Case Report


Journal of Ayurveda and Integrated Medical Sciences

2022 Volume 7 Number 1 Jan-Feb

Efficacy of Ksharasutra in the management of Charmakeela: A Case Report

S Ashraf A.1*, Kumar ES M.2, N Rao P.3

1* Anisha S Ashraf, Post Graduate Scholar, Department of Shalya Tantra, Sri Dharmasthala Manjunatheshwara College of Ayurveda & Hospital, Hassan, Karnataka, India.

2 Mahesh Kumar ES, Associate Professor and HOD, Department of Shalya Tantra, Sri Dharmasthala Manjunatheshwara College of Ayurveda & Hospital, Hassan, Karnataka, India.

3 Prasanna N Rao, Principal and Professor, Department of Shalya Tantra, Sri Dharmasthala Manjunatheshwara College of Ayurveda & Hospital, Hassan, Karnataka, India.

Sentinel pile/Charmakeela is a skin tag in the lower margin of the anal fissure which is oedematous and commonly associated with chronic Fissure-in-ano. It causes discomfort, itching, low grade infection, perianal hematoma and abscess formation. A case report of 34 years old lady who presented with complaints like anal discomfort, swelling, mild pain and itching in the anal region which has been treated with Ksharasutra application without any surgical intervention has been discussed here.

Keywords: Sentinel pile, Fissure-in-ano, Charmakeela, Ksharasutra

Corresponding Author How to Cite this Article To Browse
Anisha S Ashraf, Post Graduate Scholar, Department of Shalya Tantra, Sri Dharmasthala Manjunatheshwara College of Ayurveda & Hospital, Hassan, Karnataka, India.
Anisha S Ashraf, Mahesh Kumar ES, Prasanna N Rao, Efficacy of Ksharasutra in the management of Charmakeela: A Case Report. J Ayu Int Med Sci. 2022;7(1):385-389.
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Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2022-01-17 2022-01-19 2022-01-26 2022-02-02 2022-02-09
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
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© 2022by Anisha S Ashraf, Mahesh Kumar ES, Prasanna N Raoand Published by Maharshi Charaka Ayurveda Organization. This is an Open Access article licensed under a Creative Commons Attribution 4.0 International License https://creativecommons.org/licenses/by/4.0/ unported [CC BY 4.0].


Fissure-in-ano (Parikartika) is an ulcer in the longitudinal axis of the lower anal canal, which commonly occurs in the midline, posteriorly but can also occur in the midline anteriorly. Anterior anal fissure is common in middle aged females due to lack of support to pelvic floor. Ulcer is superficial and small but the lesion is distressing.[1] Fissure-in-ano is of two types namely acute fissure and chronic fissure. Sentinel pile (Charmakeela) is a skin tag in the lower margin of the  anal fissure  which is  oedematous and commonly associated with chronic fissure. It causes discomfort, itching, low grade infection, and perianal hematoma and abscess formation. The common etiological factors are constipation, diarrhoea, trauma, sexually transmitted diseases, etc.

In most of the patients, history and physical examination will allow the diagnosis of an anal fissure without further investigations. An acute anal fissure appears as a fresh laceration, while a chronic anal fissure has raised edges exposing the internal anal sphincter muscle fibres underneath. Chronic anal fissures are also often accompanied by an external skin tag (sentinel pile) at the distal end of the fissure and a hypertrophied anal papilla at the proximal end (difficult to see on physical examination).

In classics, Parikartika resembles with fissure-in-ano having cutting and burning pain at Guda. The factors responsible for Parikartika are found as Basti and Virechana Vyapada (complication of the Basti and Virechena procedures).[2] Chronic fissure-in-ano is having the prevalence rate approximately 30–40% of total ano-rectal sufferings whereas the incidence is supposed to be very common in constipated people particularly one who pass hard and dry stool.[3] The modern surgical treatments such as Lord's anal dilatation, fissurectomy, and sphincterotomy have their own limitations like recurrence, incontinence, etc.

