Issue : 01 DOI : 10.5281/zenodo.8147277

INTERNATIONAL

JOURNAL

DIAGNOSTICS

AND

RESEARCH

Volume : 01

Abstract

The word “Parikartika'' means “cutting agony at the anal region,” or “Kartanvat vedana .” The main signs of this

illness are a drop of blood or a streak of fresh blood, together with excruciating pain and a burning feeling that

lingers for several hours during and after a bowel movement. According to Acharya Sushruta, the person who does

not adhere to the Aahara Vidhi and consumes food like Shushka(Dry), Viruddha (Incompatible), and Vishtambhi

(Obstructing) develops a condition called Agnivaishmya (dyspepsia), which is the main cause of all illnesses. One

of the significant causes of the fissure-formation process is constipation. . The modern diet of most people is

erratic due to the prevalence of fast food. Additionally, one leads a sedentary lifestyle and is constantly under

stress. All of these cause the digestive system to become disturbed, which in turn causes a variety of diseases.

Anorectal disorders are the most prevalent ones. The disease typically develops in females during pregnancy and

after giving birth The majority of acute anal fissures resolve without surgical intervention. Finger anal dilatation,

as well as lateral internal sphincterotomy, are two common operative techniques. Ayurved Treatment in

Parikartika consists of Basti Karma, Pichoodharan, Ksharakarma, Agnikarma, Shastrakarma, and a few oral

medications administered by Sushrutacharya and Charakacharya.

Keywords: Fissure-in-ano, Parikartika, constipation

Corresponding author: Dr.Sheetal Asutkar

Article Info: Published on : 15/07/2024

ISSN No. : 2584-2757

Volume : 01

Issue : 04

Publisher

ROGANIDAN VIKRUTIVIGYAN PG ASSOCIATION

FOR PATHOLOGY AND RADIODIGNOSIS

DOI

: 1 0 . 5 2 8 1 / z e n o d o . 1 2 7 4 5 4 5 8

Reg. No. : MAHA-703/16(NAG)

Year of Establishment – 2016

INTERNATIONAL JOURNAL OF DIAGNOSTICS AND RESEARCH

Therapeutic Interventions for Fissure in Ano: An Evidence-Based Review

Dr.Sheetal Asutkar

, Dr.Yogesh Yadav

, Shreya Satpute

HOD & Professor, Department of Shalyatantra, Mahatma Gandhi Ayurved College Hospital and

Research Centre. Salod (Hi) Wardha, Datta Meghe Institute of Medical Sciences, Wardha 442001,

PG Scholar, Department of Shalya Tantra, Mahatma Gandhi Ayurved college Hospital and Research

Centre, Datta Meghe Institute of Higher Education and Research (Deemed to be University) Salod(H),

Wardha, Maharashtra, India

UG Student Final Year, Mahatma Gandhi Ayurveda College Hospital and Research center Salod[H]

Wardha, Department of Shalya Tantra, Datta Meghe Institute Of Medical Sciences (DMIMS DU) Wardha,

Maharashtra India.

Cite this article as: - Dr. Sheetal Asutkar (2024) ; Therapeutic Interventions for Fissure in Ano: An Evidence-Based Review;

Inter.J.Dignostics and Research 1(4) 8- 16, DOI: 1 0 . 5 2 8 1 / z e n o d o . 1 2 7 4 5 4 5 8

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Introduction:

The art of living in humans is also medical science,

according to the ancient indigenous science of medicine

known as Ayurveda. The modern diet of most people is

erratic due to the prevalence of fast food. Additionally, one

leads a sedentary lifestyle and is constantly under stress.

All of these cause the digestive system to become

disturbed, which in turn causes a variety of diseases.

Anorectal disorders are the most prevalent

ones

[1].

Anorectal fissure is the most painful ailment that

disallows individuals to go about their daily lives without

too much discomfort. A fissure in ano is a painful

anorectal ailment that helps people lead their regular

activities with tolerable discomfort. A split or crack is

what the word "fissure" itself means.

