Parikartika : Management of Fissure in Ano in Ayurveda

Fissure is described in Sushrut Samhita¹. It is described in the complications of Garbini (pregnant lady) in the Kashyap Samhita, Khilasthana². Parikartika resembles fissure‑in‑ano having cutting and burning pain at Guda³. Acharya Sushruta mentioned it as one of the complications in the Virachanaa ⁴ (purgation therapy) and Vasti karma (enema therapy). Acharya Charaka described it in vyapad of vaman-virechan and Basti Vyapad (a complication of medicated enema)5, and Bastinetra Vyapad (a complication of medicated enema tube)⁶.

DEFINITION:

Parikartika or Parikartana. Vyutpatti: The word Parikatika consists of two words . Pari- around, about; Kartana- the act of cutting off; Krintati– clip, cut off. Nirukti: Unbearable cutting type of pain all around Guda, Bastishiras and Nabhi is termed as Parikartika⁸.

ETIOLOGY :

 Diet-related etiology :

Diet plays a very important role in Parikartika which is evident by references. Vagbhata and Kashyapa have explained that intake of Mudga, Kodrava, Chanaka and such other pulses and Rooksha aharas which are water absorbent in nature (Sangrahi) leading to constipation. Apanavata gets aggravated in its own seat (Pakwashaya) which blocks the adhovaha srotas, dries them up (of their moisture), and produces obstruction to the movement of feces, flatus, and urine by which Parikartika occurs 8&9.As per modern science intake of nonfibrous food will lead to hardening of stools and cause Fissure-in-ano.

            When Vata is covered with feces, the stool is constipated, the patient suffers from severe pain and passes hard stools with difficulty, and evacuation is delayed. This causes Parikartana leading to Parikartika¹⁰. If a person is debilitated with Mridukoshta or Mandagni, the ingestion of Atirooksha, Atiteekshna, Atiushna, Atilavana ahara causes Dushana of Pitta and Anila and produces parikartika^11.

 Disease-Related etiology :

• Udavarta¹² (Purisajaudavarta¹³or Purisavrta Vata¹⁴)
• Arsha (Prodromal features and symptom of Vatika and Kaphaja Arsha15) – Abnormality of the internal sphincter predisposes the patient to the formation of both hemorrhoids and fissure.
• Jirnajwara¹⁶
• Vatika Atisara¹⁷
• Vatika Grahani¹⁸

Physician related etiology :

1. Virecana Vyapada – A person having Mrudu Kostha and with Alpa Bala if ingests Tiksna, Ushna and Ruksa drugs for Virechana, then this disease result.
2. Vasti Vyapada (niuruha)- If Ruksa Vasti containingTiksna and Lavana drugs is administered in heavydose; it may produce Parikartika.
3. Excessive use of Yapana Vasti – It may lead to Parikartika along with other diseases.¹⁹
4. Vasti Netra Vyapada – Due to inappropriateadministration of enema nozzle and defect in enemanozzle itself may cause this disease.

SAMPRAPTI :

In the concerned disease, the predominant vitiated Dosha is Vata. Dushya is Twak, Rakta, and Mamsa, specifically in Guda Pradesh,20 which affect gradually according to the progress of the disease. The Vyana Vayu when obstructed the pathway of Apana Vayu leads to the formation of Parikartika associated with Udavarta. Due to the etiological factor, there is Dusti of Purisavaha Srotas.21When Purusha is obstructed the natural way of Apana Vata also causes vitiation of Vayu. As a result of the pathogenesis, when Vata localizes in Twak, it becomes Ruksa and shows a tendency to crack. As the disease progress, the vitiated Vayu is localized in Rakta, and the formation of an ulcer takes place. Thereafter when it localizes in Mamsa forming knotty swelling or tags and pain.22Though there is a predominance of Vayu, but it is associated with Pitta (according to Acharya Sushruta) and Kapha (according to Acharya Kasyapa)²³

Another Samprapti is due to Agantuja Nidana where there is wound formation in the first stage and then the Doshas get sited in the Vrana, producing further symptoms. When the wound is produced simultaneously there is vitiation of Dosha which in term leads to Parikartika.

LAKSHANA/SYMPTOMS :

The terminology Parikartika is itself representing the symptom, which is the intensity of pain. It is a sharp cutting or sawing type of pain. It’s severe pain with bloody mucous discharge associated discomfort in the perianal region as per Charaka.24The pain persists before and after defecation mentioned by Susruta.25 There is vitiation of Vayu mainly the Purisavrta Vata.26 The involvement of Dushya as a disease concern will be Twak, Rakta, and Maṃsa. When vitiated Vayu affecting the following Dhatus, symptoms become more relevant as per disease concern.²⁷

SADHYASADHYATA/PROGNOSIS :

Generally, Vrana in Payu is easily curable.28 If a Vrana is left untreated, as a consequence it may lead to the Yapyatwa stage and finally leading to the Asadhyatwa stage. Parikartika which affects the superficial layer of the Twak (anal skin) are easily curable in short time. Therefore it can be included in the Sukhasadhya group. If it affects the deeper layers, it deals with wound healing. And if it is associated with Madhumeha, Kustha, Vishodusti, and Sosha, the healing of Vrana will be delayed. If Parikartika is associated with Sanniruddha

Guda, it is considered as Yapya.²⁹

In Astanga Samgraha some Arista Lakshana mentioned in relation to Parikartika.³⁰

a) When Parikartika is formed due to Amasaya cause and associated with severe thirst and Sakrutabheda.

b) When Parikartika is formed due to Pakwasaya cause and associated with severe thirst and

Gudagraha.

