RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

KARNATAKA, BANGALORE

REGISTRATION OF SUBJECT FOR DISSERTATION

BY

DR. GEETANJALI HIREMATH

FOR THE DEGREE OF AYURVEDA DHANVANTARI

M.S (AYURVEDA) IN SHALYATANTRA

TITLE OF THE TOPIC:

“A STUDY ON THE EFFICACY OF DARVI TAILA MATRA

BASTI IN TN THE MANAGEMENT OF PARIKARTIKA W.S.R

TO FISSURE-IN-ANO”

GOVERNMENT AYURVEDA MEDICAL COLLEGE,

DHANVANTARI ROAD,

BANGALORE – 09,

KARNATAKA

1

From,

DR. GEETANJALI HIREMATH

I M.S. (Ayu) Dept. of P.G Studies in Shalya Tantra

Government Ayurveda Medical College,

Bangalore-560009

To,

THE REGISTRAR,

Rajiv Gandhi University of Health Sciences,

Bangalore-560041

Through:

THE PRINCIPAL AND HOD OF PG STUDIES IN SHALYA TANTRA

Government Ayurveda Medical College,

Bangalore-560009

Respected Sir,

Sub: Submission of completed proforma for the registration of subject for

Dissertation.

With reference to above subject, I request you to kindly register the below

mentioned subject against my name for Dissertation by Rajiv Gandhi University of

Health Sciences, Bangalore as partial fulfillment of MS (Ayu) in Shalya Tantra.

TITLE OF THE DISSERTATION

“ A STUDY ON THE EFFICACY OF DARVI TAILA MATRA BASTI IN THE

MANAGEMENT OF PARIKARTIKA W.S.R. TO FISSURE-IN-ANO ”.

Here with, I am enclosing completed proforma for Dissertation.

Thanking you,

Place: Bangalore Your’s faithfully,

Date:

(DR. GEETANJALI HIREMATH)

2

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA.

ANNEXURE - II

COMPLETED PROFORMA FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

1. NAME OF THE CANDIDATE : DR. GEETANJALI HIREMATH AND ADDRESS I YEAR MS (AYU)

DEPT. OF PG STUDIES IN SHALYATANTRA,

GOVERNMENT AYURVEDA MEDICAL COLLEGE,

BANGALORE 09. RESIDENTIAL ADDRESS : D/O.VEERABASAYYA HIREMATH

AT.TALAKERI TQ.YALABURGA

DT.KOPPAL

2. NAME OF THE INSTITUTE : GOVERNMENT AYURVEDA MEDICAL COLLEGE, BANGALORE- 09

3. COURSE OF STUDY : AYURVEDA DHANVANTARI, IN SUBJECT I YEAR M.S. (AYURVEDA) SHALYA TANTRA.

4. DATE OF ADMISSION TO : 09.10.2012 THE COURSE

5. TITLE OF THE : A STUDY ON THE EFFICACY OF DISSERTATION DARVI TAILA MATRA BASTI IN THE MANAGEMENT OF PARIKARTIKA W.S.R. TO FISSURE-IN-ANO

3

6. BRIEF RESUME OF THE INTENDED WORK

6.1 NEED FOR THE STUDY:

Parikartika means “Parikruntavat vedana” i.e. cutting type of pain specially

observed in Gudapradesha (anal region). The earliest reference about

‘Parikartika’ is available from Sushrutha Samhitha (1500 B.C). Description of

nidana, lakshana and chikitsa of Parikartika is also available in Bruhatrayees and

other Ayurvedic classics.

The word parikartika is mentioned in Bastikarma vyapath and Virechana vyapath.

It is also an upadrava of Atisara.

Parikartika mentioned in Ayurvedic classics with features like severe pain,

constipation, stools streaked with blood can be correlated to ‘Fissure-in-Ano’

mentioned in Allopathic medical science.

Fissure-in-Ano is the most common and painful condition which hampers the

daily activities of the person even amounting to “difficult to sit”!. Fissure-in-Ano is

commonly seen in youngsters and in women after child birth. The present lifestyle

also contributes to this condition. About 30–40% of the population suffers from

proctologic pathologies at least once in their life time. Anal fissure comprises of 06–

15% of Anorectal disorders.

Fissure-in-ano is a medico- surgical condition, Medical treatment includes

analgesics in the form of NSAID’s, bulk laxatives and soothing ointments like

nitroglycerine. Surgical intervention is the ultimate choice in the chronic ulcers,

Surgical management includes Lord’s dilation, sphincterotomy, fissurectomy.