[2]

It is characterized

by excruciating pain and bleeding during bowel

movements and is linked to internal anal sphincter spasms.

Modern research has divided fissure-in-ano into two

categories: acute and chronic. Anal fissures typically heal

on their own and are considered to be minor, but those that

are still symptomatic after 4–6 weeks are frequently

known as a chronic fissures.

[3]

The word “Parikartika”

means “cutting agony at the anal region,” or “Kartanvat

vedana”. The main signs of this illness are a drop of blood

or a streak of fresh blood, together with excruciating pain

and a burning feeling that lingers for several hours during

and after a bowel movement. In Bruhatrayi, Parikartika is

described as an illness that develops as a result of other

illnesses rather than as a separate illness.

[4]

The phrases

“Pari” (around the anus) and “Kartika” (cutting pain) are

combined to form the word “Parikartika”. Regarding the

Parikartika idea, several distinct viewpoints are stated. It

is a tearing agony that can occur anywhere in the body,

according to Acharya Dalhana. It is described as a cutting

type of agony that is particularly centered in Guda by

Madhavnidan commentator Vijayarakshit.

[5]

According to

Kashyap, pregnant women should be treated according to

the three varieties of Parikartika (Vataj, Pittaj, and

Kaphaj). Charaka described Parikartika as a Vataj

Atisara(Diarrhea) complication, one of the symptoms of

Vataj grahani( Irritable bowel syndrome), Parikartika also

occurs due to complications of various Panchakarma

procedures in Virechan Vyapad(Complication related to

purgation therapy), Basti Vyapad(Enema complication),

Basti Netra Vyapad (complication due to enema nozzel).

Parikartika is also referred to as purvarupa (prodormal

symptom) of Arsha (Haemorrhoids) in the Sushrut Samhita

and Ashtanga Sangraha. Parikartika was mentioned by

Kashyapa as a distinct illness in the context of

Vyapada(complication).

[6]

Predisposing Factors

According to Acharya Sushruta, the person who does not

adhere to the AaharaVidhi (diet regimen) and consumes

food like Shushka, viruddha, and Vishtambhi develops a

condition called Agnivaishmya (dyspepsia), which is the

main cause of all illnesses. He continued by saying that

everyone should consume food of all six Rasas (Tastes)

every day. So all ailments, especially anorectal diseases,

are caused by an unhealthy diet, hot food, and junk

food.

[7,8]

Multiple social, psychological, and physiological variables

might influence the chronic anal fissure's start,

progression, and effects on quality of life. The severity of

depression and anxiety has a deleterious effect on patients

with CAF (Chronic anal fissure) due to the high

comorbidity of psychopathology. Stress contributes to

CAF by acting as both a trigger and an aggravating

element.

[9,10]

One of the significant causes of the fissure-formation is

constipation. Among the other contributing causes include

the passing of hard stool, erratic eating patterns, ingestion

of hot and sour foods, poor bowel habits, and lack of anal

hygiene. The disease typically develops in females during

pregnancy and after giving birth. Initially appearing as a

Superficial split in the anoderm, an acute fissure has the

potential to develop into a chronic fissure.

[11,12]

Methodology:

The terms “Fissure in ano” and “Parikartika" were

searched for in the online databases PubMed, PubMed

Central, Ayush portal, and IndMed. A total of 100

references from the databases' inception were found

through the search. The review included articles, case

studies, and case series written in English that discussed

the causes and remedies for fissures in ano. The review did

not include studies whose abstracts were unavailable or in

languages other than English. A total of 50 studies were

chosen for the final review.

Review Of Literature:

The fissures can be classified into Acute and Chronic.

Acute fissure is a longitudinal tear in the long axis of anal

canal. Chronic or complicated fissure in ano exhibits one

or more of the following characteristics, it is classified as

chronic or complex.

[13]

1. A fibrous anal polyp is present.

2. The existence of an external anal skin tag

3. Indurations or fibrosis of the edges of the fissure.

4. Visible fibres of the internal sphincter at the floor of

the fissure

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5. An infected or suppurated fissure.

