After

fallow

Up

Group A 20 18 02 00 00 <0.01

Group B 20 17 03 00 00 <0.01

Over all

out

come

Group A 20 18 02 00 00 <0.01

Group B 20 17 03 00 00 <0.01



Evaluation of Spincter spasm between two groups: Group A showed a Complete

relief in Spincter spasm during therapy at the end of 7th day 100% patients got

relieved, and at the end of 2 months 100% patients got relieved which was statistically

highly significant at the level of p <0.001

Group B showed relief in Spicter spasm during therapy at the end of 7th day patient

100% got relieved, which was statistically significant and at the end of 2 months

100% patients got relieved which was statistically not significant at the level of p

<0.001 Table- 32

Evaluation of spincter spasm between two groups

Study

period Group

No.

of

pati

ents

Spincter spasm

P value No

pain Mild Moderate Severe

Before

treatment

Group A 20 03 17 00 00 _

Group B 20 04 16 00 00 _

After

Treatment

Group A 20 20 00 00 00 <0.001

Group B 20 20 00 00 00 <0.001

After fallow

Up

Group A 20 20 00 00 00 <0.001

Group B 20 20 00 00 00 <0.001

Over all out

come

Group A 20 20 00 00 00 <0.001

Group B 20 20 00 00 00 <0.001



Evaluation of proctitis between two groups: Group A showed a Complete relief in

Proctitis during therapy at the end of 7th day 100% patients got relieved, and at the

end of 2 months day 100% patients got relieved which was statistically highly

significant at the level of p <0.001

Group B showed relief in Proctitis during therapy at the end of 7 day patient 100%

got relieved, which was statistically significant and at the end of 2 months 100%

patients got relieved which was statistically not significant at the level of p <0.01

Table- 33 Evaluation of proctitis between two groups

Study

period Group

No.of

patie

nts

Proctitis

P value No

Proctitis Mild Moderate Severe

Before

treatment

Group A 20 02 18 00 00 _

Group B 20 01 19 00 00 _

After

Treatment

Group A 20 20 00 00 00 <0.001

Group B 20 20 00 00 00 <0.001

After

fallow

Up

Group A 20 20 00 00 00 <0.001

Group B 20 20 00 00 00 <0.001

Over all

out come

Group A 20 20 00 00 00 <0.001

Group B 20 20 00 00 00 <0.001

Discussion.


DISCUSSION

Fissure-in-ano is the ailment that does not have any direct correlation in the

Ayurvedic text. ‘Parikartika’ is a condition occurring due to improper administration

of Virechana and Basti can be compared with fissure-in-ano, since both the conditions

occur in Guda and have similar clinical manifestations. Thus fissure-in-ano can be

compared with Parikartika as follows:

1. Parikartika is characterized by Kartanavat and Chedanavat Shoola in Guda,

Basti and Nabhi. Similarly fissure in ano is also characterized by sharp cutting pain

in anal region.

2. In Parikartika Guda-Kshata is result of Virechana Atiyoga uyapad Kshanana

implies injured tissue. In the same way fissure in ano is evident by the

3. longitudinal tear in the anal canal.

Since the location, nature of pathology and the predominant clinical feature

aresame, it can be said that the condition Parikartika is the clinical condition known

in current surgical practice as fissure in ano. In this study Yashtimadu Ghrita was

selected to evaluate its role in the management of Parikartika because it has

VraņaRopaņa, Shothahara, Varņa Prasadana and Shulahara properties along with

Tridoşahara, Rakta Stambhaka in actions.Yeashtimadu Ghritan and

GandakaRasayana,Abayarista was taken as control drug because the base of

Yeashtimadu Ghrita and Gandaka Rasayana, Abayarista which is also having

Vrana Ropana ,Vatanulomana ,Virechana,Vibandanashaka ,properties. For this

Discussion.


purpose 40 patients of Parikartika were divided into two grouconsisting of 20 patients

each. In group A, the patients were managed with application of

Yashtimadu -Ghrita Pichu per rectally, gandaka rasayana, Abhayarista twice a day

oraly for 21 days. Patients were managed with application of Yashtimadu Ghrita

Pichu per rectally twice a day for 21 days.In group B the main aim of management of

fissure in ano is to relieve the agonizing pain, to relieve the sphincter spasm, to heal

the ulcer and to reduce burning sensation and to stop bleeding,proctitis Significant

clinical observations recorded in this study were as follows:

Age:

Group A: Among 20 patients 55% patients were in the age group of 20 –30 years.

20% patients in the age group of 31-40 years,15% patients in the age group of 41-50

years, 5% patients in the group of 51-60 years.

Group B: Among 20 patients 50% patients were in the age group of 20 –30 years 35

% patients in the age group of 31-40 years, 10% patients in the age group of 41-50

years, 5% patients in the group of 51-60 years.

Both group: Among 40 patients In both group patients are seen in age group between

20-30 years 55% probably because of improper dietary habits, sedentary life style,

and nature of work and withholding of urges. The incidence is less in old age group

due to the muscular atony.

Discussion.


Sex:

Group A: Among 20 patients 75 % were male and patients 25 % were female

safering from fissure in ano.

Group B: Among 20 patients 75 % were male and 25 % were female safering from

fissure in ano.

Both group: The anatomical difference in the structure of the pelvic cavity between

male and female patients due to the presence of uterus and enough space for child

bearing may also be responsible for the difference in the incidence of fissure in the

both sexes. The description given in Sushruta Samhita regarding the circumference of

the ano-rectal canal suggests that it is wider in females than in males. This may also

be responsible for less incidence of fissure in females.

