Fistula In Ano an Ayurvedic Overview(Kshar Sutra) Ancient but More Effective then any other Modern Process
Fistula in ano is the most frustrating problem for anyone , it makes person suffer more then any other disease , person who has fistula in ano is unable to live his normal life, unable to do normal things and most of all it may change to Carcinoma cancer due to chronic inflammation and irritation to the tissue ,
there are many options for the treatment of fistula but most of them has high recurrence rate, so the use is limited only only the ancient ayurvedic Kshar Sutra has max 99% success rate in fistula in ano with nil recurrence rate as compared to other process and it’s very cost effective and other best thing about it no long and bad scars as compared to other processes.
IntroductionAbout Kshar Sutra
- This disease, high anal fistula, a common ano-rectal disorder which usually results as a sequel to some varieties of ano-rectal abscesses, is as old as mankind and a challenge to surgeons even today. Fistula-in-ano has been recognised as a distinct entity for thousands of years. In the fifth century B.C., Hippocrates advocated the laying open of fistulas, including complex fistulas. One would think that after 2,500 years the controversies in the management of fistula-in-ano would have been resolved. But this is not the case and much about the management of fistula-in-ano is still being debated. Available surgical procedures may not only result in incontinence but also recurrences. They cause discomfort and absence from work with the consequent economic strain.
- If the theory that both the abscess and the fistula-in-ano have a common cause is accepted, the two conditions can be considered simultaneously. Indeed, the term “fistulous abscess” has been used to describe this problem. The abscess is an acute manifestation, and the fistula is a chronic condition. A fistula is an abnormal communication between any two epithelial-lined surfaces. A fistula-in-ano is an abnormal communication between the anal canal and the perineal skin. Many of these fistulas are easily recognized and readily treated, but others can be very complex and correspondingly difficult to manage.
Fistula In Ano an AyurvedicTreatment Overview (Kshar Sutra)
- Keeping these problems in mind, Susturta (800 B.C) has described the kṣhrasūtra technique whereby a medicated alkaline thread, impregnated with the paste of Curcuma longa and latex of Euphorbia rerifolia, is employed along the fistula track which cuts itself and heals the wound naturally from inside (1). However, here are a few questions which need to be addressed to make this technique relevant in the present scenario:
- • Where and when should an abscess be drained? Can kṣārasūtra be appliedimmediately after drainage?
• Should a primary fistulotomy be performed before the kṣārasūtra application?
• What pre-operative evaluation is essential for preventing recurrences and other complications?
• Should a simple fistula be managed by fistulectomy or fistulotomy?
• Does kṣārasūtra also prove to be the best technique for the management of complex fistulae? :: yes it is.
Where and when should an abscess be drained? Can kṣarasutra be applied immediately after drainage?
- The crypto glandular nature of fistula-in-ano is now generally accepted. Eisenhammer coined the term ‘fistulous abscess’ to denote the continuum between the stage of acute abscess and chronic fistula-in-ano. An abscess can be classified as peri-anal, intra-muscular, ischio-rectal or supra-levetor. With the exception of supra-levetor and some intra-muscular abscesses, most can be managed in the clinic under local anesthesia. A cruciate incision is made as close to the anal canal as possible without damaging the external anal sphincter. The skin edges are trimmed to promote adequate drainage, and haemostasis is achieved using electrocautery. There is no need to aggressively break the loculations as they spontaneously rupture and drain into the cavity. Antibiotics may not be necessary until and unless there is a massive peri-anal abscess. Those in favour of primary fistulotomy argue that it eradicates the infection process, thereby eliminating or reducing the incidence of recurrent abscess or fistula formation. Those against primary fistulotomy point to the difficulty in identifying the fistula tract and primary opening in the setting in of acute inflammation. Overzealous probing may result in the formation of a false tract, which makes it difficult to manage supra or extrasphincteric fistula (2). In addition, proponents of delayed fistulotomy argue that acute ano-rectal suppuration will not inevitably lead to the formation of fistula-in -ano.
- kṣārasūtra application at this stage, without finding the exact internal opening, is a futile exercise. But recurrent drainage will probably have internal openings: in such conditions kṣārasūtra application may be useful and successful.
Should a primary fistulotomy be performed before kṣārasūtra application?