6. A bridged fissure with an underlying fistula (a post-

fissure fistula).

In the past, it has been seen that fissures exacerbated by

any of the aforementioned factors do not heal on their own

or respond to conservative treatment.

[14]

Anal fissures can

have a significant adverse effect on patients' quality of

life.

[15]

Various treatment modalities are given as per

modern and Ayurved which are discussed below. As per

Ayurveda the principal treatment of Parikartika is mainly

based on conservative and surgical management.

Conservative management

Para-Surgical

management

Dietary modification

[16]

Kshar( Alkali)

[21]

Matrabasti (Enema)

[17]

Agnikarma

(Therapeutic heat

burns)

Taila/Grita Pichu

( Medicated gauze)

[18]

Shashtra karma

( Surgery)

Awagahsweda

((Hot fomentation-sitz bath)

[19]

Local application of medicated

Ghrita and Taila

[20]

Dietary modifications:

[22]

In Saama (Indigestion) condition, Langhana (Fasting)-

Deepana (Appetizer) and Ruksha – Ushna (hot) – Laghu

(Light) diet

1. Madhura (sweet) and Brihaniya (Nourishing) diets are

advised in thin & lean Patients.

2. In severe Vata aggravated condition , Ghrit with

Daadimarasa should be given.

[23]

Local treatment as per Ayurveda:

Treatment in Parikartika consists of Basti Karma

(medicated enema) and a few oral medications

administered by Sushrutacharya and Charakacharya. The

majority of enemas are made with Sarpi (Clarified butter),

oil, Godugdha( Cow milk), and other ingredients as

necessary. The majority of Basti Karma ingredients, such

as Vrana Shodhaka (Wound purification) and Vrana

Ropaka(Wound healing), have Vata Pitta-pacifying

properties. Systemic oral formulations improve digestion

through Agnideepana and Amapachana and treat

gastrointestinal disorders.

[24-25]

1.Matrabasti (type of Anuvasanabasti): It acts as a

retention enema and helps in the easy voiding of stools, by

this Vatanulomana (Correcting the functions of vata

dosha) occurs and it cures the diseases caused by

aggravated Vata as Parikartika is Vata dominant disease.

By giving Matra Basti local oleation occurs spasms will

also be reduced, which lowers the discomfort. It helps

maintain the anal canal, softens the faeces, and makes

expulsion simple. It functions as a detention enema and

facilitates easy bowel movements; as Parikartika is a

Vata-dominant disease, this causes Vatanulomana , which

cures diseases brought on by provoked Vata. By

administering Matrabasti, local oleation decreases pain

while also relieving spasms. It oleates the urethra, softens

the stools and makes evacuation of urine and stools easy.

2.Taila/Grita pichu: Pichu is a unique drug delivery

system of Ayurveda, "Pichu Sthoola kavalika” –The term

"Pichu" refers to a thick cotton pad or swab. In the Pichu

Dharana procedure, a piece of cloth, gauze, or linen is

soaked in Ghrita or Taila and applied to the affected area

of the body. Pichu's local effects includes oleation,

scraping, and wound healing, are based on the body's

ability to absorb the medication.

[26]

3.Avgahasweda (hot fomentation-sitz bath): Seating in

the hot/warm tub following each bowel emptying relieves

discomfort and temporarily reduces internal sphincter

spasm. Additionally, it aids in fissure wound cleaning. It

takes 10 to 15 minutes to complete.

[27]

4.Local application of medicated taila and Ghrita:

Application of medicated taila or ghrita at the affected site

helps in healing the fissure due to the healing properties of

drugs used.

Chronic Fissure-In-Ano treatment According to the

Ayurvedic texts on Shushkarsha, Bahyarsha (External

haemmorhoids) and Sentinel Piles are related.

Sushruta Acharya Listed four treatment modalities.

1) Bheshaja (conservative line of Management)

2) Kshara (Alkali)

3) Agnikarma

4) Shastra.

