The role of Prastisaraniya kshara in the management ofPerianal abscess

Introduction

As Abscess is a collection of pus in the body and pyogenic Abscess is the commonest variety of Abscess. A) Direct infection from outside due to penetrating wounds, B) Local extension from adjacent focus of infection, C) Lymphatics, D) Blood stream of hemorrhage. The cardinal features of acute inflammation are usually present. These are rubor (redness), dolor (pain), calor (heat) and swelling (tumor). The suppurative infection gradually leads to cell death and liquification.¹ The clinical features of Vidhradhi presenting swelling, pain, redness, local temperature can be correlated to abscess The aggravated Doshas vitiate the skin, blood, muscles, fat and bone tissue, become localised and produce a troublesome swelling - deep rooted, painful, slowly bulging called vidhradhi. When this Vidhradhi completes its pakwa avasta, it burst opens or we have to do bedhana karma to drain vitiated substances leading to a cavity² . The majority of anorectal suppurative disease results from infections of the anal glands (cryptoglandular infection) found in the intersphincteric plane. Their ducts traverse the internal sphincter and empty into the anal crypts at the level of the dentate line. Infection of an anal gland results in the formation of an abscess that enlarges and spreads along one of several planes in the perianal and perirectal spaces.³ The stages of treatment of Vranasopha and Vidhradhi are similar viz, Amavasta, Pachyamanavasta, Pakvavasta.⁴ Kshara possess the qualities like Shodana (cleansing) and Ropana (healing).⁵ Hence we planned the application of Pratisarana Kshara in the management of drained abscess cavity, as it enhances the healing property.

Case report

A 15 year old male patient came to Shalya tantra OPD at our hospital with.

Chief complaints of hard mass of swelling around the anus and discomfort in sitting from 12 days. Past history told by patient was previously 6 day before he had sever throbbing pain at perianal region and was associated with tenderness and fever.

On clinical examination we found externally a large tender mass, skin with red appearance and local temperature and on per rectal digital examination we found a soft tender mass at 3 O clock position in which fluctuation and fluid thrill test were positive and there were no any internal opening found. The mass was completely fixed and tenderness elicited. After thorough examination and detail history taking we diagnosed it as perianal abscess. Later the line of treatment was planned to do Incision and drainage followed by pratisaraniya kshara application under saddle block.

Preoperative Procedure:

• Patient was nil orally 6 hours before OT

• Enema was given before surgery

• Surgical profile investigations such as CT, BT, HB%, HIV, HbSAG , RBS, were done

• Consent of the patient,

• Injection Lignocaine test dose and part preparation was done And the patient was prepared for procedure according to standard protocol.

Operative procedure:

• Under saddle block with all aseptic precaution in lithotomy posture part painted and drapped, initially manual dialation of anal canal by lignocaine jelly

• Hiltons method is adopted when there are plenty of important structures like nerves and vessel around the abscess cavity, which are liable to be injured. A of sinus forceps is forced into through the deep fascia into the cavity and blades are gradually opened and the pus is seen to be extruded out. A finger introduced to explore the abscess cavity

• After complete breaking of pus loculi and the cavity was followed by pratisarinya kshara application for about 60 seconds and nimbu swarasa wash was given. And finally the yastimadu soaked pads were inserted in the cavity followed by anal pack and sterile dressing was applied.

Post operative: patient was shifted to post-op ward and anal pack was removed after 4 hours and orally started after 6 hours, sitz bath was advised with Triphala Kwatha twice a day and patient was discharged after 2 days hostipal stay with medication.

Discharge medicines:

Triphala Guggula BD

Gandhaka Rasayana BD

Abhayarista 10ml BD with water

Triphala choorna kashay sitz bath

Follow up: Every alternate day’s patient was asked to come for dressing and it took 5 weeks to heal completely later patient was called every month for follow ups for 6 months but no any reoccurrence of abscess or fistula in ano were found.

Discussion

The most of the perianal abscess pathology has postulate of crypto anal gland infection cause. Here we adopted incision and drainage followed by Pratisarana Kshara application, most of the perianal abscess and open wound around the anal opening are more vulnerable for infection and henceforth reoccurrences chances are more in the form of abscess or fistula in ano. Kshara are prepared from herbal drugs and it includes the basic properties of the original herbal drugs. Kshara is predominant with Agnibhuta (fire element) hence having teekshna property. It consists of Sparsha Guna (consistency property) due to its predominant of Vayubhuta (wind element) and hence give quick action. So, above factors clearly state that Kshara is having predominance of Agni and Vayubhuta. Kshara is having Tejobhuta (agni element) property predominantly hence it is having the property of corrosiveness. According to Shushruta Kshara is the most superior procedure among Shastra and Anushastra (sharp instrument and substitute of sharp instrument) because it is having superior qualities like chedana, bhedana, lekhana etc. So, Khara having Lavana (Salty),Tikta (bitter) Rasa; and Ruksha (dry), Teekshana Guna (properties); Ushna (hot) Viry (Potency); and Katu (Pungent) Vipaka (attributes of durg assimilation).

Conclusion

The surgical management of perianal abscess followed by pratisaraniya kshara application yields good result and it not only cures but also minimizes the rate of complication and re-occurrence. It is a good therapy in terms of cost of treatment.