Occupation:

Group A: Among 20 patients were as Job holder 50% ,students were as

10%,agriculture were as 20%,house wife were as 20%.safering from fissure in ano.

Group B : Among 20 patients job holder were as 30%,students were as

20%,agriculture were as 40%,house wife were as 10% .safering from fissure in ano.

Both group: Among 40 patients. 40 % respectively were from job holders, who

ultimately lead to the development of fissure-in-ano due to sedentary lifestyle and

continuous sitting in same posture and stressful life style.

Discussion.


Socio-Economic Status:

Group A: Among 20 patients were from lower class 30%, middle class were as 65%,

high class were from 5% safering from fissure in ano.

Group B: Among 20 patients were as lower class 5%, middle class were as 90%.high

class were as 5%.

Both groups:

Among 40 patients in group a 65% were from middle class. In group B, 90 %

patients were from middle class. Due to habit of taking excess spicy and oily meals

once or twice a day may be the cause of Parikartika in the middle class families.

Diet:

Group A : While discussing the nature of diet, in group A- it was found that mixed

diet patients were majority in number (100%).

Group B: 100 % patients were on mixed diet. Hence the patients with mixed dietary

habits are more susceptible due to low fiber content and spicy non- vegetarian diet.

Both groups:

Among both group from 100% patient having mixed diet form non vegetarian food its

incresess the vata and pitta prakopa that’s why mixed diet patients having fissure in

ano more in number.

Discussion.


Religion:

Group A: Among 20 patients group were Hindus are 100% .muslims are 0% safering

from fissure in ano while taking the cases for clinical study.

Group B : Among 20 patients was Hindus are 95% Muslims are 5% safering from

fissure in ano while taking the cases for clinical study.

Both groups:

Among 40 patients Hindus are more in number. but Even though muslims are taking

more low fibers diet and more non vegetarian here the stastical data shows more

hindus patients are suffering with fissure in ano.based on this we can not conclude

that hindu are more sufer with this diseas.based on less number of samples droing the

conclusion is much more difficult.

Habitate:

Group A Among 20 patients were as 80% from rural area .20% from urban area

patients are safering from fissure in ano.

Group B: Among 20 patients were as 60% from rural. And 40% from urban areas so

that patients are safering from fissure in ano.

Both group : more patients are from rural area this may be due to the our college is in

rural area.so we are getting more rural patients rather than the urban.but fissure in ano

will be observed in both the area.

Discussion.


GROUP A

Effect Guda Shoola: The initial mean score of the symptom Shoola was 3.00 which

was reduced to 1.75(41.66%) after treatment. Its statistical analysis shows highly

significant result at P <0.001 level.

Effect on Rakta Srava: The initial mean score of the symptom Rakta Srava was

2.00. This was reduced to 1.15(42.5%) after treatment. It was statistically highly

significant result at P<0.001 level

Effect on Viband: The initial mean score of the symptom Vibanda was 3.00. This

was reduced to 1.85 by 38% after treatment. It was statistically highly significant

result at P<0.001 level

Effect on Gudadaha (burning sensation): The initial mean score of the symptom

gudatapa was 2.0 this was reduced to 1.0 by 50 % after treatment. It was statistically


Effect on Size of Ulcer: The initial mean score of the size of ulcer was 2.00 which

was reduced to 0.80 (60%) after treatment. Its statistical analysis shows highly


Effect on Sphincter spasm: The initial mean score of the symptom sphincter spasm

was 1.00 which was increased to 0.85 by 15% after treatment. It shows statistically


Discussion.


Effect on proctitis: The initial mean score of the symptom proctitis was 1.00 which

was increased to 0.9 by 10% after treatment. It shows statistically highly significant


GROUP B

Effect on Guda Shoola: The initial mean score of the symptom Shoola was3.00

which were reduced to 1.8(40%) after treatment. Its statistical analysis show


Effect on Raktasrava: The initial mean score of the symptom Rakta Srava was 2.00.

This was reduced to 1.40(30%) after treatment. It was statistically significant result at

<0.01 level

Effect on Viband: The initial mean score of the symptom Vibanda was 3.00.This was

reduced to 0.1 by 96 % after treatment. It was statistically highly not significant result

at >0.05 level

Effect on Gudatapa(burning sensation): The initial mean score of the symptom

gudatapa was 3.00. This was reduced to 1.85 by 38% after treatment. It was


Effect on Size of Ulcer: The initial mean score of the size of ulcer was 2.00 which

was reduced to 0.9 (55%) after treatment. Its statistical analysis shows highly


Discussion.


Effect on Sphincter spasm : The initial mean score of the symptom sphincter spasm

was 1.00 which was increased to 0.8 by 20% after treatment. It shows statistically


Effect on proctitis : The initial mean score of the symptom proctitis was 1.00 which

was increased to 0.95 by 5% after treatment. It shows statistically highly significant


COMPAIRITIVE DISSCUSSION OF BOTH GROUP (Group A and Group B)

Effect Guda Shoola:

The compairitive effect on gudashoola as in group A was 41.66% and group B was

40% improvement were observerd after the treatment. Here both groups which shows

stasticaly highly significant in nature but slight variation as1.66% is more in group A

due to internal medication.

Effect Rakta Srava:

The compairitive effect on Rakta Srava in group A was 42.5% and group B was30%

improvement were observerd ofter the treatment here both group wich shows

stasticaly highly significant in nature but slight variation as12.% is more in group A

due to internal medication.

