Diagnosis and Ayurvedic Management of Antah Pranashta Shalya (Bone Piece)Cause for Bhagandara – A Case Report

Introduction

We get a reference of group of diseases called as Ashtamahagada¹ which are considered difficult to treat. One such disease is Bhagandara, which is defined as the disease which causes splitting or discontinuity in the region of Bhaga, Vasti and Guda. ² Bhagandara is one of the commonest diseases occurring in ano-rectal region which is difficult to treat because of its high recurrence rates. Kshara karma is mentioned to be one of the treatment for the Bhagandara³ which has the properties like Dahana, Pachana, Darana, Shodana, Ropana, Shoshana, Lekhana etc.⁴ Unmargi⁵ is a type of Agantuja Bhagandara which is caused by the ingestion of non-veg diet along with the bone piece. The ingested bone piece acts as a foreign body and gets lodged in guda pradesh causing Bhagandara. The same explanation was given for Shalyaja Bhagandara by Bhavamishra. 6 Concept of Pranashta shalya is a masked subject which elaborately tells about the diagnosis and treatment of embedded foreign body.

Case Report

In the present case report, a 48-year-old male patient, a medical store worker by occupation visited Shalyatantra OPD on the evening of 03rd December 2021. He reported with a chief complaint of swelling with throbbing type of pain in the perianal region since three days. This was creating hindrance in passing the stools, and while walking and sitting.

Anubhandi vedana

Patient had developed fever on the second day which subsided on taking Dolo 650

Vedana Vruttanta

Patient was apparently normal before three days and he reported to have suddenly developed swelling with throbbing pain in the perianal region. He developed fever on the second day after which he consulted a local doctor and received treatment. Though the fever had subsided after this, there was no variation in the swelling and pain. So he consulted Shalyatantra OPD of Ayurveda Mahavidyalaya and Hospital, Hubballi.

There was no significant family history, past medical history and past surgical history in relation to the present condition.

Purva Chikitsa Vruttanta

The patient was advised to take Amoxicillin with Potassium clavulanate 625 mg BD and Paracetamol 650 mg TID by the local doctor he previously visited and the patient was on these medications at the time of the visit.

Local Examination

On local inspection of per-rectal area, a shiny induration at 6’O clock position was seen. Further digital examination of rectum confirmed normal sphincter tone and there was a tender button like induration point 3–4 cm away from the anal verge.

Systemic Examination

Vitals of the patient were within normal limits. Systemic examination did not reveal any abnormal findings. Among Ashtavidha Pariksha, Mala was reported to be painful with painful defecation since three days, while all the others were within normal limits.

Differential Diagnosis

Arsha (Inflamed or Strangulated Pile mass)

Bhagandara Pidaka/ Guda vidradhi (Perianal Abscess)

Diagnosis

On local per-rectal examination, swelling was observed away from the anal ring and there were no haemorrhoidal veins involved in the swelling. A tender button like induration point was noticed 3–4 cm away from the anal verge. Thus it was concluded as a clear case of Bhagandara Pidaka/ Guda vidradhi.

Investigations

Before taking the patient for the procedure, the following haematological investigations were performed to rule out any systemic issues.

Treatment Plan

As it was a case of abscess, an emergency attempt was made for Incision & Drainage followed by Ksharasutra Ligation.

Treatment Prior to the procedure, patient was clearly explained about the operative procedure and verbal consent was obtained.

Purvakarma

Part preparation was done followed by Inj. Tetanus 0.5 cc intramuscular and test dose Inj. Xylocaine 2% 0.2 cc intradermal was administered; then the patient was shifted to OT.

Pradhanakarma

After taking the patient to the operation theatre, he was made to adopt a lithotomy position and the perianal region was exposed. The part was painted with povidone iodine (betadine) solution followed by spirit by using a sterile cotton swab held by sponge holding forceps under all aseptic precautions. Then the part was draped using sterile cut sheets exposing the perianal region. Perianal abscess was found to be localised at 6 ‘o’clock position and was further examined for any induration. Inj. Xylocaine with adrenaline 2% was infiltrated locally around the anal verge and the perianal abscess, thus achieving rhomboidal block. A cruciate incision was made over the abscess using a No. 11 surgical blade and pus was drained from the abscess. On examining the anal canal by digital examination of the rectum after pus drainage, a foreign body was felt localised at the posterior segment of the rectum and the foreign body was confirmed by doing proctoscopic examination. Then foreign body was held with artery forceps and was extracted from the anal canal carefully. The extracted foreign body was about 4 cm in length and 2 mm in diameter. Then the probing was done from the incised opening to the internal opening to confirm the track and Apamarga Ksharasutra was ligated in the same track. Figure 1: Ksharasutra Ligation Perfect haemostasis was achieved and a pack soaked in Jatyadi taila was placed in the anal verge (Figure 1).

Paschat karma

Patient was shifted to the ward and was kept under observation for four hours. The pack was removed after four hours.

Follow up and Outcome

Patient was asked to visit every week for changing Ksharasutra. During these follow up visits, the wound was observed to be healthy and the track was reducing in size.

Discussion

The treatment of Bhagandara challenged physicians and healers for thousands of years. Even after development of medical science, there is not a specific or standard treatment for treating the disease than the Ksharasutra. The major reason for the cause of anal fistula is the infection of the anal glands, but some other factors such as Tuberculosis, Crohn’s disease, and occasionally foreign body can also be considered to be contributory. In the present case, the foreign body, a hard structure i.e. bone piece was the causative factor. It was consumed along with food unknowingly, moved to different levels and settled in Guda Pradesha causing Guda Vidradhi. On mere observation, the causative factor could be masked; however, on repeated examination and careful observation, the causative factors can be identified and the disease can be treated successfully. In the present case, it was masked by the tenderness and swelling of the anal canal and perianal region. After the drainage of abscess, the foreign body was removed from the site.

Bhagandara being one of the troublesome diseases, care must be taken for diagnosis and treatment of the disease. Otherwise, it could lead to recurrence. Ayurveda being an ancient science had explained a gold standard treatment called Ksharasutra which is the answer to all the problems faced while treating the Bhagandara by other faculty doctors.

Patient Prospective

I suffered with swelling and unbearable pain in the anal region and visited a local clinic for relief. Even after taking medication, it did not subside. Again I visited the same doctor for treatment after which he referred me to this hospital. The doctor in this hospital explained me the whole procedure and operated for the same.

During the operation, they found a bone piece which was consumed by me 6-7 day prior. After the procedure, doctor advised regular follow-up visits every week. The whole procedure was completed within one and half months.

Patient Consent

Taken

Financial support and Sponsorship

Nil

Conflict of interest

No