Ayurvedic Management of Parikarthika (Acute Fissure in Ano) – A Case Study

Among anorectal diseases, Parikarthika (Fissure in ano) is considered one of the most painful diseases. Now a days the incidence rate of this disease became more due to the irregular food habits as well as unproper modern life style changes. Due to this its recent occurrence in all types of age groups irrespective of gender. This case study described the effective management of acute fissure in ano which was managed with ayurvedic treatment modalities. A 23-year male patient came with symptoms of pain and burning during and after defecation and also having the presence of blood streak while passing of stool. The patient was diagnosed as acute fissure due to the presence of a cut longitudinal ulcer in lower part of anal canal at the 6 o’clock position. Ayurvedic treatment approach both internally and externally were followed. Jatyadi Ghritham Pichu application followed by a lukewarm water sitz bath was advised as external treatment. The complete improvement was found in this within 12 days of treatment. No reoccurrence was noted even after 3 rd month of follow up. Case Study Sreerag and Dhule; JPRI, X(X): xxx-xxx, 20YY; Article no.JPRI.73483 2


INTRODUCTION
Fissure in ano is the commonest disease of anorectal region. The occurrence of fissure in ano is more common in present era due to unproper life styles and un healthy dietary regimens. Fissure in ano is a painful anorectal condition that gives tolerance to the daily routine activities of patients. The term 'fissure' itself represents the meaning 'a split or crack'. It has been described as an acute superficial break in the continuity of the anal canal [1]. In Ayurvedic science it is known as Parikarthika which refers to a condition in which patient experiences a sensation of pain as if the anal canal is being cut around with scissors [1]. Management approach selection in Parikarthika should are to be selected on the basis of medicines and treatments which one helps for the healing of ulcer as well as to reduce the cutting and burning type of pain. The management protocols for fissure-in-ano in Ayurvedic science are Snehavasthi (Oil enema therapy), Avagaha Swedana (medicated lukewarm water sitz bath) and Lepanam (medicated ointments). Parikartika can be considered as Sadya Vrana due to the presence of painful longitudinal ulcer [2]. Hence drug preparations that have Vranaropana properties are more effective in the management of Parikartika. Jatyadi Ghritha is the one which is has properties like Saruja Shamana (Pain relieving), Vranasodhana (Wound cleansing) and Vranaropana (Wound healing) properties [3]. Due to this properties Jatyadi Ghritham is the good medical option in the management of Parikarthika.

CASE HISTORY
A 23-year male patient had complaints of constipation associated with pain and burning sensation in the perianal region during and after defaecation for 7 days. Pain was mild to moderate before 3 days which will subside after 15 minutes of defaecation. But after 3 days, pain became aggravated daily and the symptoms like pain and burning sensation was persisting upto half an hour after defaecation. The patient also had associated complaints like constipation and the presence of blood streak while passing of stool. The patient was using analgesics for this but it was giving short term relief and the symptoms was aggravating again after completing drug acting period.
Per rectal examination was done to analyze the proper diagnosis. On inspection, a cut longitudinal ulcer with indurated margin was identified at 6 O'clock position in the lower part of anal canal. Hypertonicity of anal sphincter was analyzed with digital rectal examination using a little finger.

MATERIALS AND METHOS
A single case study was conducted in the Shalya Tantra OPD of Triveni Nursing Home, Thiruvananthapuram. The selected patient was treated internally with Dusparshakadi Kashayam and Triphaladi Churnam. Jatyadi Ghrita application was done in the fissure bed as external treatment. All points of history taking, physical examination and lab investigation were noted in a special case proforma. Selected patients were noted before, during and after the proposed treatment. Single clinical case study was conducted after obtaining voluntary informed consent.

Chikitsa (Method of Treatments)
Both internal as well as external treatment approaches was followed in the patient. Dusparshakadi Kashaym (15 ml Kashayam with 60 ml lukewarm water) was given twice daily before food. Five-gram Triphaladi Churnam was given with lukewarm water at bed time daily. Application of Jatyadi Ghritham Pichu was done twice daily after lukewarm water sitz bath was advised as external treatment. Total duration of treatment was 12 days. There was no reoccurrence of disease even after 3 months of follow up.