Discussion.


Effect on Vibanda:

The compairitive effect on vibanda in group A was 1.85% and group B was

0.1(>0.05%) improvement were observerd after the treatment here group A which

shows stasticaly highly significant were as In group B there is nochangein vibanda

because there is internal medicine in group B to act on constipation.

Effect on Gudadaha:

The compairitive effect on Gudadaha in group A was 50% and group B was 38 %

improvement were observerd after the treatment. Here both groups shows stasticaly

highly significant in nature but slight variation as12.% is more ingroup A due to

internal medication which act as pitta shamaka and vatanulomaka.

Effect on Size of ulcer:

The compairitive effect on Size of ulcer in group A was 60 % and group B was 55%

improvement were observered after the treatment. here both group wich shows

stasticaly highly significant in nature but slight variation as 5 % is more in group A

due to internal medication which helps in vibhanda nashaka and further avoiding of

laceration.

Effect on Spincter spasm:

The compairitive effect on Spincter spasm in group A was 15 % and group B was 20

% improvement were observerd ofter the treatment here both group wich shows

Discussion.


stasticaly highly significant in nature but slight variation as 5 % is more in group B

due to Yeastimadu gritha is helps for vata shamana so act as spincter relaxant.

Effect on proctitis:

The compairitive effect on proctitis in group A was 10 % and group B was 5 %

improvements were observered after the treatment. here both groups shows statisticaly

highly significant in nature but slight variation as 5 % is more in group A due to Oral

medication act as vatanulomaka, vibhanda nashaka and pittashamak.

Over all Effects of Therapies: In control group A, 95 % patients got complete

remission, 05% patients had marked improvement. On the other hand in Yashtimadu

group B 93 % patients got complete remission and 5 % patients had marked

improvement and 2 % patients had moderate improvement.in constipation there is no

improvement It is obvious from the above results that the over all effects of

Yashtimadu Ghrita in providing the over all relief to the patients of fissure inano after

looking all the observational study and statistical analysis it can be come to the

conclusion that both group have the good response in treating fissure in ano expect the

vibanda laxanas that is controle group shows good result on vibanda due to the

internal medication like abhayarista,gandaka rasayana were as in trail drug the result

was similar after the treatment also becose there is no internal medication which are

on viband.

Discussion.


Significant Effects of Group A

(Yashtimadu Ghrita picchu and Abhayarista,gandaka rasayana):

7 days local application of Pichu of Yastimadu Ghrita provided significantly relief in

Guda Shula (90%), bleeding per rectum (95%), vibanda (100%) burning sensation

(95%) healed the ulcer (90%) and increased the sphincter Spasm (100%) proctitis

(100%). In this group there is no patients have complete remission 18 patients got

markly improvement 2 patients are mode rate improvement,0 patients mild changes

and 00 patients are unchanged in fissure in ano.

Significant Effects of Group B (Yashtimadu-Ghrita):

7 days local application of Pichu of yastimadu Gritha provided significantly relief in

Guda Shula (85%), bleeding per rectum (95%),constipation(100% P>0.01)burning

sensation(95%) healed the ulcer (85%) and decreases the sphincter spasm (100%)

proctitis(100%). In this group there is no patients have complete remission 17 patients

got markly improvement 3 patients are moderate improvement,0 patients mild

changes and 00 patients are unchanged in fissure in ano.

Comparison of the Effects of controle group and Yashtimadu Ghrita:

Comparison the effect obtained in both the groups showed that local application of

Pichu provided significantly better relief in Guda Shoola, Bleeding per rectum,

healing the ulcer, spicter spasm and proctitis.but its not help for the constipation

coparison to controle group.

Discussion.


Probable Mode of Action: As mentioned earlier the healing of fissure is different

from the healing of any other ulcer because in the former there is constant

contamination of the wound by faeces and its frequent friction with the mucosa while

there is continuous spasm of the sphincteric muscle. They are the important factors

which keep a fissure away from normal healing. In such situation a drug which

produces a soothing effect, Vata-Pittahara, Vedna Sthapana, Vrana Ropana and

influences reduction of inflammation will be more suitable than drug which may act

as the best healer of ulcer on other parts of the body. Yashtimadu Ghrita probably has

these properties. But as far as main symptoms are concerned pain (Burning and

Cutting) may be relieved due to the action of Vedna Sthapana, Dahaprashamana and

Vata Pittahara. It’s well known fact that the Vata and Pitta Doshas are predominant in

pain as well as in fissure. According to modern pharmacological action of drugs

patient as anti inflammatory and steroidal activity. Other drugs also have been

reported to have a similar type of property but our clinical experience suggests that its

activity is less as compared to that of Yashtimadu Ghrita. It is the amount of

inflammation and spasm which is responsible for producing the agonizing pain in

cases of fissure-in-ano. Yashtimadu Ghrita probably is able to counteract these two

factors more efficiently than the other drugs. The relief of severe pain within 24 hours

is something remarkable about this drug although the ulcer takes as with in weeks for

complete healing.

Discussion.


After the completion of treatment in group A shows over all result of highly

significant where as in group B shows over all result of statistically significant. It

shows Group A is highly significant And Group B Also have same result with out

oral medication expect constipation.group B is better then group A.

Sitz bath

Sitz bath its directly acts on local vascular bed of the ano rectal region may leads to

Vasodilatation. It warks by keeping the affected area clean and incressing the flow of

blood to it.so that which directly helps for wound healing mechanisum.

