From,
Dr. Maheshkumar Gujar,
I Year MS (Ayu),
Dept. of P.G Studies in Shalya Tantra,
Govt.AyurvedicMedicalCollege,
Bengaluru.
To,
The Registrar,
RajivGandhiUniversity of Health Sciences,
Bengaluru.
Through:
The Principal,
Govt.AyurvedicMedicalCollege,
Bangalore.
Respected Sir,
Sub: Submission of completed proforma for the registration of subject for
dissertation.
I, request you to kindly register the below mentioned subject against my name for submission of dissertation to Rajiv Gandhi University of Health Sciences, Bengaluru as partial fulfillment of MS (Ayu) in Shalya Tantra.
Title of Dissertation: A STUDY ON THE EFFICACY OF GHRITAMANDA ANUVASANA BASTI IN THE MANAGEMENT OF PARIKARTIKA W.S.R. TO FISSURE- IN-ANO.
Herewith, I am enclosing completed proforma for registration.
Thanking you,
Place: Bengaluru yours sincerely,
Date : (Dr. Maheshkumar Gujar)
RAJIVGANDHIUNIVERSITY OF HEALTH SCIENCES,
BANGALORE, KARNATAKA.
ANNEXURE - II
COMPLETED PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1.NAME OF THE CANDIDATE : DR. MAHESHKUMAR GUJAR
AND ADDRESS I YEAR MS (AYU),
DEPT. OF PG STUDIES IN
SHALYATANTRA,
GOVERNMENTAYURVEDIC
MEDICALCOLLEGE,
BENGALUR, 09.
RESIDENTIAL ADDRESS : S/O SHASHIKUMAR GUJAR.,
VASU JOSHI COMPOUND,
GUJJAR GALLI, NEAR DARBAR
HOUSE, BIJAPUR.
2. NAME OF THE INSTITUTE :GOVERNMENT AYURVEDIC
MEDICALCOLLEGE,
BENGALURU.
3. COURSE OF STUDY : AYURVEDA DHANVANTARI,
IN SUBJECT I YEAR M.S.(AYURVEDA)
SHALYA TANTRA.
4. DATE OF ADMISSION TO : 02.11.2010
THE COURSE
5. TITLE OF THE : A STUDY ON THE EFFICACY OF
DISSERTATION GHRITHA MANDA ANUVASANA
BASTI IN THE MANAGEMENT OF
PARIKARTIKA W.S.R. TO
FISSURE-IN-ANO.
6. BRIEF RESUME OF THE INTENDED WORK
6.1 NEED FOR THE STUDY:
The earliest reference about ‘parikartika’ is available from Sushrutha Samhitha (1000 B.C). We will get description about parikartika in all Bruhatrayees and later period authors of Ayurveda. The word parikartika is mentioned in Bastikarma vyapath and Vamana-virechana vyapath. Sushrutha specifies that for virechana vyapath it is Gudaparikartika and for vamana it is kantakshanana. Kashyapa has described its types in the purview of Garbini chikitsa.
The condition fissure-in-ano commonly encountered in surgical practice has similar location, pathology and predominant features of parikartika like excruciating pain, constipation, stools streaked with blood etc. Thus it is evident that parikartika can be correlated with fissure-in-ano mentioned in Allopathic science.
Fissure in ano is very commonly encountered in current day to day practice. It comprises of 6-15% of anorectal disorders and is characterized by excruciating pain during and after defecation, bleeding per anum with spasm of anal sphincter.
Fissure-in-ano is a medico- surgical condition. Medical management is said to be conservative and surgical intervention is the ultimate choice in the chronic ulcers. Medical treatment for acute fissure is oral pain killers, stool softeners, soothing ointment and self dilatation (using anal dilators) on medical advice etc. Surgical management includes Lord’s dilatation, sphincterotomy, fissurectomy, anal advancement flap.
All these methods of modern science have one or another drawback. Prolonged administration of NSAID may suppress the symptom 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.
In surgical treatment complication being haematoma, abscess formation recurrent ulcer formation and persistent mucous discharge. Most of the methods of treatment are expensive and requires long stay in the hospital. Lord’s dilation which is associated with the risk of transient faecal incontinence, after lay opening, the patient has to bear severe excruciating pain, despite of taking analgesics for 5-6days.