All these methods of modern science have one or the other drawbacks. Prolonged

administration of NSAID’s may suppress the symptoms but causes gastric irritation.

Application of soothing ointment produces sufficient relaxation of the sphincter, but

causes significant headache and recurrence rate is 50% in this particular method of

management.

4

Complications of surgery includes haematoma, abscess formation recurrent ulcer

formation, persistent mucous discharge. The main concern with surgery is the

development of anal incontinence which includes inability to control gas, mild faecal

soiling or loss of solid stool. Some degree of incontinence can occur in up to 45% of

cases in the immediate surgical recovery period and the Anaesthetic complications

cannot be ruled out. Most of the methods of treatment are expensive and requires long

stay in hospital.

General line of treatment in Ayurveda for parikartika, as a vata vikara includes

snigdha, madhura, sheeta dravya sevana, vatanulomana, agnideepana, piccha basti,

anuvasana basti.

The Basti karma is the first line of treatment for vata vikaras. as parikartika being

one of the vatavikara the basti with taila or grita is beneficial in parikartika. Most of

the drugs which are used in bastikarma are vatapitta shamaka and vranaropaka in

nature. Matra basti is a type of anvasana basti is considered for the present study.

There is always need for cost effective and patient friendly method for the

management of fissure in ano. Darvi taila is quoted as vranaropaka by charaka in

chikitsa sthana 25th capter 93rd shloka is selected for the study. Darvi taila is having the

properties like vranaropaka, kandughna, rujahara, vatanulomana in nature.

Keeping in view the lacunas of different modern medical treatments, there is a

need for an effective, safe, economical and simple therapy. Darvi taila maatra basti

may be considered as one such treatment in Ayurveda which can overcome the above

said lacunas. Hence this study is taken up to explore the possibilities of darvi taila

matra basti as an effective, economical and short term treatment for Fissure-in-ano.

Considering the above facts a holistic approach to evaluate the efficacy of ‘Darvi

taila matra basti’ in the management of parikartika (fissure-in-ano) is taken up. The

results obtained by the present study shall be anlysed and compaired with the results

of managing fissure-in-ano using ‘durva taila matra basti’ which is an established

study with a success rate of 85%.

5

6.2 REVIEW OF LITERATURE:

AYURVEDIC REVIEW:

VYUTPATTI:

Parikarta: parikrit – pari + kruntati

Pari: Around

Krintat: clip, cut off

Kartika: sharp shooting pain

Kartana: cut off 1 (p. 591)

NIDANA AND SAMPRAPTI: क्षामेणाति�म्रुदुकोषे्टण मन्दाग्नि���ा रूक्षोष्ण वा अति��ीक्ष्णॊष्ण वा अति�लवण्मति�रूकं्ष वा पी�मौषधं तिपत्ताति�लौ प्रदूष्य परि'कर्ति�)कामापादयति� l

If a person debilitated with mridukoshta or mandagni, the ingestion of

atirooksha, atiteekshna, atiushna, atilavana ahara, causes dushana of pitta and anila

and produces parikartika.2 (Ci. Ch. 34 Sl. 16 p.595)

LAKSHANA OF PARIKARTIKA:

�त्र गुद�ाभि-मेढ्रबस्ति1�शि3'ःसु सदाह परि'क�7�मति�लसंगोवायुतिवष्�म्भो -क्तारुशि;श्च -वति� l

The patient suffers from cutting pain with burning sensation in anus, umbilicus,

penis and neck of bladder, retention of flatus, wind formation and anorexia.2 (Ci. Ch.

34 Sl. 16 p.595)

�ीव्र3ूलां सतिपच्छास्रां क'ोति� परि'कर्ति�)काम l Severe pain, slimy discharge or slimy discharge with blood.3 (Si.Ch. 6 Sl. 62

p.629)

6

CHIKITSA OF PARIKARTIKA:

�त्र तिपच्छाबस्ति1�य7ष्टिष्टमधुकृष्णति�लकल्कमधुयुकं्त 3ी�ांबुपरि'तिषक्तम ;ै�ं पयसा -ुक्तवन्�ं घृ�मण्डेण यष्टिष्टमधुकशिसदे्ध� �ैले� वा अ�ुवासये� l