1. Kshara ( Medicated thread smeared with kshar) :

Ligation of the KsharSutra to the Sentinel pile masses,

which cause them to collapse. Scraping action of Kshara,

reduces the excess fibrous Tissue present over the ulcer

surface and ulcer heals & Sphincter relaxation occurs

simultaneously.

2. Agnikarma: Para surgical procedure like Agnikarma

has been widely advised by Sushruta & doing Agnikarma

Treatment has provided marked relief & no recurrence.

Excision of sentinel piles by Agnikarma i.e. by

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electro Thermal cautery is done.

[27]

3. Shashtra (Surgical management)

Successful nonsurgical management of chronic anal

fissures improves symptoms and has a positive impact on

health.

[28]

The principle aim of treatment for anal fissures as per

modern is based upon conservative and surgical

management via decreasing inner sphincter tone and hence

facilitates the blood flow with subsequent tissue healing.

The use of medications and surgery are two treatment

options. Traditional pharmaceutical care involves the use

of muscle relaxants, commonly topical and occasionally

oral agents. These medications include calcium channel

blockers, Botulinum toxin, nitrates (ISDN or glyceryl

trinitrate (GTN)), agonists and antagonists of the -

adrenoreceptors, agonists of the muscarinic receptor, and -

adrenoreceptors. Gonyautoxin, a paralytic neurotoxin

derived from shellfish, is one of the more recent

pharmacological agents being tested.

Operative management:

i. Lateral internal sphincterotomy.

[29]

a. Open method

b. Closed method

ii. Lord’s anal dilation (blunt sphincterotomy)

[30]

iii. Fissurectomy and local advancement flap

[31,32]

Anal dilatation, as well as lateral internal sphincterotomy,

are two common operative techniques. Several colorectal

surgeons believe that finger anal dilatation is no longer an

effective treatment since it has been linked to the

emergence of anal incontinence. For treating persistent

fissures, lateral sphincterotomy has long been widely

recommended. Local flap operations like V-Y

advancement flaps and rotation flaps are examples of more

recent surgical interventions. The fissurectomy and

fissurotomy procedures were developed in response to

efforts at fissure correction. The advancement of calibrated

and regulated processes using anal dilatators or pneumatic

balloons is the result of renewed interest in the anal

dilatation technique. Sphincteroly, a novel technique for

bluntly dividing internal sphincter fibers, also has been

tried.

[33]

Discussion:

Anal fissures can have a significant adverse effect on

patients' quality of life. Major symptoms of this disease are

severe agonizing pain and burning sensation during and

after defecation which lasts for some hours and is

associated with a hard stool pellet and there is a drop of

blood or streak of fresh blood. Various treatment

modalities as per Ayurveda and modern medicine are

practiced worldwide. Different studies are conducted to

check the effectiveness of the single treatment modalities

as well as comparative studies.

The study was conducted on 135 patients who underwent

lateral internal sphincterotomy and received injections of

botulinum toxin to treat CAF. In this study, lateral internal

sphincterotomy has shown a higher complication rate than

botulin toxin injection but the recurrence rate was found to

be more in botulin toxin injection.

[34]

A study was conducted at the SBV University,

Pondicherry, India, a randomized study contrasting topical

2 % diltiazem against LIS for the management of CAF. 90

CAF patients (45 in each group) were divided into groups

A and B. The study concludes that LIS provides rapid pain

relief and healing of fissures, and it offers an effective

treatment choice. However, topical diltiazem is safe, and

easy to use with minimal adverse effects and may be

considered the first option.

[35]

In a prospective experiment, 60 surgical patients with

persistent fissures in ano were randomly assigned to Group

1 (Diltiazem gel) and Group 2 (internal sphincterotomy),

each with 30 patients. According to the study, Chemical

Sphincterotomy with Topical Diltiazem 2 percent should

be recommended as the initial course of therapy for

persistent anal fissures. Patients who have therapeutic

failure from past pharmacological therapy and relapse

should be administered internal sphincterotomy.