Ksharasutra therapy is becoming popular in the day-to-day practice because of its unique advantages in curing the diseases. It is a known fact that satisfactory and curable result is being achieved in ano-rectal disorders like piles, fistula, fissure, sentinel tag etc., by the application of Ksharasutra and other products of Kshara due to its Ksharana and Kshanana[4]

property. Thus, considering all factors this case study was done to evaluate the efficacy of Ksharasutra in the management of Charmakeela.

Case Report

A 34 years old female patient approached Shalya Tantra ARC OPD with OPD number 198805. She presented with the complaints of anal discomfort, swelling, mild pain and itching in the anal region since 5 months.

History of Present Illness

Patient was apparently healthy 5 months back. Then, she had developed with constipation and there was an acute onset of pain and bleeding per rectum during defecation as streaks. The pain was present after defecation and lasted for few minutes to hours. Gradually she felt some discomfort over anal region which was associated with swelling over the anal verge. After 2 months, she had severe itching over the anal verge. So, she consulted to the Shalya Tantra ARC OPD of SDM College of Ayurveda & Hospital, Hassan for Ayurvedic management. Based on the symptoms and per rectal examination, she was diagnosed with Charmakeela (sentinel pile) as a result of chronic fissure in ano.

History of Past Illness

There were no past history of any type of allergy, diabetes mellitus, hypertension, tuberculosis or any other major systemic disorder.

Treatment History: NIL

Personal History

  • Diet : Non-vegetarian
  • Appetite : Good
  • Bowel : Constipated
  • Micturition : Regular
  • Sleep : Sound

Menstrual History

Age of Menarche - 13 years

Cycle length & Frequency - 5/28

Interval - Regular

General Examination

  • General Condition : Fair
  • Nutritional status : Well nourished

  • Pallor : Absent
  • Icterus : Absent
  • Cyanosis : Absent
  • Clubbing : Absent
  • Lymphadenopathy : Absent
  • Oedema : Absent


  • BP : 110/70 mm of Hg
  • Temperature : Afebrile, 98.4°F
  • Pulse : 76bpm, Regular
  • Respiratory rate : 18/min

Systemic Examination

Central Nervous System : Intact, Conscious, well oriented to time, place and person.

Cardiovascular System: S1 S2 M0

Respiratory System: Equal air entry to B/L lung fields, NBVS +

Per Abdomen: Soft, no organomegaly, Tenderness present in Right iliac & hypogastric region

Per Rectal Examination:

  • Inspection : Healed fissure with Sentinel tag at 12 ‘o’ clock
  • Digital Rectal Examination : Normal tonicity
  • Proctoscopy : Anal mucosal congestion


Routine hemogram test, Random blood sugar HIV, VDRL, Hepatitis-B surface antigen, were carried out before the treatment for fitness of the patient.  Reports were normal.


Charmakeela/Sentinel pile at 12 ‘o’ clock position

Treatment Methodology


Ksharasutra ligation

Purva Karma

  • Patient was laid down in lithotomy position.
  • Painting with Betadine solution followed by draping was done.
  • All the necessary instruments, Ksharasutra, etc. made ready.

Pradhana Karma

  • Apamarga Ksharasutra was applied at the base of the sentinel pile with the help of artery forceps.

Paschat Karma

  • Yashtimadhu Taila Pichu
  • Patient was instructed to do Sitz bath using Triphala Kashaya twice daily.

Follow up

  • Every consecutive week until the Ksharasutra gets cut through.
  • Signs & symptoms and size of sentinel pile was assessed every week till the Ksharasutra gets cut through.

Oral medications

  • Nimbadi Guggulu (2-0-2) A/F
  • Sukumara Ghritha 10ml BD - 6am, 6pm
  • Tab. Anuloma DS (2HS) B/F

jaims_1675_01.JPGFigure 1: Sentile Pile at 12 O’ Clock Position

jaims_1675_02.JPGFigure 2: Kshara Sutra Ligation at the base of sentinel tag


Figure 3: First Follow Up


Figure 4: Second Sitting of Kshara Sutra Ligation


Figure 5 : Second Follow Up

jaims_1675_06.JPGFigure 6 : Third Sitting of Kshara Sutra Application

jaims_1675_07.JPGFigure 7: Sentile Pile got cut through


  • The Charmakeela got cut through on 3rd week with negligible wound.
  • Patient was free from pain.
  • Patient got symptomatic relief from the symptoms and quality of life improved.