IBD And Its Management By Ayurveda

CHIKITSA/TREATMENT :

               The Mandagni is most important factor of Parikartika as well as in Arsha, Atisara, Grahani. So increasing and maintaining the Agni in an equilibrium state is necessary. Up to 70 % of acute fissures resolve with conservative medicine, if not they progress to form a chronic fissure. However, Ayurvedic preparations are used in the primary stage of the disease the chance to progression in chronic one can be minimized. The main aim of treatment is to relieve sphincter spasms and heal of fissure wounds, soothe of the anal canal and to relieve the agonizing pain and associated burning sensation and bleeding.

1. Nidana Parivarjana (removal of etiology)- It is the first step of treatment.
2. Avagahana-sweda (Hot fomentation- Sitz bath): Sitting in warm/hot water tub after each bowel movement soothes the pain and relaxes the spasm of internal sphincter for some time.
3. Local application of Durvadya taila– ³¹ Main ingredient of Durvadya taila is Durva (Cynodondactylon), Kampillaka (Mallotus philippensis), Daruharidra (Berberis aristata) and Til taila (sesame oil).
4. Matra basti (type of Anuvasana basti): It acts as a retention enema and it helps in easy voiding of stools, by this Vatanulomana occurs and it cures the diseases caused by aggravated Vata as Parikartika is Vata dominate Vyadhi. By giving Matrabasti local Snehana occurs, spasm will also be relieved and thus brings down the pain. It softens the stools, lubricates the anal canal and provides an easy evacuation.³²
5. High fibre diet: The rate of intestinal passage of food depends on the nature of the diet and its fluidity. The greater the indigestible residue and water content, the more rapidly it reaches the rectum and produces its distension and there after evacuation. Hence patients should take daily fibre rich food and plenty of fluids to improve digestion and regularize bowels. These are hygroscopic, which allows them to expand and become mucilaginous. These fibres are a complex carbohydrate, which binds with water in the colon creating larger, softer, stool. Larger, softer, stools stretch and relax the sphincter muscles helping the blood to flow and it also require little pressure to pass.

• In the Jwara Chikitsa, Acharya Charaka has also mentioned that in Jwarita person, there are chances of having Parikartika. He should consume Peya of red rice made from decoction of Vrakshamala, Badara, Pithivana, Kantakāri with powder of unriped fruit of Bela’s cortex.³³
• In relation with Garbhini Chikitsa, Acharya Kasyapa,³⁴ classified the disease in three category and given specific treatment according to the Doshic involvement.
• Taila/Ghrita pichu: It forms protective layer over fissure wound, it sooths the anal canal so relieves pain by releasing sphincter tone and it cleans the wound thus helps in healing of ulcer.³⁵

CHIKITSA FOR SHUSHKARSH / BAHYARSH :

In Ayurvedic text information available on Shushkarsha, Bahyarsha can be correlated with Sentinel Piles. Acharya Sushruta mentioned four modalities of management 1) Bheshaja (conservative line of management) 2) Kshara 3) Agni 4) Shastra.³⁶ In kshar chikitsa , kshar sutra ligation was done to sentinel piles. by this themselves they may fall within few days. Also can use as Lepa of  Pratisaraneeya kshara is done over the (Chronic fissure-in-ano) ulcer surface, by lekhan karma of Kshara, this reduces the excess fibrous tissue present over the ulcer surface and ulcer heals & sphincter relaxation occurs simultaneously.

DISCUSSION :

On the basis of location, nature of pathology and features, Gudaparikartika can be correlated to Fissure-in-ano. The detail description about Nidana (etiology), Samprapti (pathogenesis), Lakshana (symptoms) & Chikitsa (treatment) is mentioned in Sushruta samhita, Kashyapa samhita, Astanga Hridaya etc. There is detail description about conservative and surgical treatment for Fissure-in-ano.

CONCLUSION :

• Improper dietary regimen and stressful life is found to have influenced the high incidence observed today. 
• Passage of hard constipated stools is the prime cause of tear in the lower anal canal which results in excruciating pain during and after defecation, the cardinal feature of Fissure-in-ano.
• Ayurvedic preparations are all effective & these can cure fissure and regularize bowel upto 90% cases of acute fissures. These could always be offered to the patients who are not willing for operative procedure such as cardiac patients or patients with diabetes, AIDS, Hepatitis B where healing is difficult after operation.
• Kshara is used in different forms like Kshara Lepa, Ksharasutra ligation in treating Parikartika (Chronic Fissure-in-ano).

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