Basic Fundamentals of Fissure in Ano as per Ayurveda

Fissure

Fissure

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

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 Parikartika.

ETIOLOGY :

 Diet-related etiology :

Diet plays a very important role in Parikartika which is evident from references. Vagbhata and Kashyapa have explained that intake of Mudga, Kodrava, Chanaka, and other pulses and Rooksha charas which is water absorbent in nature (Sangrahi) lead to constipation. Apanavata gets aggravated in its 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 the 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 Parikartika. If a person is debilitated with Mridukoshta or Mandagni, the ingestion of Atirooksha, Atiteekshna, Atiushna, Atilavana Sahara causes Dushana of Pitta and Anila and produces parikartika.

 Disease-Related etiology :

  • Udavarta (Purisajaudavartaor Purisavrta Vata)
  • Arsha (Prodromal features and symptoms of Vatika and Kaphaja Arsha) – Abnormality of the internal sphincter predisposes the patient to the formation of both hemorrhoids and fissures.
  • Jirnajwara
  • Vatika Atisara
  • Vatika Grahani

Physician related etiology :

  1. Vairocana Vyapada – A person having Mrudu Kostha and Alpa Bala ingest TiksnaUshna, and Ruksa drugs for Virechana, then this disease results.
  2. Vasti Vyapada (niuruha)- If Ruksa Vasti containing Tiksna and Lavana drugs is administered in heavy doses; it may produce Parikartika.
  3. Excessive use of Yapana Vasti – It may lead to Parikartika along with other diseases.
  4. Vasti Netra Vyapada – Due to inappropriate administration of the enema nozzle and defects in the enema nozzle itself may cause this disease.

SAMPRAPTI :

In the concerned disease, the predominant vitiated Dosha is Vata. Dushya is Twak, Rakta, and Mamas, specifically in Guda Pradesh, which affects gradually according to the progress of the disease. The Vyana Vayu when obstructed by the pathway of Apana Vayu led to the formation of Parikartika associated with Udavarta. Due to the etiological factor, there is Dusti of Purisavaha Srotas. When 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. Though there is a predominance of Vayu, it is associated with Pitta (according to Acharya Sushruta) and Kapha (according to Acharya Kasyapa)

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. The pain persists before and after defecation mentioned by Susruta. There is vitiation of Vayu mainly the Purisavrta Vata. The involvement of Dushya as a disease concern will be Twak, Rakta, and Maṃsa. When vitiated Vayu affects the following Dhatus, symptoms become more relevant as per disease concern.

SADHYASADHYATA/PROGNOSIS :

Generally, Vrana in Payu is easily curable. 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) is easily curable in a 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, is considered as Yapya.

In Astanga Samgraha some Arista Lakshana is mentioned about Parikartika.

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.

CHIKITSA/TREATMENT :

The Mandagni is a most important factor in Parikartika as well as in Arsha, Atisara, and 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 of progression in chronic one can be minimized. The main aim of treatment is to relieve sphincter spasms and heal fissure wounds, soothe the anal canal, and 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 a warm/hot water tub after each bowel movement soothes the pain and relaxes the spasm of the internal sphincter for some time.
  3. Local application of Durvadya tail–  Main ingredient of Durvadya tail is Durva (Cynodondactylon), Kampillaka (Mallotus philippensis), Daruharidra (Berberis aristata), and Til tail (sesame oil).
  4. Matra Basti (type of Anuvasana Basti): It acts as a retention enema and helps in the 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 Snehan occurs, the spasm will also be relieved and thus brings down the pain. It softens the stools, lubricates the anal canal, and provides an easy evacuation.
  5. High fiber 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 thereafter evacuation. Hence patients should take daily fiber-rich food and plenty of fluids to improve digestion and regularize their bowels. These are hygroscopic, which allows them to expand and become mucilaginous. These fibers are a complex carbohydrate, which binds with water in the colon creating larger, softer, stools. Larger, softer, stools stretch and relax the sphincter muscles helping the blood to flow and it also requires 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 VrakshamalaBadaraPithivana, and Kantakāri with powder of unripe fruit of Bela’s cortex.
  • About Garbhini Chikitsa, Acharya Kasyapa classified the disease into three categories and gave specific treatment according to the Doshic involvement.
  • Taila/Ghrita Pichu: It forms a protective layer over the fissure wound, it smooths the anal canal and relieves pain by releasing sphincter tone and cleaning the wound thus helping in the healing of ulcers.

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. 

In kshar chikitsa, kshar sutra ligation was done to sentinel piles. of this themselves they may fall within a 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 the ulcer heals & sphincter relaxation occurs simultaneously.

DISCUSSION :

Based on location, nature of pathology, and features, Gudaparikartika can be correlated to Fissure-in-ano. The detailed description of Nidana (etiology), Samprapti (pathogenesis), Lakshana (symptoms) & Chikitsa (treatment) is mentioned in Sushruta Samhita, Kashyapa Samhita, Astanga Hridaya, etc. There is a detailed description of conservative and surgical treatment for Fissure-in-ano.

CONCLUSION :

  • Improper dietary regimens and stressful life are found to have influenced the high incidence observed today. 
  • Passage of hard constipated stools is the prime cause of tears 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 fissures and regularize bowel in up to 90% of cases of acute fissures. These could always be offered to patients who are not willing to operative procedures such as cardiac patients or patients with diabetes, AIDS, or Hepatitis B where healing is difficult after the operation.
  • Kshara is used in different forms like Kshara Lepa, and Ksharasutra ligation in treating Parikartika (Chronic Fissure-in-ano).

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