E-ISSN:2456-3110

Review Article

Pathya and Apathya

Journal of Ayurveda and Integrated Medical Sciences

2024 Volume 9 Number 8 AUGUST
Publisherwww.maharshicharaka.in

Pathya and Apathya in Bhagandara: Holistic Approaches to Fistula-in-Ano

Sahoo SS1*, Kumar PH2, Pahadiya L3, Koriya H4, Dalasinghray T5
DOI:10.21760/jaims.9.8.32

1* Satya Santosh Sahoo, Post Graduate Scholar, Dept of Shalya Tantra, National Institute of Ayurved, Jaipur, Rajasthan, India.

2 P Hemantha Kumar, Professor and HOD, Dept of Shalya Tantra, National Institute of Ayurved, Jaipur, Rajasthan, India.

3 Lokendra Pahadiya, Assistant Professor, Dept of Shalya Tantra, National Institute of Ayurved, Jaipur, Rajasthan, India.

4 Hetal Koriya, PhD Scholar, Dept of Shalya Tantra, National Institute of Ayurved, Jaipur, Rajasthan, India.

5 Tapaswini Dalasinghray, Post Graduate Scholar, Dept of Shalya Tantra, National Institute of Ayurved, Jaipur, Rajasthan, India.

Bhagandara, commonly known as fistula in ano, is a prevalent anorectal condition extensively described in classical Ayurvedic texts. Classified under Ashtamahagada by Acharya Sushruta, it initially appears as a pidika near the anus and transforms into Bhagandara upon rupture. The clinical features of this condition align closely with modern interpretations of fistula in ano, and its recurrent nature presents significant treatment challenges. While contemporary surgical methods offer various options, the management of this ailment remains complex for proctologists. Among Ayurvedic treatments, Ksharasutra has emerged as a particularly effective parasurgical intervention. In addition to surgical approaches, adherence to Pathya (beneficial) and Apathya (harmful) dietary rules plays a crucial role in the management and prevention of recurrence, enhancing overall treatment outcomes. This article explores the holistic understanding of Bhagandara, its clinical manifestations and the importance of diet in achieving optimal health.

Keywords: Bhagandara, Fistula in ano, Ksharsutra, Pathya Apathya

Corresponding Author How to Cite this Article To Browse
Satya Santosh Sahoo, Post Graduate Scholar, Dept of Shalya Tantra, National Institute of Ayurved, Jaipur, Rajasthan, India.
Email: 		Sahoo SS, Kumar PH, Pahadiya L, Koriya H, Dalasinghray T, Pathya and Apathya in Bhagandara: Holistic Approaches to Fistula-in-Ano. J Ayu Int Med Sci. 2024;9(8):205-210.
Available From
https://jaims.in/jaims/article/view/2631

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2024-07-13 2024-07-23 2024-08-03 2024-08-13 2024-08-27
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None Nil Yes 12.21

© 2024by Sahoo SS, Kumar PH, Pahadiya L, Koriya H, Dalasinghray Tand 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].

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Introduction

In Ayurveda, Bhagandara, or Fistula-in-ano, is classified among the eight principal diseases (Ashta Mahaaroga).[1] This condition arises when the regions of Bhaga, Guda, and Basti become torn or damaged. It can progress through two stages: the apakva-avasthaa, referred to as Pidakaa, and eventually leads to the Pakvaavasthaa, resulting in Bhagandara.[2]

Anal fistulas are characterized by a chronic abnormal passage that typically contains granulation tissue, creating a connection from the anorectal lumen (the internal opening) to an external site on the skin of the perineum or buttocks, and, in rare cases for women, to the vagina.[3]

Patients with fistula-in-ano typically experience recurrent purulent discharge, often mixed with blood, leading to discomfort that is temporarily alleviated upon pus discharge. A history of anorectal sepsis is common, and the passage of gas or feces through the external opening suggests an internal opening in the rectum. Ancient Ayurvedic texts and Hippocrates recognized the need for surgical intervention in such cases, highlighting the therapeutic challenges. Kshara Sutra therapy, emphasized in Shalya Tantra, has emerged as a preferred treatment method due to its effectiveness in reducing recurrence and incontinence risks.

