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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.