In the present study, weekly assessment was done to find out the efficacy of Ksharasutra by relief in postoperative pain, oozing and days required for complete wound healing.[5]

Probable mode of action of Ksharasutra: Ksharasutra is prepared using Apamarga Kshara (Achyranthus aspera L.), Snuhi Ksheera (latex of Euphorbia nerifolia L.), and Haridra Churna (powder of Curcuma longa L.) and

prepared with a standard method described in Ayurvedic Pharmacopia of India.[5] The properties of Apamarga Kshara are  Chedana (excision), Bhedana (incision), Ksharana (debridation), Stambhana (haemostatic), Shodhana (purification) and Ropana (healing). Chedana and Bhedana properties of Kshara helped in the excision of the sentinel pile.[6] and makes the wound healthy by Shodhana property.[3] The Snuhi Ksheera is slightly acidic in nature but also has antibacterial property[7] which helped to check secondary infection. The Haridra has anti-inflammatory as well as anti-bacterial properties and hence, it is capable to make the wound clean, healthy, and promote early healing.[3]

Table 1: Criteria of Assessment 

Grade Description
Criteria for pain
0 Patients free from pain
1 Pain at the time of defecation and bearable which does not require any analgesic drug
2 Pain at the time of defecation and continuous which relieves after giving oral analgesic drug
3 Unbearable and continuous pain which relieves after giving injectable analgesic
Criteria for oozing
0 Observe dry gauze piece after 24 h of dressing
1 Observe spot of blood on gauze piece after 24 h of dressing
2 Observe partially wet gauze piece with blood after 24 h of dressing
3 Observe complete wet gauze piece with blood after 24 h of dressing
Criteria for wound healing
0 Complete healed wound with healthy scar
1 Partially healed wound with healthy granulation tissue
2 Cleaned wound without slough/discharge
3 Wound with discharge


Though surgical management is the choice of treatment but it carries significant morbidity, expensive and needs long time for the recovery with post operative complications. Ksharasutra application is a minimal invasive parasurgical procedure which is cost effective. Ksharasutra ligation of sentinel pile is a safe, ambulatory, OPD procedure that is a good alternative to surgical management. Hence, applicability of Ksharasutra plays an important role in the management of Charmakeela.


  1. Bhat MS, SRB’S Manual of surgery, 5th New Delhi : Jaypee Brothers medical publishers; 2016 pg. 976
  2. Sushruta, Sushruta Samhita, Chikitsa Sthana. Vamana-Virechan Vyapada Adhyaya, 34/37. In: Shastri A, editor. 12th Varanasi: Chowkhambha Surabharati Sanshtan; 2001. p. 147.
  3. Dudhamal, T. S., Baghel, M. S., Bhuyan, C., & Gupta, S. K. (2014). Comparative study of Ksharasutra suturing and Lord’s anal dilatation in the management of Parikartika (chronic fissure-in-ano). Ayu35(2), 141–147. https://doi.org/10.4103/0974-8520.146219
  4. E-Samhita - national institute of Indian medical heritage. (n.d.). Nic.In. Retrieved January 30, 2022, from https://niimh.nic.in/ebooks/esushruta/?mod=adhi
  5. 1st ed. Part-II. II. New Delhi: Dept. of AYUSH, Govt of India; 2001. Ksharasutra(Medicated thread). Ayurvedic Pharmacopia of India; pg. 209–13. 
  6. Sushruta, Sushruta Samhita, Sutra Sthana. Ksharapakavidhi Adhyaya, 11/3. In: Shastri A, editor. 12th ed. Varanasi: Chowkhambha Surabharati Sanshtan; 2001. p. 34.
  7. Rasik AM, Shukla A, Patnaik GK, Dhawan BN, Kulshrestha BK, Srivastava S. Wound healing activity of the latex of Euphorbia nerifolia Linn. Indian J Pharmacol. 1996;28:107–9.