PARIKARTIKA

(FISSURE IN ANO)

DEFINATION

PARIKARTAN VAT VEDANA

PARI – ALL AROUND

KARTANA VAT VEDANA – CUTTING PAIN

A CONDITION IN WHICH PATIENT EXPERIENCES A SENSATION OF PAIN AS IF GUDA IS BEING CUT AROUND WITH SCISSORS

ETIOPATHOGENESIS

1. VIRECHANA VYAPADA – MENTIONED BY CHARAKA & SUSHRUTA IN CONTEX OF VAMANA & VIRECHANA VYAPAD.(THIS DISEASE RESULTS WHEN A PERSON HAVING MRIDU KOSHTA & ALPA BALA,INGESTS TIKSHNA, USHNA & RUKSHA DRUGS FOR VIRECHANA.)

2. BASTI VYAPAD – IF RUKSHA BASTI CONTAINING TIKSHNA & LAVANA DRUGS IS ADMINISTERED IN HEAVY DOSE.

3. BASTINETRA VYAPADA – DUE TO INAPPROPRIATE ADMINISTRATION OF BASTINETRA & DEFECT IN BASTINETRA ITSELF.

4. VATAJA ATISARA – ACCORDING TO CHARAKA & VAGBHATA, IT IS A SYMPTOM IN VATAJA ATISARA DUE TO TRAUMA BY HARD STOOL

5. ACCORDING TO KASHYAPA THIS IS THE DISEASE OF GRAVID WOMEN.

6. EXCESSIVE USE OF YAPANA BASTI LEADS TO PARIKARTIKA ALONG WITH OTHER DISEASES

SYMPTOMS

SUSHRUTA – CUTTING & BURNING PAIN IN THE REGION OF GUDA, NABHI, MEDHRA & BASTISHIRA. ARREST OF FLATUS & LOSS OF APPETITE

(PAIN IN RG OF UMBILICUS, URINARY BLADDER & SUPPRESSION OF FLATUS ARE THE COMMON REFLEX SYMPTOMS OF ANAL FISSURE)

MANAGEMENT

A. LOCAL MEASURES

SUSHRUTA – 1) PICCHA BASTI WITH TILA KALKA + MADHUYASHTI + GHRITA + MADHU

2) ANUVASANA BASTI FORTIFIED WITH YASHTIMADHU OR GHRITMANDA

3) BASTI & PARISHEKA WITH OIL

CHARAKA – SNEHA BASTI, PICCHA BASTI, SHITALA BASTI FORTIFIED WITH KASHAYA & MADHURA DRAVYAS

B. GENERAL MEASURES

SUSHRUTA –1) COLD WATER BATH

2) FOOD WITH PLENTY OF MILK.

3) PITTASHAMAK CHIKITSA

SUMMARY –

1. DIPANA & PACHANA

2. VATAPITTA SHAMAN

3. COOLING EXT APPLICATION

4. PREPARTIONS TO COMBAT CONSTIPATION

TREATMENT AT GLACE

OIL BASTI – ANU / NARAYANA / YASHTIMADHU / JATYADI TAILA

SITZ BATH – WITH WARM WATER MIXED WITH ALUM

LAXATIVES – MRUDU ANULOMANA DRAVYA LIKE HARITAKI TO RELIEVE CONSTIPATION.