[36]

In a study patients were randomly randomized to receive

treatment either with a basic anal dilatation or a lateral SC

sphincterotomy. The allocation of patients was 30 for

lateral SC sphincterotomy and 28 for straightforward anal

dilatation. They concluded that lateral SC sphincterotomy,

as opposed to anal dilatation, is the preferred course of

treatment for individuals with chronic anal fissures.

[37]

In a study, ninety people diagnosed with fissure in ano

Glyceryl Trinitrate(GTN) Lotion significantly reduced

discomfort, prevented hemorrhage, and promoted

recovery. After 12 weeks, the GTN group demonstrated

that 86.6 percent of the chronic anal fissure had healed. At

6 and 12 weeks, however, the LIS group demonstrated

86.7% and 100% healing of the CAF, and the PIS group

demonstrated 80% and 100% healing of the chronic anal

fissure, respectively. Twenty percent of patients in the

GTN group experienced mild headaches as a secondary

effect, which were effectively handled with

acetaminophen. Although not substantial, comorbidities

including anal leakage and flatus incontinence were

somewhat more common after posterior sphincterotomy

than after lateral sphincterotomy. LIS thus outperforms

PIS.

[38]

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In a study of 50 patients having CAF participated in quasi-

experimental research at a university hospital in Kerman,

where 25 got 20 units of botulinum toxin and 25 had LIS.

Botulinum toxin was found to be an efficient non-invasive

option in the clinical assessment for the management of

CAF.

[39]

According to the results of some other non-randomized

controlled experiments LIS and botulinum toxin injection

therapies appear to be equally beneficial in the

management of CAF,.

[40]

In a study conducted at Shahed University's performed a

prospective randomized controlled experiment. In this

research, 130 CAF patients were included. Two groups of

patients were created randomly. 65 individuals got oral

nifedipine (ON) and the same amount received topical

nifedipine (TN) . In the topical nifedipine group, ulcer

healing happened in 43 (73.33%) patients as opposed to 29

(49.5%) patients who received oral nifedipine, which was

substantially different (P 0.05). The oral nifedipine group

experienced higher adverse effects than the topical

nifedipine group, including headaches and redness.

Topical nifedipine has a greater function for treating anal

fissures with a positive effect and fewer complications,

even though oral nifedipine can lessen anal fissure

symptoms and indicators.

[41]

The study was carried out at the general surgery division

of a tertiary care facility in Eastern India. It was discovered

in this study that LIS was a superior kind of therapy for

CAF to fissurectomy. LIS had fewer postoperative

complications than fissurectomy. However, there was no

relapse in the fissurectomy group, although there was a

greater rate of relapse in the LIS group.

[42]

In a study Yashtimadhu Ghrita was administered to 18 of

the 36 patients admitted in Group A (n = 18), while

lignocaine-nifedipine ointment was applied locally to 18 of

the 36 Parikartika patients in Group B (n = 18). When

treating Parikartika symptoms, Yashtimadhu Ghrita and

lignocaine-nifedipine ointment both are similarly efficient

(acute fissure in ano). Mild adverse effects were reported

with lignocaine-nifedipine ointment.

[43]

In a study there were 30 patients with fissures in the ano,

of which 15 were in group A and 15 were in group B.

Group A (Ksharasutra) took less time than Group B to

provide postoperative pain, bleeding, edema, and tissue

repair alleviation (OLIS). OLIS produced superior

outcomes in the treatment of Parikartika relative to

Ksharasutra ligation (chronic fissure-in-ano).

[44]

In a study, patients with CAF were arbitrarily chosen from

the OPD and IPD of ShalyaTantra, IPGT, and RA, Gujarat

Ayurved University, Jamnagar, Gujarat, India. 50 patients

in Group A and 50 patients in Group B.

Group-A: Under appropriate anesthetic, Ksharasutra

suturing (KSS) at the fissure bed and trans-fixation of the

sentinel tag, if present, were performed. Compared to

Group-A, patients in Group B (KSS with Lord's anal

dilatation) experienced lower postoperative discomfort and

recovered faster (KSS). Each group’s surgical wounds

healed in 21 days, so it can be deduced that neither

Ksharasutra nor the rectal installation of Jatyadi Taila,

which aided in the rapid healing process, caused any

septicemia. No unfavorable medication or Ksharasutra

side effects were seen throughout or during this surgery.