- Controversy exists as to whether an immediate fistulotomy be performed before kṣārasūtra application. Those in favour of primary fistulotomy argue that it eradicates the infectious process, thereby eliminating or reducing the incidence of recurrence. Moreover it drains all the infectious material very fast, thus minimising post-operative pain (3).
- Nearly 60 percent of those patients treated with partial fistulotomy with kṣārasūtra application were spared repeated fistulotomy (4). Disturbances in continence were found in some cases apart from heavy bleeding and a big wound. Higher antibiotics are essential in the post-operative period. Primary fistulotomy, except in rare instances, should be discouraged.
What pre-operative evaluation is essential for preventing recurrences and other complications?
- A careful history and physical examination are crucial in the evaluation of the patient with a chronic fistula-in-ano. A focused history regarding gastrointestinal symptoms, diarrhoea, previous ano-rectal surgery, and prior history of any ano-rectal abscess is taken. Careful examination for stigmata of peri-anal Crohn’s disease should be done, including lateral fissures, hypertrophied skin tags, and anal stenosis. Sigmoidoscopy is routinely performed at the time of fistulotomy, but in the absence of significant history or physical findings, it is not necessary to aggressively rule out Crohn’s disease (5).
- Tools currently available include fistulography, sonography, magnetic resonance imaging and manometers. All biophysical evaluations have their role in assessing the internal sphincter from the anal mucus and ultrasonography in the evaluation of the pathology in the ischio-rectal fossa and in the evaluation of supra-anal infra-levator extensions. However, these procedures have the disadvantage of being expensive and are not uniformly available (6).
- The goals of surgery for fistula-in-ano are the eradication of infection and prevention of recurrence while minimising disturbances of fecal continence. A retrospective study of 975 high anal fistula cases with kṣārasūtra application to study the associated factors revealed that the majority had true high anal fistulae, horse-shaped extension and some even did not have an internal opening. Previous fistula surgery was also a factor associated with recurrences.
Does kṣārasūtra also prove to be the best technique for the management of complex fistulae?
- Several techniques are available to treat a patient with a fistula. However, modern surgical procedures like fistulotomy or fistulector my not only result in recurrence but also cause a number of complications like stenosis, retention of urine, sphincteric incontinence. Discomfort, surgery induced weakness and economic strain are additional disadvantages. These surgical processes require patients to undergo painful operative and post-operative procedures and can also result in incontinence. Treatment should always be a balance between curing the inflammatory process and preservation of the sphincter function. (7)
- More complex fistulas like high anal fistula, horseshoe extension or fistulas in high-risk situations, especially in female patients with anterior fistulas, require investigation before treatment in order to decrease complications of incontinence or non-healing. We have not found fistulography to be helpful for these fistulas. However, ultrasound and MRI can certainly provide important information about anatomy and identify multiple tracts and occult small abscesses. These tests are particularly important in the recurrence of poorly draining fistula or in situations where the patient has symptoms of pain and intermittent drainage although no fistula tract can be identified (8).
- Keeping all these problems in mind, there is a new approach of kṣārasūtra which is employed after probing the track with a malleable probe and holding the thread in the sphincter bundle. Because of its kṣaṇana (burning) and kṣaraṇa (cutting) properties, the thread cuts the track from inside gradually and allows for simultaneous healing. In this, the cutting property may be attributed to the alkaline nature of the thread and the healing property may be attributed to the turmeric powder and the latex of Euphorbia nerifolia (9).
- This less extensive surgical procedure does not disturb the sphincter bundle, thus safeguarding the sphincter tone and preventing post-operative incontinence. The kṣārasūtra holds the major track and allows the other minor track to drain and heal spon-taneously given sufficient time and scope. This can destroy the cryptic material of the track and prevent recurrence. It does a chemical fistulectomy and averts incontinence. The efficacy of the treatment is measured with UCT (unit cutting time). The correlation between the length of the track and duration of treatment is statistically significant (10).
Conclusion on Kshar Sutra
- Anal disease, although a common cause of morbidity in the general population, is often poorly understood and managed by medical students, general practitioners and surgical trainees. Surgical residents frequently fail to grasp the finer details required by anal surgery, considering it not particularly exciting compared to other more prominent procedures. Acute ano-rectal abscess and fistula-in-ano are usually quite simple to manage. Most acute abscesses can be dealt with in a clinic under local anesthesia without major trouble to the patient. Those patients who develop a chronic fistula-in-ano can usually be managed by simple fist-ulotomy methods. An array of surgical techniques is available to the surgeon treating a patient with high anal-fistula, but, in conclusion, kṣārasūtra undoubtedly proves to be a superior and more successful procedure with a 98 percent success rate some says 99.96% success rate.