To overcome all these problems and to prevent surgical intervention, the present study is planned to evolve an effective treatment by Ayurvedic approach. In Ayurvedic management snigdha, madhura, sheeta dravya sevana, application of pichha basti and Anuvasana basti with yastimadhu taila or ghrita manda and many other medical lines of treatment has been explained. Hence in this study an attempt is made to evaluate the efficacy of Ghritamanda Anuvasana basti which has combined action like vrana ropana due to its madhura rasa, anulomana due to its sara guna, shoolagna property. Matrabasti is a type of Anuvasana basti and can be administered more conveniently and has an altogether better effect.
Keeping in view of the lacunas of different modern medical treatments, there is a need for an effective, safe, economical, simple and short term therapy.Ghrita manda Anuvasana 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 Ghrita manda Anuvasana basti as an effective, economical and short term treatment for Fissure in ano. To establish the significance of the effect of Ghrita manda, another study with Doorvataila and its effect on Parikartika has also been taken up which has already been established with 85 % of success rate from previous studies.
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:
क्षाqÉåhÉÉÌiÉqÉëÑSÒMüÉå¹åhÉ qÉÇSÉÎalÉlÉÉ Âक्षोष्णuÉÉ AÌiÉiÉÏक्षोष्णuÉÉ AÌiÉsÉuÉhÉqÉÌiÉÃक्षqÉç uÉÉ mÉÏiÉqÉÉæwÉkÉÇ
ÌmɨÉÉÌlÉsÉÉæ mÉëSÕwrÉ mÉËUMüÌiÉïMüÉqÉÉmÉSrÉÌiÉ|
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:
iÉ§É aÉÑSlÉÉÍpÉqÉåRíûoÉÎxiÉÍvÉUÈxÉÑ xÉSÉWû mÉËUMüiÉïlÉqÉÌlÉsÉxÉÇaÉÉåuÉÉrÉÑÌuÉwiÉqpÉÉå pÉ£üÉÂÍcÉ¶É pÉuÉÌiÉ|
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)
iÉÏuÉëvÉÔsÉÉÇ xÉÌmÉcNûÉxÉëÉÇ MüUÉåÌiÉ mÉËUMüÌiÉïMüÉqÉç||
Severe pain, slimy discharge or slimy discharge with blood.3 (Si.Ch. 6 Sl. 62 p.629)
CHIKITSA OF PARIKARTIKA:
iÉ§É ÌmÉcNûÉoÉÎxiÉrÉï̹qÉkÉÑ¢üwhÉÌiÉsÉMüsMüqÉkÉÑrÉÑ£üÇ, vÉÏiÉÉqoÉÑmÉËUÌwÉ£üqÉç cÉælÉÇ mÉrÉxÉÉ pÉÑ£üuÉliÉÇ bÉëiÉqÉhQåûhÉ rÉ̹qÉkÉÑMüÍxÉkSålÉ iÉæsÉålÉ uÉÉ AlÉÑuÉÉxÉrÉåiÉç||
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.3 (Ci. Ch. 34 Sl. 16 p.595)
GHRITA MANDA DEFINITION
विलिनघ्रृतस्य घनीभूत उपरितनो भागो मण्ड:।
Vilina ghrtia means the ghrita which is completely setteled, so the supernant /upper layer of ghrita which is above the ghanibhuta bhaga(thickened part) is known as ghrita manda.4 (Su.Ch.45.Sl.106.p.205 Dalhana commentary )
असिक्थो मण्ड:
That without thick part is manda. 4(Su.Ch.46.Sl.344.p.238 Dalhana commentary).
GHRITA MANDA GUNAS
सर्पिर्मणड: मधुर सर: योनि स्रोत्राक्षिशिरसांशूलघ्नोबस्तिनस्याक्षिप्रपूर्णेषुपदिश्यते॥
Sarpimanda is sweet, laxative, relieves the pain, of vagina, ears, eyes and head usefull for therapies like enema, nasal drops.6 (Su.Ch.46.Sl.344 P.425).