The study's findings revealed that Ksharasutra is one

modality that may be employed to treat Parikartika.

[45]

There were 50 Parikartika patients altogether. Standard

Apamarga Ksharasutra,sitz bath Panchavalkala kwatha,

Eranda Bhrishta Haritaki Churna 5 g at night, along with

Triphala Guggulu Vati and Jatyadi Taila Pichu (Gauze

soaked in oil) for regional retention over the anal area.

Sentinel pile ksharasutra trans-fixation and ligation (KSL)

an appropriate anesthetic was used when working with the

fissure bed. The study concluded that Parikartika

Ksharasutra ligation, which involves lesser postoperative

discomfort and is simple to conduct, is a great substitute

for contemporary surgery. After the Ksharasutra was

removed, the wound continued to be normal, and the mean

surgical wound recovery duration was 21 days.

Consequently, it is an effective method for treating chronic

fissures.

[46]

In a study of 50 patients were diagnosed with Parikartika

treatment lasted a single stage with Ksharasutra suturing

for Parikartika, and patients were evaluated every week

for up to four weeks at the IPD (male and female Shalya

wards) as well as after leaving the hospital. In all, 56

percent of patients were judged to be cured, while 28

percent of patients were reported to be improving. 10% of

patients showed substantial improvement, while 6% of

patients showed modest improvement. As a result, all

patients received treatment by the evaluation criteria

established for the needed duration for relief in signs and

symptoms, and no patient was identified as having "No

alleviation."

[47]

In a study of 130 cases , 70 cases got complete relief, 29

cases got marked relief.14 cases got moderate relief, 1 case

got mild relief while 16 cases were dropped out from the

study as they did not turn up for follow-up. Thus it is

concluded that the efficacy of this treatment is highly

encouraging and the fissure healed without leaving any

scar. And this can be achieved with minimum expenditure

and without any risk. The principal drug and the

supportive therapy including the diet prescribed, dose

schedule, and duration of the treatment are as Kasisadi

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Taila Vasti, Hot sitz bath: 2-3 times a day, Jatyadi Ghrita:

Applied externally as well as rectally once a day Triphala

Churna: 3 gm At bedtime with Luke warm water as a

laxative Diet: Avoid spicy and non-vegetarian food and

Take plenty of water and milk at bedtime.

[48]

Conclusion:

Due to the popularity of fast food, the majority of people's

diets are unpredictable today. One also lives a sedentary

lifestyle and experiences continual stress. These all result

in Agnidushti(vitiation of digestive fire), which in turn

results in several disorders. Anorectal diseases are the most

common of them. According to Ayurveda,

Nidanparivarjan(avoiding causative factor) and shaman

Chikitsa ( palliative treatment) assist to avoid the disease

since, as the saying goes, prevention is always preferable

to treatment. The Ayurvedic therapy methods include

shaman Chikitsa (Agnideepana, Aamapachana, and Vata

Pitta Shamak Dravya) Basti Karma, Pichu Dharan, and

Awagaha Sweda. Para Surgical procedures include

Agnikarma, Shastrakarma, as well as Ksharakarma

(Vrana Shodhaka and Vrana Ropaka). Anal dilatation,

sphincterotomy, fissurectomy, antibacterial, purgatives,

and lotions are among the therapies used in

allopathy medicine. Modern surgical therapy is more

useful for CAF than Ayurvedic medicine. Modern

surgeries make use of advanced equipment which has a

targeted approach and are focused on reducing

complications and hospital stay. But they require special

expertise to perform and also are not widely available and

they are not cost efficient. Also, they come with

complications and recurrence. On the other hand,

Ayurvedic modalities focus on lifestyle modifications

along with surgical management and are aimed at reducing

the recurrence of the disease, and have minimal risk and

side effects. Thus the integrative approach using both

modern and Ayurveda treatment modalities should be done

to improve the outcomes in the management of fissure-in-

ano.

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