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1. Bhaskar Rao, M. An overview of ksharasutra and its application in high anal fistula. NAMAH 2001; 8:4: 28.
2. Seow-Choen, F., Nicholls, R.J. Anal fistula. British Journal of Surgery 1992; 79: 197-205.
3. Deshpandy, P.J., Sharma, K.R. Treatment of fistula-in-ano by a new technique, review and follow-up of 200 cases. American Journal of Proctology 1976: 39.
4. Schouten, W.R., van Vroonhoven, T.J.M.V. Treatment of ano rectal abscess with or without primary fistulotomy: results of a prospective randomized trial. Dis. Colon Rectum 1991: 34-60.
5. Gracia Aguilar, J., Belmonte, C., Wong, W.D., Goldberg, S.M., Madoff, R.D. Anal fistula surgery: factors associated with recurrence and incontinence. Dis. Colon Rectum 1996; 39: 723-9.
6. Kuijepers, HC, Schulpen, T. Fistulography for fistula-in-ano: is it useful? Dis. Colon Rectum 1985; 28: 103-6.
7. Pescatori, M., Maria, G., Anastasis, G., Rinallo, L. Anal manometry improves the outcome of surgery for fistula-in-ano. Dis. Colon Rectum 1989; 32: 588-95.
8. Krongorg, O. To lay open or excise a fistula-in-ano: a randomized trial. British Journal of Surgery 1985; 72: 970.
9. Bhaskar Rao, M. Post-operative wound healing with ksharasutra — a new approach in high anal fistula. Ancient Science of Life 1995: 123-8.
10. Bhaskar Rao, M., Prasad, S.V. Multi-centre study of ksharasutra in high anal fistula. A Journal of NTR. UHS; 199: 83-7.
मात्रा और मात्रा ‘क्षार-सूत्र’ आयुर्वेदिक शल्य चिकित्सा ही भगन्दर (Fistula) मेें 100 प्रतिशत परिणाम देने वाली है जो कि सुश्रुत (Father of Surgery) , आयुष विभाग ;स्वास्थ्य एवं परिवार कल्याण मंत्रालय, भारत सरकार दिल्लीद्ध द्वारा प्रमाणित हैं एवं अब रिसर्च के बाद आध्ुनितक पद्वति द्वारा भी प्रमाणित हो चुकी है।
क्षार सूत्रा क्या है व कैसे काम करता है, जानेः-
धगे पर क्षार (Alkaline-PH9.5) सहित तीन आयुर्वेदिक औषध् िकी 21 कोटिंग की जाती है पहली 11 कोटिंग स्नुही अर्क से ;काटने का कार्यद्ध दूसरी 7 कोटिंग अपामार्ग क्षार से ;इंपफेक्शन को खत्म करने काद्ध तथा तीसरी 3 कोटिंग हरिद्रा से जो कि जख्म भरने का कार्य करती है अत क्षार सूत्रा द्वारा किये गये भगंदर की चिकित्सा में तीनों ही कार्य एक साथ चलते रहते है इसलिए भगन्दर दुबारा नही होता जबकि अन्य पेथी में पहले काटते हैं तथा बाद में दवा खिलाकर इंपफेक्शन रोकने व जख्म भरने की कोशिश की जाती है जो कि कभी सपफल होती भी है और अध्कितर नहंीं भी।
इसलिए अन्य पेथियों में भगंदर 50 प्रतिशत दुबारा हो जाते हैं। भगन्दर (Fistula) के लक्षणः- गुदा के पास पफंुसी का बार बार उभरना उसमें से पानी, पस या खून आना, दर्द, दवा खाने से आराम तथा बाद में पिफर वैसे ही हो जाना आदि।
- 1- आॅपरेशन बेहोशी में होता है।
- 2- 5-7 दिन ;ठमक त्मेजद्ध या हास्पिटल में भर्ती रहना पडता है।
- 3-रोजाना पट्टी के लिए हास्पिटल जाना पड सकता है।
- 4- ;भ्पही ।तपजप.ठपवजपब द्ध खानी पडती है।
- 5- खून चढाना पड सकता है।
- 6- अगर भगन्दर बहुत गहारा ;भ्पही ।दंसद्ध है जो कि गुदा रिंग
(Sphinter) मल त्याग की क्रिया को नियंत्रित करने वालाद्ध के पार चला गया है तो आॅपरेशन के दौरान
ंिरंग कटने से मल रोकने की नियंत्राण शक्ति खत्म हो जाती है तथा मल अपने आप कपडों में निकल जाता है।
- 1- केवल सुन्न करके होता है।
- 2- कोई आवश्यकता नहीं।
- 3- कोई आवश्यकता नहीं।
- 4- कोई आवश्यकता नहीं।
- 5- कोई आश्यकता नहीं।
- 6- क्षार सूत्रा को भगन्दर में डाल दिया जाता है तथा वह हर हफ्रते बदला जाता है
भगन्दर (Fistula) and Kshar Sutra
जिससे हर हफ्रते (1cm average) की दर से रास्ता काटता जाता है तथा पीछे का कटा रास्ता भरता रहता है जिससे ंिरग के एक दम के कट जाने का खतरा नहीे होता और न ही मल नियंत्रात को क्रिया में कोई बाध आती।
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Fistula in Ano Question? and their Answers ::
What is an anal fistula?