MODERN CONSEPT

► FISSURE – CRACK / SPLIT / CLEFT / GROOVE

► SYNONYMS – ANAL FISSURE, ANAL ULCER, ULCER IN ANO, FEACAL ULCER

DEFINATION

• ACUTE SUPERFICIAL BREAK IN THE CONTINUITY OF ANODERM IN MID POSTERIOR(12 O CLOCK) OR MID ANTERIOR(6 O CLOCK) POSITION

•

• AGE & SEX PREVALENCE 12 O CLOCK & 6 O CLOCK RATIO

IN WOMEN – 60:40

IN MEN – 90:10

• IN CHILDREN LATERAL SITES & MULTIPLICITY IS VERY COMMON

• MORE COMMON IN WOMEN THAN MEN

CAUSES OF SPECIFIC SITE

• THE ANAL WALL, AT REST IS JUST LIKE ANTERIO-POSTERIOR SLIT WITH ANTERIOR & POSTERIOR COMISSURES SAME AS THE ORAL

ANGULAR TISSUES, WHICH ARE MORE VULNERABLE TO PRODUCE FISSURE AT THIS SITE

• POSTERIOR WALL OF ANO-RECTAL

JUNCTION IS RELATIVELY POORLY

SUPPORTED BY MUSCULATURE ON THIS ASPECT

• POSTERIOR RECTAL WALL FORMS ACUTE ANGLE WITH THE POSTERIOR ANAL CANAL

ETIOLOGY

• OVERSTRETCHING OF THE EPITHELIAL LINING OF ANAL CANAL BY THE PRESSURE OF HARD FAECAL MATTER

• IN FEMALES PRESSURE EXERTED BY PARTURITION

TYPES

1. PRIMARY / SIMPLE / TRUE / NON SPECIFIC / IDIOPATHIC –

COMMONEST VARIETY

PRESENT AT 12 & 6 O CLOCK

DO NOT CROSS DENTATE LINE

RESPOND TO CONSERVATIVE TREATMENT VERY WELL

1. SECONDARY / SPECIFIC –

PRESENT AT SITES OTHER THAN 12 & 6 O CLOCK

ASSOSIATED WITH OTHER DISEASES.

a) MULTIPLE FISSURE IN ADULTS DENOTES SYSTEMIC DISEASE EX.- INTESTINAL TUBERCULOSIS, SYPHILIS ETC.

b) IF FISSURE CROSS THE DENTATE LINE - ULCERATIVE COLITIS, CHRON’S DISEASE, INTESTINAL TUBERCULOSIS, SYPHILIS

c) IF PRESENT WITH RUBBERY INGUINAL LYMPHNODE – PRIMARY SYPHILITIC INFECTION

d) Ca ANAL CANAL MAY CAUSE ANAL FISSURE

MAY BE SEEN FOLLOWED BY HEAMORRHOIDECTOMY

ANATOMICAL & PATHOLOGICAL CHANGES

IN ACUTE STAGE IT IS A SIMPLE LINEAR SPLIT IN THE ANODERM

IN CHRONIC STAGE

• ULCER MAY BECOME DEEPER. MARGINGS BECOME INDURATED & THICKENED(DUE TO REPEATED CONSTIPATED BOWEL)

• THERE DEVELOPES A TYPICAL SENTINAL TAG AT THE DISTAL END OF FISSURE.

• SIMULTANEOUSLY AN ANAL PAILLA DEVELOPS AT THE PROXIMAL END OF FISSURE WITHIN THE ANAL CANAL, WHICH MAY BECOME HYPERTROPHIED.

THESE 3 SIGNS ALTOGETHER IS CALLED AS TRIED OF CHRONIC FISSURE.

SYMPTOMS

PAIN –

ACUTE PAIN ASSOCIATED WITH DEFAECATION.

NATURE OF PAIN – CUTTING, TEARING, SPLITTING, BURNING.

MAY LAST FROM FEW MINUTES TO SEVERAL HOURS.

DEGREE OF PAIN VARIES FROM MILD DISCOMFORT TO EXCRUCIATING PAIN.