MATRA OF MATRA BASTI
तत्रनुवसनाख्यो हि बस्तिर्य: सो अत्र कथ्यते।
अनुवसनभेदश्च मात्राबस्तिरुदीरित:॥
पलव्दयं तस्य मात्र तस्मात् अर्धादपिवा भवेत्।
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)7.(Pk. Ch.7.(v) Sl.84. p.572 )
MODERN VIEW:
FISSURE-IN-ANO:
The cases of Parikartika which can be correlated with Fissure in ano having the features namely excruciating pain in anal region, bleeding during and after defecation,
INCIDENCE:
It is more common in women, mostly seen between 30-50 yrs of age. It occurs commonly in the midline posteriorly, the least protected part of anal canal. In males fissure usually occurs in midline posteriorly (90%) and much less anteriorly (10%). In female on the midline posteriorly are slightly common than anteriorly. The relative frequency of anterior fissure in females may be explained by trauma caused by fetal head on the anterior wall of the anal canal during delivery.
AETIOLOGY:
- Constipation – most common aetiological factor.
- Spasm of the internal sphincter has also been incriminated to cause fissure-in-ano
- When too much skin has been removed during operation for haemorrhoid, anal stenosis may result in which anal fissure may develop when hard motion passes through such stricture.
Secondary causes:
- ulcerative colitis
- Crohn’s disease
- syphilis
- 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 symptom
There are 2 types of fissure-in-ano
- Acute
- Chronic
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 margin. 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. Inflammation and indurations always present at the margin. Base consists of scar tissue and internal sphincter muscle. Spasm of internal sphincter is always present.
CLINICAL FEATURES:
Pain in anal region during and after defecation
Constipation
Bleeding per anum i.e stools streaked with blood
Burning sensation in anal region
Sentinel pile refers to tag of skin at the outer end of the fissure
Discharge
TREATMENT:
Conservative, pain killers, stool softener, soothing ointment, dilatation using anal dilators
Surgical, Lord’s dilatation, posterior sphincterotomy, lateral anal sphincterotomy, excision of anal ulcer5.
ABBREVIATION:
Ci. – chikitsa sthana
Si. – siddhi stana
Sl. – shloka
Ch. – chapter
Su. – sutra stana
Pk – poorva khanda
6.3 OBJECTIVES OF STUDY:
- To evaluate the efficacy of Ghrita manda Anuvasna basti (matrabasti) in the management of Parikartika.
- To evaluate the efficacy of Doorvataila matrabasti in management of Parikartika.
- To evaluate the significance of Ghrita manda Anuvasna basti(matrabasti) in the management of Parikartika by comparing its effects with Doorvataila matrabasti on the same.
PREVIOUS WORKS DONE:
- Sindhav vijayasinha. V – Role of yastimadhavdi Ghrita in the management of
parikartika w.s.r fissure-in-ano (Dissertation). Jamnagar: Gujarat
AyurvedicUniversity; 2001.
- Raghavendra. B – Effect of Doorvadi taila in the management of parikartika
w.s.r to fissure-in-ano (Dissertation). TMAE society’s Ayurvedic medical
college, Hospet: RajivGandhiUniversity; 2005.
- Aravind kumar – management of parikartika by Doorvadi taila pichu and
Gudamarga vivardana a comparative study (Dissertation). Ayurveda
Mahavidyalaya, Hubli: RajivGandhiUniversity; 2006.
- Abhinetri Hegde- “Management of Parikartika / Fissure-in -ano with
Doorva taila and Yashtimadhu taila – A Comparative Study”Govt
AyurvedicMedicalCollege, Bengluru: RajivGandhiUniversity;2010.
7. METHODOLOGY:
7.1 SOURCE OF DATA:
Patients with lakshanas of parikartika will be selected from the OPD and IPD of SJIIM Hospital, Bengaluru.
7.2 METHOD OF COLLECTION OF DATA:
The patients who are presenting with the features of Parikartika which can be correlated with 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 having classical features of Fissure in ano namely excruciating pain in anal region during and after defecation, bleeding per anum, constipation, burning sensation,presence of sphincter spasm and with a longitudinal ulcer in the anal region will be selected.
Acute Solitary fissures will be included.
B. EXCLUSION CRITERIA:
Patient with any other ano rectal diseases.
Patient with other systemic disorders.
C. SAMPLING PROCEDURE:
40 cases of Parikartika shall be selected and they will be distributed randomly in 2 groups namely Group A and Group B with 20 cases each.