- A fistula in ano is a tunnel like- pipe like track, developed in the perennial region, usually having one or more external openings around the anus leading to an internal opening in the mucosa of the anal canal or the rectum.
- Anal fistula is termed “Bhagandara” in Ayurveda. In Ayurveda fistulas, like other diseases have been classified according to the vitiation of one per more of the three doshas i.e. the vata, the Pitta & the kapha. They have been classified also according to the shape & site of the track of the fistula. Special treatment for such different kinds of fistulas is mention in detail. It is worth noting that the complex & most challenging horse shoe fistula ( complex Ischio-rectal fistula) has been dealt with in detail in Sushruta a classical Ayurveda text) even as early as 300 ad.
- The Ksharsutra treatment was probably first advised per this type of fistula named Parikshepi Bhagandara by Sushurta. This Ksharsootra treatment, with a little modification has proved its worth even in modern times.
- Anal fistula, a rare condition, is a chronically inflamed, abnormal tunnel between the anal canal and the outer skin of the anus. It often drains watery pus, which can irritate the outer tissues and cause itching and discomfort.
How does it occur?
- An anal fistula usually results from an infection that forms in the tissue lining the anal canal. The infection may be caused by spread of bacteria that normally exist in the rectum. Occasionally, it may occur as a result of :
A healed sore in the rectal area
Ulcerative colitis, a disease associated with ongoing breakdown of tissues that causes a sore in the lining of the colon
Diverticulitis, inflammation of harmless growths in the wall of the intestines
Crohn’s disease, a chronic inflammation of the intestines
Cancer of the large intestine.
What are the symptoms?
- Symptoms of anal fistula may include :
A patient of fistula in ano often suffers from a recurrent, small or large boil/boils/abscess surrounding the anus, accompanied with pain, discomfort & pus/blood discharge.
The symptoms subside when the boil / abscess burst spontaneously causing some more discharge for a couple of days.
The boil / abscess “heals up” temporarily but almost always reappears after some times.
- Itching, discharge of watery pus, irritation of tissue around the anus, discomfort & pain these are the main symptoms of the fistula in ano
How is it diagnosed?
- To diagnose an anal fistula, the doctor will review your symptoms, give you a physical exam, and may use the following procedures:
Anoscopy / Proctoscopy , a procedure in which the doctor inserts an instrument called an anoscope into the rectum to inspect the anus and lower part of the rectum
Probing examination: a procedure in which the surgeon insert an instrument called anal probe it to the external fistulous opening to internal fistulous opening.
Sigmoidoscopy , a procedure in which a doctor uses a flexible or rigid scope to inspect the lower part of the intestine for inflammation and/or disease
A biopsy to evaluate for inflammation or cancer
Lower gastrointestinal (gi) series, a procedure that uses a special fluid to show the intestines better on x-ray
A lower gi series requires a clean, clear gi tract. The doctor will prescribe a special diet, including plenty of water, for the day before the procedure. In addition, you may be given an enema the morning of the procedure.
Causes of anal fistula?
- In a few cases there is a previous history of ano-rectal abscess.
Some times a fissure in ano/ anal fissure gets infects & the infection travels down to form a track or a fistula.
- However in most cases there are no definite causes found.