Surgical intervention for fistula-in-ano necessitates hospitalization and ongoing post-operative care, and it carries notable risks, including a recurrence rate ranging from 0.7% to 26.5%, as well as a significant potential for impaired continence, which can affect between 5% to 40% of patients.[4]

Modern Review

Most anorectal fistulas are primarily caused by cryptoglandular infections due to enteric bacteria. These infections often originate from the anal glands, leading to the accumulation of pus in the intersphincteric space. This pus can spread in multiple directions - upward, downward, or laterally - resulting in abscess formation, most commonly in the perianal region or ischiorectal fossa.[5] The management of these abscesses typically involves drainage, either through surgical intervention or, in some cases, spontaneous rupture.

Once the anorectal sepsis has drained, a communication may develop between the perianal region and the anal canal at the dentate line. If this communication remains, it can lead to the formation of an anorectal fistula, characterized by an abnormal connection between the anal canal and the skin.[6]

Clinical Presentation[7]

Anorectal fistulas present with a variety of symptoms that can significantly impact the patient's quality of life:

  • Purulent Discharge: A hallmark symptom is the presence of purulent discharge around the anus and from within the anal canal. This discharge can be continuous or intermittent, depending on the severity of the fistula.
  • Hygiene Issues: The discharge can lead to difficulties with anal hygiene, resulting in skin irritation and soiling. This can cause embarrassment and social withdrawal for affected individuals.
  • Recurrent Infections: Patients often have a history of recurrent episodes of anorectal sepsis. These episodes may require surgical drainage or may rupture spontaneously, leading to acute pain and swelling.
  • Associated Conditions: The clinical history may include various underlying conditions such as sexually transmitted diseases (STDs), inflammatory bowel disease (IBD), or malignancy. Each of these conditions can complicate the clinical picture and management of anorectal fistulas.
  • Physical Examination: On physical examination, there is often an external opening located around the anal canal. However, particularly in patients with intersphincteric fistulae, the external opening may not be visible, making diagnosis challenging. A thorough examination, including digital rectal examination, is essential for accurate assessment.
  • Pain and Discomfort: Patients frequently report pain or discomfort in the anal region, especially during bowel movements or when sitting. This pain can be sharp or throbbing and may exacerbate with prolonged sitting.

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  • Impact on Daily Activities: The condition can significantly hinder daily activities, affecting work and social interactions due to both physical discomfort and psychological burden of managing symptoms.
  • Diagnostic Imaging: In some cases, imaging studies such as ultrasound, MRI, or contrast fistulography may be necessary to assess extent of fistula and its relation to anal sphincter complex. These studies can help guide surgical planning.
  • Management Options: Management typically involves surgical intervention to promote healing and prevent recurrence. Options may include fistulotomy, seton placement, or advancement flap procedures, depending on complexity of fistula and patient's overall health

Pathology of Anorectal Fistulas

Ayurvedic Perspective

In Ayurveda, anorectal fistulas, or Bhagandara, are classified as a chronic condition resulting from derangement of doshas (body energies). The key elements of its pathology include:

  • Dosha Imbalance: Bhagandara is often attributed to an imbalance of Vata and Pitta doshas. Vata, associated with movement and dryness, contributes to tearing and disruption of tissues, while Pitta, associated with heat and metabolism, can lead to inflammation and infection.
  • Dhatu Dysfunction: The pathology involves a disruption in dhatus (tissues), particularly Rakta (blood) and Mamsa (muscle), which can result in necrosis and granulation tissue formation.
  • Aama Formation: The presence of Aama (toxic, undigested material) can further aggravate condition, leading to systemic imbalances and chronic infection. The accumulation of aama is often a result of poor digestion and diet, contributing to formation of fistulous tracts.
  • Stage of Disease: Bhagandara is typically viewed in two stages: Apakva (immature) and Pakva (mature). In Apakva stage, focus is on managing symptoms and reducing inflammation, while in Pakva stage, focus shifts to addressing established fistula and preventing recurrence.