CRITERIA FOR OVERALL EFFECT OF THERAPHY

Result Percentage of parameters Patients in

group A

Patients in

group B

Complete

Remission

100% relief in the subjective and

objective parameter.

00 00

Markly

Improvement

More than 75% in the subjective

and objective parameter.

18 17

Moderate

Improvement

50 to 74% relief in the subjective


02 03

Mild

Improvement

25 to 49% relief in the subjective


00 00

Unchanged Result below 25% was consider as

unchanged.

00 00

Discussion.


Group A

Group B

0% 0%

90%

10%

0%

Patients in

Complete Remission 100% relief in the subjective and objective parameter.

Markly Improvement More than 75% in the subjective and objective parameter.

Moderate Improvement 50 to 74% relief in the subjective and objective parameter.

Mild Improvement 25 to 49% relief in the subjective and objective parameter.

Patients in

Complete Remission 100% relief in the subjective and objective parameter.

Markly Improvement More than 75% in the subjective and objective parameter.

Moderate Improvement 50 to 74% relief in the subjective and objective parameter.

Mild Improvement 25 to 49% relief in the subjective and objective parameter.

Conclusion.


CONCLUSION

The clinical study was carried out to evaluate the efficacy of in between two group in

which one group selected as controle group here adviced Yashtimadu gritha picchu

along with bhayarista, gandaka rasayana and isecond group adviced only Yashtimadu

gritha picchu in the management of Guda Parikartika, On the basis of Ayurvedic texts,

views of ancient scholars, facts and observations done in the present clinical research

work some points can be concluded like –

The site of Parikartika is Guda, which is similar to the site of fissure-in-ano.

Vata and Pitta Doşha have dominancy in the development of the disease

Parikartika, but Vata is predominant.

Sedentary life style and hard work and stressful life like businessmen, in the

modern era, is having a key role in occurrence of the disease Parikartika

(fissure-in-ano).

Fissure-in-ano was present commonly at 6 o’clock position and most of the

time it is a single fissure only. However the fissure at 12 o’clock or at other

site may also be found either alone or in combination.

Excessive consumption of Lavaņa, Katu, Tikta, Rukşha, Uşhņa,lagu Ahara

and irregular diet and diet timings are the main precipitating factors of this

condition.

For the management of fissure in ano pichu of Yashtimadu Ghrit along with

and oral medication and only Yashtimadu Ghrita pichu were adapted.

Conclusion.


The most evident symptom present i.e. pain and spasm of anal sphincter can

be relieved much earlier in both the groups shows similar result so that only

pichu can helps to controle the pain and spincter spasm.

In the cases of Rakta Srava, (bleeding) in fissure-in-ano even thow both the

group showes good control also controle group showes slightly better than the

trail drug.

In the cases of ulcer size in fissure-in-ano in the both the groups showed

effective results in healing and good control after 7 days.

In the cases of sphincter spasm, during therapy at the end of 7 day patients got

Complete relieved in both group where it provides same relief.

In the follow up study, it was observed that the results achieved in both the

groups are effective and stable and was showed constant relief on pain,

burning sensation, bleeding, and ulcer, spasm of sphincter, constipation and

proctitis but in group B upon constipation were there is no result was

observed.

Expect the constipation in the present study it can be concluded that both the

group was same effect and observed after treatment. as well as after treatment

and after fallow up in group B Pichu never shows the result upon the

constipation and constipation is the main cause ot trigger back once again to

the fissure-in-ano (Parikartika).

Yashtimadu Ghrita was found more effective in relieving the feature of disease

Parikartika (fissure-in-ano).

Conclusion.


Yashtimadu Ghrita is easily applicable, cost effective and can be widely used

in general practice.

SUGGESTION

As chronic conditions may need long term therapy for achieving better results

and to avoid reoccurrence so, in future same topic should be taken for further

research to overcome some lacunas if found, for better results more numer of

samples.

Summary.


SUMMARY

Ayurveda is an age old science of health which emphasize on the health than

to cure disease. The fissure-in-ano is very common and painful condition still there is

no satisfactory method of treatment, medical or surgical. On the basis of symptoms,

the disease fissure-in-ano can be compared to the disease Parikartika described in to

Ayurveda.

According to Tridoşha theory, Parikartika has been mentioned under the

Vatika disease along with Pitta Doşha. Guda is the site of Apana Vayu and severe

pain and burning sensation in the ano-rectal area the two major symptoms are due to

Vata and Pitta Doşha only. No detailed description of Parikartika (fissure-in-ano) is

available in the Ayurveda. Though, Acharya Kashyapa has made an effort but detailed

description was not given by him also. However, Kashyapa had mentioned this

condition in relation to a pregnant woman which is quite logical.

It was decided to conduct the present clinical research work entitled “Effect of

Yashtimadu Ghrita in the management of Parikartika (Fissure-In-Ano).

The main objective of selecting this study was to find out efficacious and cost

effective treatment for the patients of Parikartika from the treasure of Ayurveda. In

the Āyurvedic text, few references are found to a condition Parikartika and its

management. Most of the Acharyas have indicated chiefly Ghŗita, Madhu, Tila Kalka

and Yaşhtimadhu for this condition.

Summary.


Yashtimadu Ghrita has been described as a drug for Vraņa which are having

lakshana like Raktasrava, Daha, etc. Hence the present work is an attempt to assess

the efficacy of this preparation for treatment of the disease Parikartika.