- Possible contributing factors
Tearing of the lining of the anal canal.
Infection from an anal gland
Chron’s, ulcerative colitis, tuberculosis
- Guide lines to approach an expert for investigating a possibility of anal fistula.
- Recurrent boils developing at the same site. (around the anus)
Burning sensation or pain in perennial region
Pus discharge /blood discharge in perianal or from the anus.
Modes of treatments of anal fistula?
- Anal fistulas are almost never found to heal spontaneously. The inner wall of the fistula develops fibers tissue & payogenic membrane not allowing spontaneous healings.
The most commonly followed mode of treatment is laying open the entire track of the fistula and removing the fibrous tissue & payogenic membrane. This sometimes, in complex fistulas is done in two or more sittings. In certain cases a silk setone is passed through parts of the track. (see detail )
The Ksharsutra / Ksharsootra ( Medicated Setone ) Ligation.
Laser Surgery ( Fistulectomy / fistulectomy by laser beam )
Laying open the fistula and applying a skin graft.
Laying open, excision of the fistulous track and suturing the wounds.
Coring out the fistulous track. ( link with core technique for fistula )
Sealing with fibrin glue.
Fistula Plug Management.
VAFT Technique for anal fistula.
Reconstruction with flap surgery for anal fistula.
- Ayurveda has a unique way of treating fistula in ano. Simple as well as complex fistulas, high anal fistulas, fistulas with multiple track, recurrent fistulas, chron’s fistula, tubercular fistula, all respond well to the Ksharsutra ligation procedure.
What is Ksharsutra / Ksharsootra?
- The Ksharsootra /Ksharsutra is a type of thread / medicated setone prepared by coating and recoating the thread 15 to 21 times with different drugs of plant origin. The mechanical action of the treads and the chemical action of the drugs coated on the thread, to gather do the work of cutting, curetting, draining, and cleaning the fistulous track, thus promoting healing of the track/ wound.
- A number of drugs like,
Apamarg kshar (see picture)
Kadali kshar (see picture)
Arka kshar (see picture)
Nimb kshar (see picture)
Snuhi ksheer (see picture)
Udumber ksheer (see picture)
Papaiya ksheer (see picture)
- And natural antibiotic like haridra powder, guggulu, etc are used in the preparation of different kind of Ksharsutra. It takes a number of days to prepare this Ksharsutra since the previous coat has to dry before the next is applied.
- Different kinds of Ksharsootra are prepared using different drugs. These Ksharsutra are passed through the track (usually under short anesthesia) and the two ends of the thread are tied forming a loop.
- The drugs coated on the thread are continually released through out the length of the track there by cutting, curetting, draining cleansing and healing the track simultaneously in the track after about eight days the thread loosens because it has cut through some of the tissues and also is now almost bare ( with no drugs on it). A new thread is now replaced in the track by a special method.
- The changing of the thread is a simple opd procedure taking about 1 to 2 minutes and requires no anesthesia.
- the thread gradually cuts through the tissue. The tissues above the thread heal up. Hence when at last the loop of thread comes out, the track is healed.
- Ksharsootra (medicated setone) therapy is practiced in India since times immemorial. Modified and revived by the late Dr. P. J. Deshpande. The Ksharsootra therapy is a unique treatment of Ayurveda gaining popularity globally.
- Special types of medicated setone are used in this procedure Found to be effective in any ano rectal conditions, it has many advantages in the treatment of Anal fistulae.
Benefits of the ksharsutra ligation procedure over other methods in anal fistula?
- The Ksharsootra ligation method is an age old, time tested procedure originally performed by Sushruta (the father of surgery) around 300 ad. The fact that it is still in practice to day is a proof in it self of its efficacy.
- The Ksharsutra procedure is performed under short acting anesthesia / local anesthesia and some times even without anesthesia.
- The procedure usually dose not require hospitalization for more than 4 to 5 hours.
- The patient requires minimal bed rest & can resume his / her daily routine within 12 to 24 hours.
It gives freedom from pain full dressings.
- There is no loss of glutial mussels and hence the anatomy of the peri anal region is not distorted. The procedure lives just a pencil scar at the site.
- The recurrence rate which is usually found to be quite high after other methods is less than 2% after Ksharsutra ligation procedure. This is because the medicines on the thread gradually and continually curate the payogenic membrane and fibrous tissue in the track and thus leave no pus pockets un drained.