Patient should be treated with picchabasti mixed with paste of yastimadhu and

black sesamum along with honey and ghee. He should also be sprinkled with cold

water, fed with milk, anuvasana basti with ghee scum or oil processed with

yastimadhu.2 (Ci. Ch. 34 Sl. 16 p.595)

DARVI TAILA REFFERANCE:

दुवा71व'सशिसदं्ध वा �ैलं कंतिपल्लके� वा lदावHत्व;श्च कल्के� प्रधा�ं व्रण'ोपणम ll Oil cooked with durva swarasa or kampillaka or paste of Daruharidra

bark is an important wound healer.3 ( Ci.ch.25 sl.93 p.416 )

MATRA OF MATRA BASTI

�त्र�ुवास�ाख्यो तिह बस्ति1�य7ः सो अत्र कथ्य�े lअ�ुवास�-ेदश्च मात्राबस्ति1�रुदीरि'�ः llपलद्वयं �1य मात्र �1मा� अधा7दतिपवा -वे� l

Matrabasti is a type of anuvasana basti and matra (dose, quantity of enema

material) of anuvasana basti is two pala or even half of that (one pala).4 (pK. Ch.7 (v)

Sl.84. p.572)

MODERN VIEW:

7

FISSURE-IN-ANO:

Fissure-in-ano is a very common and painful condition. Fissures occur most

commonly in the midline posteriorly, the least protected part of the anal canal. In

males fissures usually occur in the midline posteriorly (90%) and much less

commonly anteriorly (10%). In females fissures on the midline posteriorly are slightly

commoner than anteriorly (60:40). The relative frequency of the anterior fissures in

the females may be explained by the trauma caused by the foetal head on the anterior

wall of the anal canal during delivery.

AETIOLOGY:

The predominantly posterior midline location of fissures has been explained by

a)posterior angulation of the anal canal, b) relative fixation of the anal canal

posteriorly, c) divergence of the fibers of the external sphincter muscle posteriorly

and d) the elliptical shape of the anal canal.

1. Constipation has been the most common aetiological factor.

2. Spasm of the internal sphincter has also been incriminated to cause fissure-in-

ano.

3. When too much skin has been removed during operation for haemorrhoids,

anal stenosis may result in which anal fissure may develop when hard motion

passes through such stricture.

4. Secondary causes of anal fissures must be remembered. These are:

1. Ulcerative colitis

2. Crohn’s disease

3. Syphilis

4. Tuberculosis

PATHOLOGY:

Fissure starts proximally at the dentate line. So whole of the anal fissure lies in the

sensitive skin of the anal canal and that is why pain is the most prominent symptoms.

There are 2 types of fissure-in-ano,

1. Acute

2. Chronic

8

Acute fissure-in-ano is a tear of the skin of the lower half of the anal canal. There

is hardly any inflammatory induration or oedema of its edges. Anal sphincter muscle

spasm is always present.

Chronic fissure-in-ano is a deep canoe shaped ulcer with oedematous margins. At

the upper end of the ulcer there is hypertrophied papilla. At the lower end of the ulcer

there is skin tag known as ‘sentinel pile’. There is a characteristic inflammation and

induration at the margins. Base consists of scar tissue and internal sphincter muscle.

Spasm of internal sphincter is always present. Sometimes infection may lead to

abscess formation. Chronic fissure-in-ano may have a specific cause e.g. Chron’s

disease, ulcerative colitis, tuberculosis and syphilis, so during operation biopsy must

be taken from a chronic fissure to exclude secondary cause mentioned above.

CLINICAL FEATURES:

This condition is more common in women. It is mostly seen between 30 and 50

years of age. It occurs sometimes in children and may cause acquired megacolon. But

it is rare in the aged due to muscular atony. Constipated hard stool while passes

through the anal canal in patients where there is spasm of internal sphincter and

hypertrophied anal papilla an acute tear of the anal canal will occur. This ACUTE

FISSURE will cause spasm, pain of the defaecation and passage of bright streaks of

blood along with the stool or will be seen in the tissue paper. If the acute fissure is

fails to heal, it will gradually develop into a deep undermined ulcer. This is termed

CHRONIC FISSURE-in-ano.

Pain and bleeding are the two main symptoms of this condition. Pain starting with

and following defecation has been variously described as sharp, biting, burning etc.

Pain is sometimes intolerable and pain is the main symptom of Fissure-in-Ano. After

the pain goes off the sufferer remains comfortable till the next action of bowel. The

bleeding of anal fissure is variable, but usually occurs as streaks on the outside of the

stool or spots noted on toilet tissue. Slight discharge may accompany a fully

established chronic fissure. Pruritis ani may be another symptom of this condition.

