Eranda Kshara an effective alternative for Apamarga Ksharasutra - A Case Study

Amala J. Tharesa; Srinivas Masalekar

Eranda Kshara an effective alternative for Apamarga Ksharasutra - A Case Study

J. Tharesa A.^1*, Masalekar S.²

DOI:

^1* Amala J. Tharesa, Post Graduate Scholar, Dept. of Shalya Tantra, Govt. Ayurveda Medical College and Hospital, Bengaluru, Karnataka, India.

² Srinivas Masalekar, Associate Professor, Dept. of Shalya Tantra, Govt. Ayurveda Medical College and Hospital, Bengaluru, Karnataka, India.

Bhagandara which is correlated to Fistula in Ano, is considered as one of the Ashta Maharoga[1] (8 major diseases) by Acharya Susrutha, that is diseases which are difficult to cure. In modern science treatment of Bhagandara includes fistulotomy, fistulectomy, LIFT, VAAFT etc., but till date none of these methods have proven to give complete cure in fistula in ano. Kshara Sutra therapy is a parasurgical procedure which is used in fistula in ano and is mentioned by Acharya Susrutha in the context of Nadi Vrana Chikitsa Adhyaya.[2] The Kshara Sutra therapy is found to be effective in treating Bhaganadara as it is minimal invasive procedure with least recurrence nature. Among 28 Kshara Gana mentioned in classics all drugs have been researched to assess the effectiveness by using it as Kshara Sootra and Apamarga Kshara Sutra has been standardized. Though Apamarga is proven to be effective Ksharasutra, as it is a seasonal plant its collection is found to be very difficult and makes it costly. Eranda is a drug, which is easily available throughout the year, grown abundantly everywhere in India, cost effective, from which Ksharasutra can be made easily. The present study was undertaken to assess the role of Eranda Ksharasutra in treatment of Bhagandara in a patient who approached OPD of SJIIM Hospital, Bengaluru.

Keywords: Bhagandara, Fistula in ano, Eranda Ksharasutra

Corresponding Author	How to Cite this Article	To Browse
Amala J. Tharesa, Post Graduate Scholar, Dept. of Shalya Tantra, Govt. Ayurveda Medical College and Hospital, Bengaluru, Karnataka, India. Email:	Amala J. Tharesa, Srinivas Masalekar, Eranda Kshara an effective alternative for Apamarga Ksharasutra - A Case Study. J Ayu Int Med Sci. 2022;7(1):371-374. Available From https://jaims.in/jaims/article/view/1640

Introduction

The word Bhagandara is derived from two words Bhaga and Darana that is tear in ano rectal region. The formation of Pidaka in Guda pradesha leads to development of Bhagandara.^[3] It is characterized by opening around Guda Pradesha with painful discharge. According to modern science, the word fistula is derived from Latin word which means reed, pipe or flute. It is an abnormal connection between anal canal and rectum which has an external opening in perianal skin and internal opening in anal canal.^[4] It usually results from an anorectal abscess which burst spontaneously or opened inadequately.

Kshara Karma is considered as one of the most important Parasurgical procedure as it can produce excision, incision, scrapping and can pacify all three Doshas. In present days Ksharasutra therapy is the chief treatment modality adopted for Bhagandara in Ayurvedic science. Hence it demands the usage of a drug which is easily available for making Ksharasutra. Eranda is plant which is mentioned to be effective in its Kshariya form in diseases like Medo Roga, Ksudra Roga. Also, it possesses properties like Kapha-Vatahara (pacifies Vata and Kapha), Sirovirechana, Dipana - Pacana (carminative), Medohara (disintegrates fat). Hence in the present study an effort is made to access Eranda in its Kshara form and to evaluate its effectiveness as Ksharasutra in management of Bhagandara.

In this case, patient presented with complaints of profuse pus discharge, pain and swelling. After routine blood investigations and careful examination with probe the case was diagnosed as fistula in ano associated with external hemorrhoids which is confirmed by TRUS report and fistula was of inter-sphincteric type. In this case study, Fistula in ano was treated with Eranda Kshara Sutra. Fistula was cured and there were no complications during the treatment and there was no recurrence.

Case Report

Gender - Male

Age - 56 yrs.

Occupation - Engineer

Date of first visit - 27/07/2021

Date of recovery - 28/8/2021

Chief complaints and duration - Patient complaints of pain, swelling, pus discharge in the perianal region since 3 months.

H/O Present illness: 56 yrs old male patient presents with complaints of painful swelling, mass and itching in the perineal region on 26/07/2020 at our OPD. On examination patient had external opening at 5 ‘o’ clock position with tenderness. Provisional diagnosis was made as fistula in ano, which was confirmed by trans rectal ultrasonography on 31/07/2021. Features were suggestive of inter-sphincteric fistula in ano.

H/o past illness

h/o surgery for inguinal hernia - reports not available

General Examination

GC - moderate
CVS - S1 S2 Heard
Pulse - 82/min, BP-120/70mmhg
RS - B/L Air entry is clear
Digestive system - Appetite - Normal, Bowel - regular, hard
Uro genital system - NAD

Local Examination

Patient made to lie in lithotomy position and findings were noted.

Inspection: swelling 1 × 1 cm, watery discharge, no redness, no scar marks.

Palpation: temperature slightly raised, tenderness present.

Per rectal examination: dimpling was noted at 5 ‘o’ clock position.

Probing: approximately 3 cm track which had external and internal opening at 5 ‘o’ clock position.