- Chances of partial or complete incontinence of flatus or / and faces (loss of control of passing stool / flatus) are always present in many types of fistula, (especially in fistulae involving the sphincter muscles after the conventional procedure. ( Fistulectomy Fistulotomy ). There are no chances of developing incontinence in Ksharsutra ligation method.
How can i take care of myself ?
- Using stool softeners Adding fiber to your diet
- Drinking plenty of water, up to 8 eight-ounce glasses a day
- Taking warm baths
- Using clean, moist pads to wipe the area around the anus, to remove irritating particles and fluid from the fistula
- Using special skin creams to soothe irritated tissue.
- How can i help prevent an anal fistula?
- Follow these guidelines to help prevent an anal fistula. They help to keep the lower gastrointestinal tract healthy.
- Eat food high in fiber.
- Drink plenty of water each day (up to eight 8-ounce glasses).
- Have regular physical exams to look for underlying diseases of the rectum.
- Be aware of the signs and symptoms of bowel disease, and seek medical attention if any appear.
Reimbursement and Cashless TPA Health Insurance for the Process Of Kshar Sutra is available now. In NCR, Ghaziabad and Noida
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Fistula is a deadly disease which occurs most commonly on the rectum.
A yellow liquid gets formed on the area which is very painful.
Bhagandara is the name by which fistula is known as in Ayurvedic practice. Three kinds of the disease are recognised with different treatments. One of the important therapies for curing fistula in Ayurveda is Kshar Sutra.
This involves cutting up some tissues and these take time to heal. Before performing this procedure, several herbs are given to the patient such as Kadali Kshar, Apamarg Kshar, Nimb Kshar, Papaiya Kshar and Snuhi Kshar.
Anal fistula is generally treated through surgery but it is known to recur after some time.
You need to be very conscious of this fact when looking to get your condition treated.
Ayurvedic remedies for fistula are known to cure the disorder for good. Several techniques and therapeutic procedures are available in Ayurveda that eliminate the problem from its root.
Although Kshar Sutra is a slow process on the whole but it is getting global recognition gradually as a very effective treatment for fistula. The great advantage in undergoing this treatment is that the patient does not need to be admitted to a hospital. He can carry on with his regular everyday work without any trouble.
and most of all 100% treatment without any recurrence.
Agnikarma is another treatment for fistula in Ayurveda. This involves use of hot iron or caustic agent for destroying the affected tissues.
Another Ayurvedic treatment for fistula is known as Enema. In this treatment, hot bath is given to the patient suffering from it. Lower body parts are involved in this therapy. A few other types of fomentation is also recommended. The patient needs to be constantly checked for any signs of suffering for diseases such as hypertension, diabetes, TB or any other.
The main reason for rise of this disease these days is the unhealthy lifestyle which people have started to lead. It is expected that with Ayurvedic remedies for fistula treatment becoming popular, the lifestyle recommended by the holistic system of medicine will also gain ground.
BHAGANDAR (FISTULA IN ANO)
- A fistula is an abnormal communication between two epithelial/endothelial-lined surfaces.
- A fistula in ano has its external opening in the peri anal skin and its internal opening in the anal canal.
- Anorectal sepsis can be complicated by a fistula in ano in about 50% of patients during the acute phase of sepsis or within 6 months thereafter.
- A fistula in ano forms during the chronic stage of an acute inflammatory process that begins in the intersphincteric anal glands.
- The fistula tracts will follow the course of the original
abscess cavities and subsequent external drainage.
- Escherichia coli 60%
- Staphylococcus aureus 23%
- Streptococcus, B.Proteus 17%
- Always mixed infection
Source of Infection
- Cryptoglandular infection 90%
- Penetration of rectal wall
(bone piece, fish bone or any FB)
- Blood borne infection
(TB, Syphillis, AIDS, etc.)
BHAGANDAR (FISTULA IN ANO) Kshar Sutra Treatment
- supralevator abscess, external, perianal abscess, intersphincteric abscess, ischiorectal abscess, internal sphincter
- An extension from a cutaneus boil
Other cause of FIA
- Crohn’s disease.
- diverticulitis with perforation and fistula to
- hydroadinitis suppurativa;
- pilonidal sinus;
- malignancies of the distal rectum, anal
canal or perianal
- skin tuberculosis;
- If the anus is bisected by a line in the frontal plane, an external opening inferior to that line connects to the internal opening via a short direct tract.