Here, Yashtimadu Ghrita is having Vraņa Shodhana, Vraņa Ropaka, Vedanā

Sthāpana and Vata- Pittahara properties and it has been advocated in Ayurvedic

literature by Acharya Sushruta for the management of Vraņa.

Therefore, it has been chosen for the present research work. Total 40patients

were selected, diagnosed and randomly divided into two groups.In group A, 20

patients were given Yashtimadu Ghrita Picchu and abhayarista gandaka rasayana

internally twice a day for 7 days, while in group B, 20 patients were given plain

Yashtimadu Ghrita Picchu twice a day for 7 days, and assessed 7thday during

treatment period.fallow up to 2 months.

All the patients in both the groups were given Picchu application in anal route

being followed at RGEAMC & H for patients of ano rectal disoders.

So, here on the basis of this study the following observations can be drawn –

In group A and group B both groups shows 55 % patients were of the age

group of 18 –28 years.

In total group A and group B 25 % patients were females.And group A 75%

Male in group B 75% male total 75% male its shows more male patients

40% patients were job holders in both the groups .

Summary.


40% patients from urban area 60% patients more from rural area while

clinical study.

97.5% patients are from hindus while clinical study.

100 % patients were in group A and 100 % patients were in group B of mixed

diet

77.5 % patients from middle class from both groups.

100% %patients were in group A and 85 % patients were in group B belongs

to non-operated category

50 % patients were suffering from bleeding per rectum in group A .70%

patients from group B.

100% patients suffered from constipation in group A where as 100 % patients

suffered from constipation in group B

15% patients suffered from severe pain and 80 % patients from moderate pain

mild pain 05%in group A where as in group B 73.3 % patients suffered from

severe pain 7.5% and patients from moderate pain 85% and 7.5% mild pain

Discharge observed in b groups.

No cases were observed in having any associated diseases in both the groups.

In group A out of 20 patients, 10(50 %) patients were reported having

posterior fissure, 5 (33.3%) patients were reported having anterior fissure and

10 (50 %) patients had both anterior & posterior fissure in ano. Where as in

group B out of 20 patients, 9 (45%) patients were reported having posterior

fissure, 8 (40 %) patients were reported having anterior fissure and 03(15%)

Summary.


patients had both anterior & posterior fissure in ano. Hence maximum patients

suffered from posterior fissure in ano.

In group A Yashtimadu Ghrita group Piccchu and oral medication Patients

found completely cured where as In Group B Yashtimadu gritha Piccchu also

have same effect expect constipation showed improvement in signs and

symptoms of Parikartika.

So, from the above mentioned facts, thoughts, data and results it can be

summarized that controle group i.e. group A can be good for relieving

cardinal symptoms, general symptoms and quick healing of ulcer in the

patients of Parikartika (fissure-in-ano) and even economical also to the

patients.

Case sheet froforma.


POST GRADUATE DEPARTMENT OF SHALYATANTRA CASE

PROFORMA OF RAJIVE GANDHI AYURVEDIC MEDICAL COLLEGE

RON

FOR


MANAGEMENT OF

PARIKARTIKA w. s. r. to FISSURE-IN-ANO

GUIDE : Dr. Chetan kardale

CO-GUIDE :Dr.kumar kantimata

P.G SCHOLAR : Dr. VEERESH SATTIGERI

CASE NO.: DATE :

NAME: MARITAL STATUS: Marred /Unmarried

AGE: ECONOMICAL STATUS: Low / Middle High

SEX: OPD NO:

ADDRESS: IPD NO :

RELIGION D.O.A :

OCCUPATION: D.O.D : PLACE:

\



CHIEF COMPLAINTS:

HISTORY OF PRESENT ILLNESS:

PAST HISTORY

1. Whether patient has similar complaints --- YES / NO.

earlier than the present episode

2. History of any systemic illness --- YES / NO.

3. History of any other Medical treatment --- YES / NO.

4. History of any surgeries undergone --- YES / NO.

5. Obstetric and gynecological history ---

6. Gynecological history



PERSONAL HISTORY

1. Nature of food --- Vegetarian Non vegetarian

Spicy Non spicy

2. Nature of work--- Strenuous Moderate Sedentary

3. Bowel habit --- Regular / lose / constipated

If Constipated : mild / moderate / severe.

4. Micturation --- Frequency / 24 hrs

5. Sleep ---

6. Habits ---

FAMILY HISTORY



GENERAL EXAMINATION

Conjunctiva:

Nails :

Tongue :

Odema :

Lymphadenopathy :

Cyanosis :

Clubbing :

Pallor :

Prakriti – Vata Pitta Kapha Vatapitta Vatakapha Pittakapha Sannipataja

Saara – Pravara / Madyama / Avara

Samhana - Pravara / Madyama / Avara

Satva : – Pravara / Madyama / Avara

Satmya : – Pravara / Madyama / Avara

State of agni – Tikshana Manda Vishama Sama

Bala – Pravara / Madyama / Avara



VITAL DATA

BLOOD PRESSURE ---

PULSE RATE ---

TEMPERATURE ---

RESPIRATORY RATE ---

SYSTEMIC EXAMINATION

CVS. ---

R.S. ---

CNS. ---

P/A ---

Clinical features:

1. Pain in anal region : mild/moderate/severe/unbearable

2. constipation : No Vibandha Mild Moderate Severe

3. Pruritis: Mild Moderate Severe



4. Anilasanga (flatus passed): Effortlessly / with difficulty.

5. Pain –duration (after defecation in min) : 15 / 30 / 60 / >60

i) During defecation = No pain Mild Moderate Severe

ii) After defecation = No pain Mild Moderate Severe

6. Size of the ulcer (in m m ):

7. Bleeding : Present / Absent

Amount of Blood = Mild Moderate Severe

Relation with defecation = Blood after defecation

Mixed with faces

On the surface of faces

Bleeding occur at some other time than

defecation



LOCAL EXAMINATION

ON INSPECTION:

1. Fistula ---

2. Haemorhhoids ---

3. Prolapse ---

ON P/R EXAM:

INVESTIGATIONS

HB % ---

TC ---

DC ---

ESR ---

RBS ---

Other investigations, if required ---



SPECIFIC EXAMINATION - ASSESMENT CRITERIA

Date of starting therapy ( day 1 ) :

Date of first follow-up ( day 8 ) :

A.SUBJECTIVE CRITERIA --

1. Pain –nature :

Pain- nature

Day 1 Day 8 Follow-up (every 15 days )

1 2 3 4 5 6 7 8 9 10 11 12

Pain- nature

Symptoms Grading

Absent O

Mild 1

Moderate 2

Severe 3

Unbearable

4



2. Constipation :

Constipation


1 2 3 4 5 6 7 8 9 10 11 12

Constipation

Motion passed Grading

Every day 0

Once in 2 days Mild 1

Once in 2-3days Moderate 2

Once in 3 or more days Severe 3

3.Bleeding :

Bleeding


1 2 3 4 5 6 7 8 9 10 11 12



Bleeding

Symptoms Grading

Absent 0

One streak Mild 1

2-3 streaks Moderate 2

>3 streaks/ drops Severe 3

4. Buning sensation:

Burning sensation

Day 1 Day 8 Follow-up (every 15 days)

1 2 3 4 5 6 7 8 9 10 11 12

Burning sensation

Symptoms Grading

Absent O

Mild 1

Moderate 2

Severe 3

Objective criteria :



1.spincter spasm :

Spincter spasm


1 2 3 4 5 6 7 8 9 10 11 12

Symptoms Normal Spasmodic

Grading 0 1 (Not

allowed)

2.Size of the ulcer (in mms.) :

Size of the ulcer (in mms.)


1 2 3 4 5 6 7 8 9 10 11 12

Size of ulcer in mm

Symptoms Grading

0mm to 2 mm 1

2mm to 4mm 2

4mm to 6mm 3

2. Proctitis



proctitis


1 2 3 4 5 6 7 8 9 10 11 12

Proctitis

Symptoms Grading

Absent O

Present 1

RESULT

CURED

IMPROVED

UNCHANGED

NOT FOLLOW - UP

Bibliography.


BIBLIOGRAPHY AND REFRENCES

1. Sushruta, Sushruta Samhita with Nibandha Sangraha Commentary

Choukhamba Sanskrit series 2002.Sutra Sthana 15/4



3. Agnivesa, Charaka Samhita with Ayurveda Dipika Commentary,

Choukhamba Sanskrit series .Varanasi.1994.Vimana Sthana 5/4


Choukhamba Sanskrit series .Varanasi.1994.Siddhi Sthana 9/3


Choukhamba Sanskrit series .Varanasi.1994.Sharira Sthana 7/10








Choukhamba Sanskrit series 2002.Sharira Sthana 6/26





Bibliography.




13. Vagbhata; Astanga Hridaya with Sarvaga Sundara Commentary, Krishnadas

academy, Varanasi 1995.Sharira Sthana 3/8




Choukhamba Sanskrit series 2002.Nidana Sthana 4/26

16. Vagbhata; Astanga Hridaya with Sarvanga Sundara Commentary, Krishnadas

academy, Varanasi 1995.Nidana Sthana 7/ 4-6




Choukhamba Sanskrit series 2002.Nidana Sthana 2/ 5-8


academy, Varanasi 1995.Nidana Sthana 7/4-5





22. Vagbhata, Astanga Hridaya with Sarvanga Sundara Commentary, Krishnadas


Bibliography.



















academy, Varanasi 1995.Sutra Sthana 12/8-9


Choukhamba Sanskrit series 2002.Nidana Sthana 2/6-8


Choukhamba Sanskrit series 2002Chikitsa Sthana 34/16

Bibliography.



Choukhamba Sanskrit series .Varanasi.1994.Chikitsa Sthana 3/156






academy, Varanasi 1995.Nidana Sthana 1/16














Choukhamba Sanskrit series 2002.Uttara Sthana 55/37

Bibliography.











academy, Varanasi 1995Sutra Sthana 4/3


Choukhamba Sanskrit series .Varanasi.1994.Chikitsa Sthana 19/ 5




Choukhamba Sanskrit series .Varanasi.1994.Chikitsa Sthana 19/ 5


academy, Varanasi 1995. Nidana Sthana 8/57


Choukhamba Sanskrit series 2002.Nidana Sthana 2/9



Bibliography.









Choukhamba Sanskrit series 2002.Chikitsa Sthana 34/3-6


Choukhamba Sanskrit series .Varanasi.1994.Siddhi Sthana 6 /61


Choukhamba Sanskrit series 2002.Chikitsa Sthana 34/16










Choukhamba Sanskrit series .Varanasi.1994.Chikitsa Sthana 28/26-27

Bibliography.










71. Vagbhata, Astanga Hridaya with Sarvaga Sundara Commentary, Krishnadas

academy, Varanasi 1995. Nidana Sthana 8/5-7






Choukhamba Sanskrit series 2002.Sutra Sthana 25/7-8




academy, Varanasi 1995. Nidana Sthana 15/9



Bibliography.