TREATMENT:

9

A. Acute ulcers:

Acute ulcer with short history usually heals with conservative treatment.

Conservative treatment includes

(a) Oral pain medication, which may be taken before any anticipated bowel

movement.

(b) Stool softeners may be used to make the stool soft enough to be passed without

anal spasm. Weak bulk laxative or cathartics is best in this condition.

(c) Nitric oxide is a neurotransmitter which induces relaxation of the internal

sphincter. Glyceryl trinitrate is a nitric acid donor and is applied as an ointment to the

anal canal to produce the relaxation of the internal sphincter. And it improves blood

flow to the area which further helps in healing of the fissure.

(d) Soothing ointments may be applied with doubtful efficacy. 5% xylocaine

ointment may be introduced with a fine nozzle into the anal canal.

(e)Self dilatation is highly important as this will relax the anal musculature and

resolves with healing of the fissures.

(f) Injection of long acting anaesthetic solutions promotes little relief and significant

complications.

B. Chronic ulcers:

Though in these cases conservative treatment may be tried, yet in majority of

Cases this treatment fails and surgical management should be called for.

1. ANAL DILATATION- Lords procedure of anal dilatation is the simplest method

of the anal canal. Under the general anaesthesia and the patient in lithotomic position

the index and the middle fingers of each hand are inserted simultaneously into the

anus and pulled apart to give maximal anal dilatation. Any constricted bands should

be well stretched and the fibrosis around the fissure should be ironed out. The patient

can go home same day.

2. POSTERIOR SPHINCTEROTOMY AND FISSURECTOMY- The patient10

remains in lithotomic position and general anaesthetised. A well greased Sim’s

speculum is introduced. Superficial transverse fibres of internal sphincter are divided

and the floor of the fissure is made smooth. If the ulcer is deep with fibrotic edges, the

ulcer should excised. If sentinel pile is present, it should be excised.

3. LATERAL ANAL SPHINCTEROTOMY- In this operation the internal

sphincter is divided away from the fissure either on the right or left lateral position.

4. EXCISION OF ANAL ULCER along with skin graft to limit the convalescent

period has not been successful. Even anal skin has been lifted up to cover the

defect of anal canal following excision of ulcer. This is called ‘V-Y anoplasty’. This

has also been unsuccessful.

5. ANAL ADVANCEMENT FLAP- In this technique edges of the fissure are

excised and mobilised as full thickness anal skin flap. These flap are slid over the

fissure and sutured in place. This technique has become popular recently as there is

little risk of damage to the underlying internal sphincter, so there is no chance of

incontinence.5 (p.1084-86)

ABBREVIATION:

Ci. – chikitsa stana

Si. – siddhi stana

Sl. – shloka

Ch. – chapter

Su. – sutra stana

Pk. – poorva khanda

P. – inclusive page no.

pp. – printed pages

11

6.3 PREVIOUS WORKS DONE:

Sindhav vijayasinha. V – Role of yastimadhavdi Ghrita in the management

of parikartika w.s.r fissure-in-ano (Dissertation). Jamnagar: Gujarat

Ayurveda University; 2001.

Raghavendra. B – Effect of Doorvadi taila in the management of parikartika

w.s.r to fissure-in-ano (Dissertation). TMAE society’s Ayurveda medical

college, Hospet: Rajiv Gandhi University; 2005.

Aravind kumar – management of parikartika by Doorvadi taila pichu and

Gudamarga vivardana a comparative study (Dissertation). Ayurveda

Mahavidyalaya, Hubli: Rajiv Gandhi University; 2006.

Abhinetri Hegde - “Management of Parikartika / Fissure-in -ano with

Doorva taila and Yashtimadhu taila – A Comparative Study” Govt

Ayurveda Medical College, Bengluru: Rajiv Gandhi University; 2010.

6.4 OBJECTIVES OF STUDY:

To evaluate the efficacy of ‘Darvi taila matrabasti’ in the management of

Parikartika.

To evaluate the efficacy of ‘Durva taila matrabasti’ in management of

Parikartika.

To evaluate the significance of ‘Darvi taila matra basti’ in the management of

Parikartika by comparing its effects with ‘Durva taila matrabasti’.