Modern Perspective

From a modern medical standpoint, the pathology of anorectal fistulas is characterized by:[8]

  • Cryptoglandular Infection: The most common cause of anorectal fistulas is a cryptoglandular infection, where bacteria invade the anal glands, leading to abscess formation. The infection is primarily caused by enteric bacteria, such as Escherichia coli.
  • Abscess Formation: The initial phase involves the formation of an abscess in the intersphincteric space, which may expand and rupture, creating an abnormal channel (fistula) between the anal canal and the perianal skin.
  • Tissue Inflammation and Granulation: The inflammatory response leads to the production of granulation tissue. As the abscess resolves, the persistence of communication between the anal canal and external skin results in the formation of a fistulous tract lined with this granulation tissue.
  • Chronicity: Once established, the fistula may become chronic, characterized by intermittent drainage of pus, discomfort, and potential complications, such as recurrent infections or complications with sphincter function.
  • Risk Factors: Several factors may contribute to the development of anorectal fistulas, including a history of inflammatory bowel disease (such as Crohn's disease), previous anal surgery, trauma, or radiation therapy. Certain lifestyles and dietary factors can also predispose individuals to anal abscesses and subsequent fistula formation.
  • Diagnostic Techniques: Modern medicine employs various diagnostic tools, including physical examination, imaging studies (such as ultrasound and MRI), and sometimes endoscopic techniques, to accurately diagnose the extent and type of fistula present.

Management of Specific Types of Bhagandara[9,10]


  • Śataponaka Bhagandara: This variant is characterized by multiple openings on the external skin. Ayurvedic texts suggest that one tract should be excised at a time, allowing for healing before addressing the next.

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Attempting to excise all tracts in a single incision can lead to injury of the rectal walls and sphincters, resulting in impaired sphincter function and potential leakage of flatus, feces, or urine. Both Suśruta and Vāgbhata outline different incision techniques based on the location of the tracts and their relationship to the anal sphincters.

  • Ūṣtragrīva Bhagandara: For this type, no specific incision technique is prescribed. The treatment involves simple excision of the tract, followed by the application of Kṣāra to eliminate necrotic tissue. Suśruta advises against cauterization with Agni (fire) as it can exacerbate Pitta Dosha.
  • Parisrāvī Bhagandara: In this type, the track is first located with a probe, then excised, and the wound is cauterized using Kṣāra or Agni.

    After cauterization, the wound should be washed with warm water, and a Vasti of warm Anutaila (oil) is administered. Suśruta provides various incision methods based on the nature of the track and the patient’s condition.
  • Śambūkāvarta Bhagandara: This type is considered Asādhya (incurable) due to the involvement of all three doshas. Therefore, only conservative measures are recommended for treatment.
  • Unmārgī Bhagandara: Also classified as Asādhya, this type arises from injury caused by a foreign body.

    The treatment principle involves excision of the track and removal of the foreign body, followed by cauterization with Agni. Afterwards, Kṛimihara (anti-parasitic) drugs are applied locally and taken internally.
  • Parikṣepī Bhagandara: Vāgbhata suggests that this type should be treated similarly to Nādivraṇa, utilizing Kṣārasūtra (medicated thread) for management.
  • Ṛiju Bhagandara: There are no specific treatment protocols outlined for Riju Bhagandara. It can be managed like other simpler forms of
  • Arśo Bhagandara: This condition occurs when Arśas (hemorrhoids) coexist with Treatment for Arśas should be prioritized before addressing the fistula.

Pathya (Wholesome Guidelines) for Bhagandara

To effectively manage Bhagandara, incorporating specific foods and practices into your diet can aid in healing and restoring balance.