78. Kashyapa Samhita, Nepal Rajguruna Pandit Hemraj Sharma, 1938 Khil

Sthana 10/101-105




















Choukhamba Sanskrit series .Varanasi.1994.Siddhi Sthana 6 /67

Bibliography.







Choukhamba Sanskrit series 2002.Chikitsa Sthana 34/16, 38/ 85




Choukhamba Sanskrit series 2002.Chikitsa Sthana 37/27-29

94. Gray’s Anatomy : Edited by Williams P.L.ELBS, 38th edition , 1995

95. Bailey and Love’s short practice of surgery, Londan by R.C.G. Russell,

Norman. S. Williams and Christopher J.K Bulstrode, 24th edition, 2004, page

no -1252-1253 and page no 1522

96. Bhaisajya Ratnavali- Varna Shotha Chikitsa Adhyaya- by Ambikadutt

Shashtri edited by Rajeshwardutt Shastri printed by Chaukhamba Sanskrit

Samsathana,14th edition 2001,47/80


Choukhamba Sanskrit series 2002.Sutra Sthana 45/ 96-97


academy, Varanasi 1995. Sutra Sthana 5/38


Choukhamba Sanskrit series .Varanasi.1994.Nidana Sthana 1/ 40

Bibliography.




101. The chikitsa explained in the Sushruta Samhita commentary choukhamba

Sanskrit sutrasthana chapter 5th sloka-42 page no-19.

102. Kashyapa Samhita- chapter no -2 sloka- 1 page no- 163

103. Charaka Samhita,chikitsa sthana chapter -34th sloka- 16th page no –595.

104 Baishaja kalpana shoba hiremath text English translation chapter 9 page no

230

SL.NO

OPD / IPD NO

PATIENT NAME AGE

SEX M/F

OCCUPATION

RELEGION H / M / C

RURAL OR URBUN- R / U

MARRIED / UNMARRIED

ECONOMICAL STATUS L/M/H

EDUCATIONAL STATUS

HABBITSMOOKER/ALCOHOL/TOBACO

VEGITARION / MIXED

1 26713 Sri.shekarappa u 45 M Driver H R M M PUC Smook M 2 27733 Smt. Ratnavva.k. 23 F Housewife H R M M SSLC - M 3 28376 Sri Basavara pattar 35 M Farmar H U M M PUC Tobaco M 4 29995 Sri.Mahesh guttannavar 35 M Driver H R M M BA T/A M 5 30835 Smt. Renuka 28 F Housewife H R M M PUC - M 6 30596 Sri Saranappa 28 M Driver H R M L PUC T/Al M 7 30598 Smt. Kariyavva madar 30 F Housewife H R M M PUC - M 8 30597 Sri.Subbanna.D 32 M Contracter H R M M BA - M 9 32008 Sri. Basappa kavadikai 60 M Farmar H R M L PUC T/A M

10 38568 Sri.Irappa hosalli 43 M Farmar H R M L PUC Alcohol M 11 33333 Sri Nagaraj rotti 22 M Student H U U M B.com - M 12 33369 Sri Anand javar 26 M Teacher H R M L B.SC Tobocco M 13 23979 Sri.satish p 30 M Driver H R M L SSLC - M

14 24213 Sri.Siddanagouda p 23 M Contrter H R M L PUC Alcohol M 15 26386 Sri.Vinay belagankar 50 M Farmar H R M M BA Tobaco M 16 26521 Sri Andaneshwar.k. 27 M Teacher H R M M TCH - M 17 27717 Smt.Renuka katali 40 F Teacher H U M M B.SC - M 18 29595 Sri.Hnumanth .k. 28 M Driver H R M M SSLC - M 19 29597 Sri. Iranna hadali 22 M Student H R U M BA - M 20 29598 Smt.Neelavathi.l. 20 F Housewife H U M H PUC - M 21 29594 Sri.Prakash.H. 40 M Farmar H U M M SSLC - M 22 29593 Smt. Laxmi.G. 20 F Student H R U M BA - M 23 29596 Sri. Basanagoda.C. 50 M Contracter H R M L BA Alcohol M

24 29599 Sri.Nazeer sultan 22 M Warker M U U M SSLC - M 25 29734 Sri.Rajath sing 22 M Student H U U M BAMS Alcohol M 26 29732 Sri. Manju ugalat 26 M Farmar H R M M BA - M 27 29737 Sri. Basalingappa.S. 45 M Farmar H R M M SSLC - M 28 29904 Smt Sujatha.J. 26 F Student H U U M BA - M 29 29905 Sri.Pramod .S. 29 M Student H U M M MA T/A M 30 33820 Sri.Siddappa .N. 55 M Farmer H R M M SSLC - M 31 33821 Sri.Devappa.K. 35 M Farmar H R M M PUC Tobaco M 32 29906 Sri. Suresh.G. 32 M Farmar H U M M SSLC - M 33 36580 Sri.Muttu kolli 26 M Farmar M U M M Un edc Tobacco M 34 36590 Sri.Sngappa patil 35 M Frmar H R M M PUC T/A M 35 36660 Dr.Turbeen 38 M Lecturer H U M H MD - M 36 36670 Smt. Radika.C. 36 F Housewife H U M M Un.edc - M 37 36900 Sri.Praveen.N. 28 M Nursing H U M M GNM - M 38 37921 Smt. Prameela .P. 28 F Teacher H U M M TCH - M 39 37927 Smt.Mahalxmi.P. 29 F Housewife H U M M PUC - M 40 38008 Sri. Subhas.D. 32 M Contracter H R M M B.Com Tobacco M