7. METHODOLOGY:

12

7.1 SOURCE OF DATA

Patients with lakshanas of parikartika will be selected from the OPD and IPD of

SJIIM Hospital, Bangalore.

7.2 METHOD OF COLLECTION OF DATA:

The patients who are presenting with the features of Parikartika which can be

correlated with acute Fissure-in-ano in modern science namely excruciating pain in

anal region during and after defecation, constipation, bleeding per anum i.e. stools

streaked with blood, burning sensation in anal region, presence of longitudinal tear in

the anal region and sphincter spasm shall be selected for study.

A. INCLUSION CRITERIA:

Patients suffering from Parikartika (Acute Fissure-in-ano) with symptoms of

painful defecation, burning sensation, bleeding per anum i.e. stools streaked with

blood, constipation, spasm of the sphincter and solitary anal fissure.

B. EXCLUSION CRITERIA:

Patient with any other ano rectal diseases.

Patient with other systemic disorders.

Note: The pathological conditions mentioned in exclusion criteria were ruled out

after considering the features and required investigations.

C. SAMPLING PROCEDURE:

40 cases of Parikartika will be selected and they will be distributed randomly in 2

groups namely Group A and Group B with 20 cases each.

D. STUDY DESIGN

13

GROUP A:

Patents of this Group will be treated with darvi taila matra basti once a day for 7 days.

GROUP B:

Patients of this Group will be treated with durva taila matra basti once a day for 7

days.

Observations regarding the changes in the features of both the groups will be made

before treatment and after 7th day of treatment. These observations will be recorded

in the proforma of case sheet prepared for the study.

To the patients of both groups Triphala choorna one karsha will be given daily at

night during the procedure period with warm water as a stool softener.

Advice: During the treatment suitable Pathya and Apathya will be advised to both the

groups.

In cases where total relief was obtained, a period of 60 days will be fixed to study the

possibilities of recurrence and the same will be recorded in proforma of case sheet.

The results obtained shall we statistically analysed and conclusions are drawn.

F. ASSESSMENT CRITERIA:

Assessment will be made with the following parameters:

a. Subjective parameters:

1. Pain

2. Burning sensation

3. Bleeding

4. Constipation.

b. Objective parameters:

1. Ulcer present or absent14

2. Spasm of the sphincter

7.3. INVESTIGATIONS: NIL

7.4. WHETHER THE ETHICAL CLEARANCE HAS BEEN OBTAINED

FROM THE INSTITUTION: Shall be obtained.

8. BIBILIOGRAPHY:

1. Monier Williams. Sanskrit English Dictionary. Chaukhambha Sanskrit Series.

1sted.Varanasi: pp.1333.

2. Sushruta. Sushruta Samhita -Text with English translation by P V Sharma.

1sted. Varanasi: Chaukhambha vishwabharati; 2005. Vol II, pp.695.

3. Caraka. Caraka Samhita-Text with English translation by Prof. P V Sharma.

7th ed. Varanasi: Chaukhamba orientalia; 2005. Vol II, pp.879.

4. Bhavamishra. Bhavaprakash of Bhavamishra -Text, English Translation, Notes,

Appendices and Index, Translated by Prof.K.R.Srinkantha

Murthy. 2nd ed. Varanasi: Chowkamabha Krishnadas Academy; 2001, Vol I,

pp.738.

5. Somen Das. A concise text book of Surgery. 5th ed. Calcutta; 2008,

pp.1346.

09 SIGNATURE OF THE CANDIDATE

15

10 REMARKS OF THE GUIDE

11 NAME AND DESIGNATION OF THE GUIDE

Dr. SHILPA.P.N B.A.M.S., M.S (AYU)LECTURER,DEPT. OF P.G. STUDIES IN SHALYA TANTRAGOVT.AYURVEDA MEDICAL COLLEGE BANGALORE-560009

11.1 SIGNATURE OF THEGUIDE

11.2 CO – GUIDE _

11.3 SIGNATURE OF THE CO-GUIDE

_

11.4 NAME AND DESIGNATION OF HOD

Dr. R. VIJAYASARATHI, B.S.A.M.,B.A.M.S.,M.D.(AYU). PROFESSOR ,DEPT. OF P.G. STUDIES IN SHALYATANTRA,GOVT. AYURVEDA MEDICAL COLLEGE,BANGALORE – 560009

11.5 SIGNATURE OF HOD

12REMARKS OF THE PRINCIPAL

12.1 SIGNATURE OF THE PRINCIPAL

16