Here’s a comprehensive list of Pathya recommendations based on traditional Ayurvedic principles:

Dietary Recommendations[11,12]

Takra (Buttermilk): Known for its cooling properties, buttermilk aids digestion and helps balance Pitta dosha.

Rices:

  • Rakta Shali, Maha Shali, and Shashtika Shali: These varieties of rice are nutritious and easy to digest, providing essential nutrients without aggravating the condition.

Vegetables:

  • Mulaka (Radish): Aids digestion and detoxification, promoting a healthy gut environment.

Legumes:

  • Kulattha (Horse Gram): Known for its detoxifying properties and ability to promote digestion.

Fruits:

  • Bilwa (Aegle marmelos): Supports digestive health and has anti-inflammatory properties.

Herbs:

  • Kutaja (Holarrhena antidysentrica): Used for its beneficial effects on digestive health and for addressing dysentery.
  • Shunthi (Ginger): Aids digestion, reduces inflammation, and has warming properties.
  • Pippali (Long Pepper): Enhances digestion and respiratory function.

Other Foods:

  • Dadima (Pomegranate): Rich in antioxidants and supports digestive health.
  • Mamsa Rasa (Meat Soup): Provides nourishment and supports healing, particularly when well-prepared.
  • Ushna Jala (Hot Water): Drinking warm water aids digestion and helps maintain proper hydration.

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Beverages:

  • Arishta, Tushodaka, Seedhu, Madira: These fermented drinks can aid digestion and support gut health when consumed in moderation.
  • Yavagu (Gruel) and Yusha (Broth): Light and nourishing, these preparations can support digestion without overloading the system.

Dairy:

  • Dugdha Pana (Milk Consumption): Milk can be beneficial, especially when warm, as it nourishes the body and promotes healing.

Lifestyle Practices

  • Avgahana (Tub Bath): Taking a tub bath can help relax the muscles and improve circulation in the pelvic area, aiding recovery.

Apathya (Unwholesome Guidelines) for Bhagandara

For individuals suffering from Bhagandara, it is crucial to avoid certain foods and lifestyle practices that can exacerbate the condition. Here’s a detailed list of unwholesome practices to be mindful of:

Dietary Avoidances

Foods with Unwholesome Rasa:

  • Kashaya Rasa (Astringent): Excessive intake can aggravate Vata and contribute to dryness.
  • Katu Rasa (Pungent): These can increase heat in the body and worsen inflammation.
  • Lavana Rasa (Salty): High salt intake can lead to water retention and aggravate Pitta dosha.
  • Ruksha (Dry) and Guru (Heavy) Guna: Foods that are dry or heavy can hinder digestion and worsen symptoms.

Temperature Extremes:

  • Ati Sheeta (Excessively Cold) and Ati Ushna (Excessively Hot) Ahara: Foods that are either too cold or too hot can disturb the digestive process.
  • Vidahi Anna (Corrosive Foods): These foods can cause irritation and inflammation in the digestive tract.

Unwholesome Food Combinations:

  • Abhishyanda Ahara: Foods that are overly moist can increase Kapha and lead to digestive disturbances.
  • Viruddha Ahara: Contradictory food combinations that can disturb digestion.
  • Ajeerna Bhojana: Consuming food that is difficult to digest can worsen symptoms and lead to complications.
  • Excessive Meat and Fats:

Mamsa (Meat), Vasa (Fat), and Sneha (Oily Foods): Overconsumption can lead to heaviness and digestive issues.

Lifestyle Avoidances

Physical Strain:

  • Riding of Horses and Camels: These activities can cause undue pressure and strain on the pelvic region.
  • Strenuous Exercise: High-impact activities can exacerbate symptoms and lead to discomfort.

Sexual Activity:

  • Excessive Intercourse: Engaging in vigorous sexual activity can put strain on the anal region and worsen the condition.

Sleep Practices:

  • Diwaswapna (Day Sleep): Sleeping during the day can disturb the body’s natural rhythms and lead to increased lethargy, affecting recovery.