- if the external opening is posterior to this imaginary line, the fistula tract follows a curved route to the internal opening in the posterior midline.
Goodsall’s rule Classification of FIA
- Intersphincteric (the most common): The fistula track is confined to the intersphincteric plane.
- Trans-sphincteric: The fistula connects the intersphincteric plane with the ischiorectal fossa by perforating the external sphincter.
- Suprasphincteric: Similar to trans-sphincteric, but the track loops over the external sphincter and perforates the levator ani.
- Extrasphincteric: The track passes from the rectum to perineal skin, completely external to the sphincteric complex. Clinical classification
High anal fistula-
- these open into the anal canal at or above the anorectal ring.
Low anal fistula-
- these open into the anal canal blow the anorectal ring.
Sign and symptoms
- Anal fistulae can present with many
- Discharge – either bloody or purulent
- Pururitis- itching
- Systemic symptoms if abscess becomes infected
- Diagnosis is by examination, either in an outpatient setting The examination can be an anoscopy.
- The opening of the fistula onto the skin may be seen
- The area may be painful on examination
- there may be redness
- An area of induration may be felt – thickening due to chronic infection
- A discharge may be seen
- It may be possible to explore the fistula using a fistula probe (a narrow instrument) and in this way it may be possible to find both openings of the fistula
Digital Rectal examination Better after enema Find
- I. Sphincter tone
- II. Pain or Tenderness
- III. Palpable Mass
- IV. Internal opening of Fistula
- V. Temp
Internal opening of Fistula …… Digital examination
- vi. Male
- Prostate, Seminal vesicles, Base of bladder
- Male & Female
- Ischio Rectal Abscess
- Blood- RE
- Smear C & S
Kshar Sutra Chikitsa
Properity of kshar
- Distroys the unhealthy tissues.
- Deberides the wound.
- Promots the healing of healthy tissues.
- It distroys the fibrous tissues and acts as fibrolytic agent.
- I. Lithotomy table within a OT.
- II. Spot light
- III. Ksharsutra dressing trolley
- IV. Instrument box
Preparation of the patient
- Evacuation of bowel
- Shaving of local area
- Inj. T.T.
- Xylocane sensitivity test
- Swedan of local area
- Washing of local area by antiseptic lotion.
Procedure of threading
- • Patient should be keep in lithotomy position.
- • Cleaning by antiseptic lotion and covered by a sterile clothes.
- • Explain the major procedure to patient.
- • Instruct to patient to relax the anal sphincter.
- • Now probing should be done through the path of least resistance under L.A. guided by the finger inside the anal canal.
- • Tip of probe should come out through anal orifice.
- • Now threaded the plain thread of suitable length in the eye of probe. (Primary threading)
- • Pull the probe through the anal orifice to leave the thread behind fistulous track.
- • Now tight the two end of thread moderatly.
- • Finally dressing by Jatyaditail or Anu tail.
- • Chang the thread by kshar sutra at a regular interval of 7 days by rail and train method.
- Jatyaditail or anu tail basti
- Sitz bath
- Proper antibiotic
- Haritaki Churn or Panchsakar Churan HS
- Abhayarista 4 TSF BD.
- Analgesics and anti-inflmmatory drugs.
- Diet- nutritious vegetarian diet.
Sitz bath tub
- • After subsequent changing of thread, in a few week, ksahar sutra comes out with the knot intact from the tract. This is known as cut through. Cut through indicates complet division of track.
How does Kshar Shutra work!
- • Cutting due to pressure necrossis
- • Kshar helps in cleaning debris from track, sterilization of track
- • Quick and Good healing of track
- • Slow cutting and healing result in nil recurrence and minimal sphincter mechanism distrubances.
Problem during the therapy
- I. Duration of treatment- depend on the length of track.
- II. Allergic reaction
- III. Discharge
- IV. Incontinence- may be due to trauma to sphincter, so that never cross the ano rectal-ring.
- V. Foreign body sensation.
- VI. Anal stenosis.
Advantage of kshar sutra
- Minimal trauma and no tissue loss as compare to fistulectomy.
- Almost no bleeding as compare to fistulectomy.
- Anesthesia is seldom required.
- Minimal hospital stay.
- No dressing as compare to fistulectomy
- No anal stricture if properly treated.
- Nil recurrence 99.96%
- Very narrow and fine scare as compare to fistulectomy
- Therapy is cost effective.