Application of Jatyadi Ghrita Pichu:
Pichu is one type of treatment procedure in Ayurveda in which a cloth or gauze piece soaked in the medicated oil is kept in the affected body parts. The warm sitz bath was given to the patient for 10 minutes before Pichu application. Anal sphincter tonicity was assessed by digital examination. A sterile gauze piece soaked in the Jatyadi Ghrita (Pichu) was placed at anal canal and left for 2-3 hours. Pichu was applied daily for 12 days. . Triphala is well known medicine for its wound-healing quality and also having detoxifying and rejuvenating actions [7]. Triphala acts as a mild laxative and also heals the tissue along with increasing the digestion of the patient.

RESULTS
The signs and symptoms of fissure in ano like pain during and after defaecation, burning sensation after defaecation, blood oozing from ulcer and healing of ulcer were considered as criteria for result analysis. The pain during and after defaecation was reduced on the third day after treatment. Burning sensation after defaecation was reduced after the fifth day of treatment. The complaints of blood oozing while passing of stool was completely relieved on the second day itself. The complete ulcer healing was noted on the 12 th day of treatment.

DISCUSSION
Fissure in ano is one of the painful anorectal diseases which presents as an acute superficial break in the continuity of the anal canal. Parikarthika can be considered as Sadya Vrana due to the presence of painful longitudinal ulcer [2]. Treatment protocols for fissure in ano should be based on the medicines which aid the healing of ulcers as well as to reduce the cutting and burning type of pain. Each medicine used in the patient has different properties as mentioned previously. The main advantage of this treatment is the complete reduction of complaints like pain, burning sensation, oozing of blood during and after defaecation within 5 days after the treatment. Complete healing of ulcer in fissure in ano within 12 days is one of the another advantage noted.
Jatyadi Ghritha is the one which is having properties like Saruja Shamana (Pain relieving), Vranasodhana (Wound cleansing), and Vranaropana (Wound healing) properties [3]. Jatyadi Ghritham Pichu helps to keep Vrana moist and thus promotes the healing process through its above-mentioned properties. Jatyadi Ghritha helps to increase granulation tissue formation thus promoting ulcer healing [8]. Due to these properties of Jatyadi Ghritham Pichu makes it a good treatment option in the management of Parikarthika. Pachana and Rakta Shodhana property of Dusparshakadi Kashayam improves the vascular circulation in the anorectal region and reduces spasms and congestion. Due to these properties, Kashayam helps in the healing of anal fissures [9]. Triphala also heals the tissue along with increasing the digestion of the patient at the same time acting as a mild laxative. Triphala is well known for its woundhealing quality. Constipation is one of the reasons for the occurrence of fissure in ano. Triphala helps in easy bowel movements and thus relieves constipation. Yashtimadhu is also one of the ingredients in the Triphaladi Churnam which has Vrana Ropana properties. Lukewarm water Sitz bath helps to clean the fissure wound area, improve the blood flow of the regions, and thus helps to relax the anal sphincter.

CONCLUSION
Fissure in ano is a painful anorectal condition that gives tolerance to the daily routine activities of patients. Most of the fissure in ano patients suffered pain and burning sensation in the perianal region during and after defaecation, presence of an indurated ulcer and also has a habit of constipation. So, the treatment principle of acute fissure in ano should be based on the aim to healing of ulcer, reduction of pain and burning sensation and also to correct the constipation. Both internal and external treatments formulated in this case are to satisfy the above mentioned treatment principles. Lukewarm water sitz bath and Jatyadi Ghritha Pichu helps to cleaning and healing of wound and also promotes granulation tissue formation and ulcer healing. Dusparshakadi Kashayam improves the vascular circulation in the anorectal region and reduces spasm and congestion anal sphincter muscles. Triphaladi Churnam helps to promote the digestion of the patient and also acting as a mild laxative which helps to reduce the constipation. Due to above mentioned properties, the treatment combinations like Jatyadi Ghritham Pichu, Dusparshakadi Kashayam and Triphaladi Churnam are considered to be as a good treatment option in the management of Parikarthika.

RESEARCH SIGNIFICANCE
The study highlights the efficacy of " Ayurvedic " which is an ancient tradition, used in some parts of India. This ancient concept should be carefully evaluated in the light of modern medical science and can be utilized partially if found suitable.

CONSENT AND ETHICAL APPROVAL
As per international standard or university standard guideline Patient's consent and ethical approval has been collected and preserved by the authors.