Exposure to Excessive Vata and Heat:

  • Excessive Vata Seva: Activities that increase Vata (e.g., windy or dry environments) can aggravate symptoms.
  • Atapa Sevan (Exposure to Excessive Heat): Overexposure to heat can lead to increased Pitta and worsen inflammation

Conclusion

This review highlights the multifaceted nature of, emphasizing its classification, clinical presentation, and the significance of tailored treatment approaches. Vaidya Lolimba Raja and Acharya Charaka underscore the profound significance of Pathya Aahara (wholesome diet) and Vihara (lifestyle practices) in maintaining health and preventing disease. Vaidya Lolimba Raja emphasizes that adherence to a Pathya Aahara can negate the need for medicinal intervention, while persistent consumption of Apathya Aahara inevitably leads to disease manifestation.


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Acharya Charaka reinforces this notion, stating that a wholesome regimen is fundamental to life, whereas neglecting it is akin to inviting death. The evidence indicates that inappropriate and irregular dietary and lifestyle practices significantly contribute to the development of Gudagata Rogas, including Bhagandara. In our modern context, many individuals lack awareness regarding the importance of good dietary habits and lifestyle choices, leading to a rise in these disorders.

To foster health and prevent illness, it is crucial to embrace the recommended Aahara and Vihara regimens tailored to one’s individual constitution (prakriti). Following principles such as Ashta Aahara Vidhi Visheshaytana, practicing Dinacharya (daily routines), Ritucharya (seasonal routines), and maintaining a balanced sleep cycle are essential components of a healthy lifestyle. By prioritizing these holistic approaches, individuals can enhance their well-being and mitigate the risk of developing conditions like Bhagandara, promoting a healthier future for themselves and their communities.

References

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2. Sushruta Samhitaa; Dalhana, Nibandasangraha commentary; Edited by Jadavji Trikamji Aachaarya and Naarayan Ram Aachaarya; Chowkhambha Surabhaarati Prakaashana, Vaaraanasi, 1st edition; Reprint 2008; Nidaanastana 4/3,pp. 280.
3. Bailey & Love's Short Practice of Surgery, Twenty Fifth edition 2008, Chapter 69, page no. 1262.
4. Garcia-Aguilar J, Belmonte C, Wong WD, Goldberg SM, Madoff RD. Anal Fistula Surgery: factors associated with recurrence and incontinence. Dis Colon Rectum, 1996; 39: 723-9
5. A manual on clinical surgery by S. Das, 6th edition, chapter 36, page no. 401.
6. Master of Surgery, 5th edition, volume 1, chapter 148, page no. 1613.
7. Master of Surgery, 5th edition, volume 1, chapter 148, page no. 1613.
8. Bailey & Love's Short Practice of Surgery, Twenty Fifth edition 2008, Chapter 69, page no. 1263.

9. Suśruta Saṃhitā, edited with Āyurvedtatvasandīpikā by Dr.Ambikāduttasāstrī, Chaukhambha Sanskrit Sansthan, 2010 Edition Varanasi Vol-1 Nidānsthāna- 4, verse no-10,page no- 316
10. Aṣṭāng Hṛdya, edited with Vidhyotini Tika by Atrideva Gupta, Chaukhambha Prakasan 2008 Edition, Varanasi Uttar Tantra-28, Verse no-18-20, page no-752
11. Acharya Sushruta, Sushruta Samhita, Sutra Sthana – 46, Ayurveda-Tattva-Sandipika Hindi Commentary, Edited by Kaviraja Ambikadutta Shastri, by Publishers Chaukhamba Publications, New Delhi, 2014; 240
12. Acharya Charaka, Charak Samhita, Sutra Sthan- 25, Vidyotini Hindi Commentary edited by; Pt. Kasinatha Sastri and Dr. Gorakha Natha Chaturvedi, published by Chaukhamba Bharati Academy, Varanasi, 2013; 463


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