TRUS: there is evidence of inter- sphincteric fistula in ano. The external opening at 5 ‘o’ clock position. The course of sinus is straight. The fistulae measure 2.9 × 0.5 cm (length× diameter approximately). The internal opening in the mucosal plane is at 2.2 cm from the external anal orifice. No secondary tracts. No evidence of curved tract.

Preparation of Kshara Sutra

Snuhi Ksheera = 11 coatings

Snuhi Ksheera + Eranda Kshara = 7 coatings

Snuhi Ksheera + Haridra Churna = 3 coatings

The surgical linen thread was autoclaved and mounted on the hangers. The thread was smeared with Snuhi Ksheera using a guaze piece dipped in Snuhi Ksheera. Then this wet threaded hanger was placed inside Ksharasutra cabinet after that it was dried for a day. Next day, dried thread was again smeared with latex of Snuhi. The process was repeated for 11 days. On 12^th day again thread was smeared with Snuhi Ksheera then in the wet condition the thread was spread with Eranda Kshara. The thread was dried and the same procedure repeated for 7 times for 7 days. On 19^th day the dry thread was smeared with latex of Snuhi, and then in wet state immediately with Haridra Churna. The procedure was repeated for 3 days continuously. In this way the thread has total 11 coatings of Snuhi Ksheera, 7 coatings of Snuhi Ksheera + Eranda Kshara and 3 coatings Snuhi Ksheera + Haridra Choorna. The prepared Sutras were then stored in Ksharasutra cabinet.

Pre-operative

Patient is advised to do routine investigations like CBC, ESR, CT BT, RBS, HIV, HbSAg, urine routine and all reports were found to be within normal limit. Then patient consent was taken and posted for the Khsara Sutra application.

Kshara Sutra prepared with Eranda as per standard protocol was kept ready. Part preparation was done. Injection T.T. 0.5 ml and plain 2% xylocaine test dose were given.

Operative Procedure

Patient was made to lie in lithotomy position. Under all aseptic precautions, painting and draping of part done. Per rectal examination was done. A suitable malleable probe lubricated with lignocaine jelly was forwarded along the path of least resistance and guided by the finger in the anal canal to reach into its lumen. Then the tip was directed to come out of the anal orifice through the internal opening in the anal canal. A suitable length of linen thread was taken which was sterilized and threaded in the eye of the probe. Thereafter the probe was pulled out through the anal orifice, to leave the thread behind in the fistulous tract. The two ends of plain thread were then tied together with a moderate tightness outside the anal canal. This procedure

is called primary threading. On the 3^rd day primary thread was replaced by Eranda Ksharasutra by adopting rail – road method.

Post-operative

Sitz bath with warm Panchavalkala Kwatha twice daily was advised.

Triphal Choorna 5-10 gms with warm water at bed time was prescribed.

Follow up: Ksharasutra change was done at weekly interval. The same procedure was followed for successive changes.

Observation

The initial length of track was 3cm, which got cut in 3 weeks and got healed in 1 week. Pain reduced after every successive sitting and there was no burning sensation which was common with Apamarga Ksharasutra. After complete cutting of tract patient came for follow up for 3 months. No signs and symptoms of recurrence were observed.

Before treatment

On Ksharasutra application

Track Has Been Cut

Healed track

After treatment

Conclusion

Ksharasutra has now become the foremost treatment choice for ano rectal disorders especially Fistula in ano. The main advantage of Ksharasutra is, it can save the sphincters without leading to incontinence. Kshara Sutra therapy is the minimal invasive Parasurgical procedure which can be performed with minimal equipment’s and instruments. Complications and recurrence followed by Kshara Sutra therapy is very minimal. Along with cutting of the tract Ksharasutra

also heals the wound by promoting the drainage of tract and formation of healthy granulation tissue. In the present study Eranda Kshara Sutra have found be as effective as Apamarga Ksharasutra in cutting rate, healing and pain management. So Eranda Kshara Sutra can be used as better alternative for Apamarga Kshara Sutra in Ano rectal disorders especially in Fistula in ano.

Reference

Acharya Sushrutha: sushrutha samhitha with Nibandhasangraha commentary of Sri Dalhanacharya, Edited by Vaidya Yadavji Trikamji Acharya, Chaukhamba Surbharati Prakashanam, Varanasi, reprint 2008, Sutra Sthana, Chap.33, Verse 4, Pp 824, Pg-144
Acharya sushrutha: sushrutha samhitha with Nibandhasangraha commentary of Sri Dalhanacharya, Edited by Vaidya Yadavji Trikamji Acharya, Chaukhamba Surbharati Prakashanam, Varanasi, reprint 2008, Chikitsa Sthana, Chap.8, Verse 12, Pp 824, Pg-439
Susrutha Samhita – English transalation of text and Dalhana’ s commentary along with critical notes by P.V.Sharma. Chaukambha Vishwabharati.2005 vol 2 Nidanasthana 4/3,5
Shenoy K Rajgopal, Shenoy Anita, Manipal Manual of Surgery, 4^th edition 2014, New Delhi, CBS publishers, p-799

Manuscript Received	Review Round 1	Review Round 2	Review Round 3	Accepted
2022-01-22	2022-01-24	2022-01-31	2022-02-07	2022-02-14
Conflict of Interest	Funding	Ethical Approval	Plagiarism X-checker	Note
Nil	Nil	Yes	18%

Case Report

Eranda Ksharasutra

Journal of Ayurveda and Integrated Medical Sciences