DUE TO THIS ACUTE PAIN PATIENT WITHHOLDS DESIRE TO DEFAECATE WHICH LEADS TO FURTHER CONSTIPATION

BLEEDING

QUANTITY OF BLEEDING IS VERY MINIMAL UNLESS COMPLICATED BY HEAMORRHOIDS OR OTHER DISEASE

DEEP ACUTE FISSURE SHOW ACTIVE & MORE THAN SLIGHT BLDING

IN CHRONIC FISSURE BLDING IS IN THE FORM OF STREAKING OR SPOTTING OF THE FEACES

DISCHARGE

MILD SEROUS DISCHARGE WHICH MAY SOIL THE UNDERCLOTHES & DEVELOP PRURITIS ANI

CHRONIC ULCER MAY LEAD TO SUBMUCOUS ABSCESS WHICH MAY BURST TO GIVE PURULENT DISCHARGE

REFLEX SYMPTOMS

PAIN IN LOWER ABDOMEN, DYSURIA

IF PAIN IS SEVER, THERE MAY BE RETENTION OF URINE

P/R EXAMINATION

ON INSPECTION - SENTINAL TAG,POST ANAL ABCSESS OR LOW ANAL FISTULA MAY BE SEEN.

ON PALPATION – DIGITAL EXAMINATION MAY NOT BE POSSIBLE DUE TO INTENSE PAIN.SPASM OF THE EXTERNAL SPHINCTER IS FELT IN DIGITAL EXAM.

CONSERVATIVE OPERATIVE ADJUVANT THERAPY

A) PALLIATION A) STRETCHING OF SPHINCTERS A) WARM SITZ BATH B) FISSURECTOMY B) HOT PACK / COMPRESS

(LOCAL C) INTERNAL POSTERIOR C) LAXATIVES

APPLICATION) SPHINCTERECTOMY D) ANAL HYGIENE

B) USE OF

ANAL

DIALATORS

C) INJECTION

TREATMENT

CONSERVATIVE MANAGEMENT

PALLIATION & LOCAL APPLICATION

ALL MEANS OF RELIEVING PAIN COME UNDER PALLIATION.

5% XYLOCAINE OINT.

ORALLY ANALGESICS

USE OF ANAL DILATORS

TO RELAX THE ANAL SPHINCTERS WHICH WILL ALSO HELP TO HEAL THE FISSURE.

SHOULD BE STARTED WITH ANAL DIALATORS OF SMALL SIZE

GRADUAL DILATATION USING LARGER DILATORS AT LEAST TWICE A DAY FOR A MONTH

EXCESSIVE DILATATION MAY LEAD TO INCONTINENCE.

INJECTION TREATMENT

LONG ACTING LOCAL ANAESTHETIC SOLUTION MAY BE INJECTED

OUTDATED NOW-A-DAYS, AS IT MAY CAUSE ABCSESS & FISTULA DUE TO NEEDLE INFECTION

OPERATIVE MANAGEMENT

STRETCHING OF SPHINCTER

BY LORD’S MANUAL ANAL DILATATION

DONE UNDER GENERAL ANEASTHESIA & PATIENT IN LITHOTOMY POSITION

FISSURECTOMY

WITH PATIENT IN LITHOTOMY POSITION,TRIANGULAR INCISION IS MADE WITH SCALPEL STRATING FROM ANAL MARGIN ON EACH SIDE OF FISSURE.WHOLE FISSURE BED WITH THE SENTINAL TAG IS EXCISED

INTERNAL SPHINCTERECTOMY

AFTER FISSURECTOMY THE INTERNAL SPHINCTERS ARE EXPOSED, WHICH CAN BE DIFFERENTIATED BY A FIBROUS BAND.

THESE FIBERS ARE EXCISED WHICH IS FELT BY THE ABSENCE OF RESISTENCE

POST OPERATIVE CARE

ANALGESICS

LAXATIVES

SITZ BATH

ADJUVENT THERAPY

WARM SITZ BATH – SHOULD BE ADVISED TO TAKE FROM NEXT DAY OF SURGERY UPTO WOUND HEALING. IT REDUCES PAIN & SWELLING

HOT PACK / COMPRESS – TO OVERCOME PAIN & INFLAMATION

LAXATIVES – FOR SMOOTH PASSAGE OF STOOL

ANAL HYGIENE – LAST BUT NOT LEAST. ANAL AREA SHOULD BE WASHED WITH DILUTED ANTISEPTIC LOTION.