D.STUDY DESIGN
Groups / Chikitsa / Vidhi / AvadhiA / Ghrita manda Anuvasana basti / Once Daily in morning / 7 Days
B / Doorvataila Matra basti / Once Daily in morning / 7 Days
In group A ghrita manda anuvasana basti (matrabasti) will be given after food in the morning, with or without bowel evacuation for 7 days.
In group B Doorvataila matra basti will be given after food in the morning, with or without bowel evacuation for 7 days.
To the patients of both groups Triphala choorna one karsha will be given daily at night during the procedure period with warm water as stool softener. As passing of hard stool will hinder the process of healing and to avoid further complications.
Advice: Roughage diet, increased intake of fluids for both groups.
The observations of the changes in features before treatment and after treatment shall be made and the same shall be recorded in the proforma of the case sheet prepared for the study.
The parameters will be suitably graded. Data obtained from the results will be analyzed by using suitable statistical methods and the results will be evaluated.
FOLLOW UP:
Duration of 60 days shall be fixed for observing possible recurrences in cases where total relief would be obtained with the treatment.
E. DURATION
The duration of the study will be 11/2 years.
F. ASSESSMENT CRITERIA:
Assessment will be made with the following parameters:
a .Subjective parameters:
- Pain in anal region
- Constipation
- Bleeding per anum i.e. stools streaked with blood
- Burning sensation in anal region.
b. Objective parameters:
- Ulcer healing
- Sphincter spasm.
7.3. Does the study requires any investigations to be conducted on the patients?- No
7.4. Has the Ethical Clearance been obtained from your Institution in involving the study subject (Human or Animal)? Yes
8. BIBILIOGRAPHY:
- Monier Williams. Sanskrit English Dictionary .Chaukhambha SanskritSeries.
1sted. Varanasi: pp.1333.
- Sushruta. Sushruta Samhita -Text with English translation by P V Sharma. 1st
ed.Varanasi: Chaukhambha vishwabharati; 2005. Vol II, pp. 695.
- Caraka. Caraka Samhita-Text with English translation by Prof. P V Sharma.
1st ed. Varanasi: Chaukhamba orientalia; 2005. Vol II, pp. 879.
- Sushruta. Sushruta Samhita- with the commentaries, Nibhandha Samgraha
Commentary of Dhalhanacharya edited by Vaiya Yadavji Trikamji
Acharya and Narayana Ram Acharya Kavyatirtha. 7th ed. Varanasi:
Chaukhambha Surabharati; 2002. pp. 824.
- S Das. A concise text book of Surgery. 4th ed. Calcutta: S Das; 2006 pp. 1344.
- Sushruta. Susruta Samhita - Text, English Translation, Notes, Appendices and
Index Translated by Prof. K.R.Srikantha Murthy.2nd ed. Varanasi:
ChaukhambhaOrientalia; 2004. Vol. I, pp. 656.
- Bhavamishra.Bhavaprakash of Bhavamishra -Text, English Translation, Notes,
Appendices and Index, Translated by Prof.K.R.Srinkantha
Murthy.Varanasi: ChowkamabhaKrishnadasAcademy; 2004, Vol I
pp. 738.
09 / SIGNATURE OF THE CANDIDATE10 / REMARKS OF THE GUIDE
11 / NAME AND DESIGNATION OF THE GUIDE / Dr. R. VIJAYASARATHI,
B.S.A.M., B.A.M.S.,M.D. (Ay),Professor ,
Dept. of P.G. Studies in Shalyatantra,
Govt.AyurvedicMedicalCollege,
Bangalore – 560 009
11.1 / SIGNATURE OF GUIDE
11.2 / CO – GUIDE
11.3 / SIGNATURE OF CO-GUIDE
11.4 / NAME AND DESIGNATION OF HOD / Dr. B.A. VENKATESH,
B.S.A.M., B.A.M.S., M.D.(Ay),
Professor & HOD,
Dept. of P.G. Studies in Shalyatantra,
Govt.AyurvedicMedicalCollege,
Bangalore – 560 009
11.5 / SIGNATURE OF HOD
12 / REMARKS OF THE PRINCIPAL
12.1 / SIGNATURE OF THE PRINCIPAL
1