SUBJECTIVE CRITERIA OBJECTIVE CRITERIA

SL NO

OPD/IPD NO

PATIENT NAME PAIN-IN NATURE

CONSTIPATION

BLEEDING

BURNING SENSATION

SPINCTER SPASM

SIZE OF ULCER PROCTITIS

BT AF BT AT BT AT BT AT BT AT BT AT BT AT

1 26713 Sri.shekarappa u 3 1 3 1 3 1 3 1 1 0 2 1 1 0

2 27733 Smt. Ratnavva.k. 2 0 2 0 0 0 2 0 1 0 2 1 1 0

3 28376 Sri Basavara . p. 2 0 2 0 0 0 2 0 1 0 2 1 1 0

4 29995 Sri.Mahesh.G. 2 0 1 0 0 0 2 0 1 0 2 1 1 0

5 30835 Smt. Renuka 2 0 2 0 2 0 2 0 1 0 2 1 0 0

6 30596 Sri Saranappa 3 1 2 1 3 0 3 0 1 0 2 1 1 0

7 30598 Smt. Kariyavva 2 0 2 0 2 0 2 0 1 0 1 1 1 0

8 30597 Sri.Subbanna.D 1 0 1 0 0 0 1 0 1 0 1 1 0 0

9 32008 Sri. Basappa ka. 2 0 3 0 2 0 3 1 1 0 2 1 1 0

10 38568 Sri.Irappa hosalli 1 0 2 0 0 0 2 0 0 0 2 1 1 0

11 33333 Sri Nagaraj rotti 1 0 2 0 0 0 2 0 0 0 1 1 1 0

12 33369 Sri Anand javar 2 0 2 1 0 0 2 0 0 0 2 1 1 0

13 23979 Sri.satish p 2 0 2 0 2 0 2 0 1 0 2 1 1 0

14 24213 Sri.Siddanagoud 2 1 2 0 1 0 2 0 1 0 2 1 1 0

15 26386 Sri.Vinay.B. 2 0 2 0 o 0 2 0 1 0 1 1 1 0

16 26521 Sri Andaneshwar 2 1 2 0 0 0 2 0 1 0 1 1 1 0

17 27717 Smt.Renuka .K. 2 0 2 0 2 0 2 0 1 0 2 1 1 0

18 29595 Sri.Hnumanth .k. 2 0 2 0 2 0 2 0 1 0 2 1 1 0

19 29597 Sri. Iranna hadali 2 0 2 0 2 0 2 0 1 0 2 1 1 0

20 29598 Smt.Neelavathi.l. 2 0 2 0 3 0 2 0 1 0 3 1 1 0

21 29594 Sri.Prakash.H. 2 0 2 2 0 0 2 0 0 0 2 1 0 0

22 29593 Smt. Laxmi.G. 2 1 2 2 1 0 2 0 1 0 2 1 1 0

23 29596 Sri. Basanagoda. 2 0 2 2 1 0 1 0 1 0 2 1 1 0

24 29599 Sri.Nazeer sultan 2 0 2 2 2 0 2 0 0 0 2 1 1 0

25 29734 Sri.Rajath sing 2 0 2 2 2 0 2 0 1 0 2 1 1 0

26 29732 Sri. Manju ugalat 2 0 2 2 2 0 2 0 1 0 2 1 1 0

27 29737 Sri. Basalingapp 2 1 2 2 2 0 2 1 0 0 2 1 1 0

28 29904 Smt Sujatha.J. 2 0 2 2 2 0 2 0 1 0 2 1 1 0

29 29905 Sri.Pramod .S. 2 0 2 2 0 0 2 0 1 0 2 1 1 0

30 33820 Sri.Siddappa .N. 2 0 2 2 0 0 2 0 1 0 1 1 1 0

31 33821 Sri.Devappa.K. 2 0 2 2 2 0 2 0 1 0 2 1 1 0

32 29906 Sri. Suresh.G. 2 0 3 3 2 0 2 0 1 0 2 1 1 0

33 36580 Sri.Muttu kolli 2 0 2 2 2 0 2 0 1 0 2 1 1 0

34 36590 Sri.Sngappa patil 2 0 2 2 2 0 2 0 1 0 1 1 1 0

35 36660 Dr.Turbeen 2 0 2 2 2 0 2 0 1 0 2 1 1 0

36 36670 Smt. Radika.C. 2 0 2 2 0 0 2 0 1 0 1 1 1 0

37 36900 Sri.Praveen.N. 2 0 2 2 2 0 2 0 1 0 2 1 1 0

38 37921 Smt. Prameela .P 2 1 2 2 2 0 2 0 1 0 3 1 1 0

39 37927 Smt.Mahalxmi.P 1 0 1 1 0 0 1 0 0 0 1 1 0 0

40 38008 Sri. Subhas.D. 3 1 2 2 2 0 2 0 1 0 3 1 1 0

DEDICATED TO

MY

Parents

INTRODUCTION

OBJECTIVES

REVIEW OF

LITERATURE

DRUG REVIEW

OBSERVATIONS

&RESULTS

MATERIALS AND

METHODS

CONCLUSION

SUMMARY

BIBLIOGRAPHY

&

REFERENCES

ANNEXURE

DISCUSSION

MASTER

CHART

Documents

“AYURVEDA VACHASPATI”