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TITLE OF CASE

Ayurvedic management of Complex anal fistula with rectal communication - A case report       

Dr Ramesh Bhat

 

ABSTRACT

A 57-year-old male patient presented with complaints of severe pain in anal region associated with pus discharge for 2 years. He is a known case of type 2 diabetes mellitus and is under medication for the same. He had undergone two surgical procedures for his complaints. The first Procedure was Incision and drainage of ischiorectal abscess, and the second procedure was Seton replacement. The patient did not get complete relief from his symptoms. So he consulted Dr Ramesh Bhatt, who diagnosed this condition as Bhagandara. The primary treatment followed was Ksharasutra supported by internal medications. After undergoing Ksharasutra treatment for 4 months- the thread changed once every week, the pus discharge completely stopped and a repeat sonofistulogram showed no evidence of fistula in ano. The patient got complete relief from his symptoms and the medicines were stopped.

 

KEYWORDS

Fistula, ksharasutra, bhagandara, standalone, case report, ayurveda, primary threading

 

INTRODUCTION

A fistula-in-ano or an Anal Fistula is an abnormal tract that is hollow or a cavity lined with granulation tissue connecting a primary opening located inside the anal canal to another opening called a secondary opening located in the perianal skin. These secondary tracts can be multiple and may have their origin from the primary opening. This is a painful condition that can disrupt the normal activities of an individual. The symptoms are pus or blood exudation from the non-healing abscess, painful defecation, signs of infection like fever may also be present.

Diagnostic criteria: Physical examination and medical history are the primary diagnostic criteria. If the pain is too severe or it is a high-level fistula, then investigations like endoscopic ultrasound or MRI will be prescribed to identify the fistula tract. Internal fistulas may be evaluated using barium contrast X-ray, MRI or CT scan. The internal opening of the fistula can be identified with a Fistula probe, Anoscope, Flexible sigmoidoscopy or Colonoscopy, or an injected dye solution. In this patient, the diagnosis was confirmed with clinical examination and with a MRI Fistulogram.

Prognosis & Treatment:

There are surgical and non-surgical options of treatment. Fistulotomy, Endorectal advancement flap and Ligation of the intersphincteric fistula tract are the most commonly followed surgical procedure in the treatment of Fistula. The non-surgical procedures include seton placement, fibrin glue and collagen plug. But these procedures may cause complications like sphincter muscle damage leading to the incontinence of the sphincter, rectal prolapse, faecal soiling, and anal stenosis. Even after complete excision of the tract, the chances of recurrence are still present.

PATIENT INFORMATION

A 57 year old male patient presented with complaints of severe pain over the anal region associated with pus discharge since 2 years. Patient consulted modern hospital and was advised for MRI fistulogram. The MRI findings reveals posterior complex anal fistula. He is a known diabetic and is on anti-diabetic medication. 

Surgical History- Two surgical procedures in USA. First Procedure - Incision and drainage of ischiorectal abscess (12/8/2021). Second procedure – setons placement (21/10/2021).

No significant family/genetic/psychosocial history.

CLINICAL FINDINGS

Peri anus examination revealed induration over the right posterolateral region and two rubber setons were in situ. Digital rectal examination revealed induration and tenderness of anal mucosa at 6’O clock position at above the level of the anal valve. Peri anus skin exfoliation, edematous, chronic skin inflammation with active discharge through the external opening was observed.    

TIMELINE

Image 1. Timeline of events added below

DIAGNOSTIC ASSESSMENT

Modern Diagnostic parameter; The biomedical diagnosis was confirmed as Complex anal fistula with an MRI Fistulogram done in August 2021. (Reports not submitted). But on Ayurvedic consultation, December 2021, Sonofistulogram was done to confirm the diagnosis. 

Image 2. Baseline Sonofistulogram dated December 2021 added below

Ayurvedic Assessment was done based on the presenting complaints and clinical evaluation. The treating physician confirmed the Ayurvedic diagnosis as Bhagandaram.

Differential Diagnosis-  Vidradhi. 

On the basis of previous treatment records and special Investigations, the physician diagnosed the condition as bhagandara.

Prognosis- There are surgical and non-surgical options of treatment. Fistulotomy, Endorectal advancement flap and Ligation of the intersphincteric fistula tract are the most commonly followed surgical procedure in the treatment of Fistula. The non-surgical procedures include seton placement, fibrin glue and collagen plug. But these procedures may cause complications like sphincter muscle damage leading to the incontinence of the sphincter, rectal prolapse, faecal soiling, and anal stenosis. Even after complete excision of the tract, the chances of recurrence are still present.

This patient had already undergone two surgical procedures in USA. First Procedure - Incision and drainage of ischiorectal abscess (12/8/2021). Second procedure – setons placement (21/10/2021). But the symptoms persisted and hence he opted for Ayurvedic management. 

THERAPEUTIC INTERVENTION

Refer the tab ‘Treatment’ in the Portal. 

FOLLOW-UP AND OUTCOMES

The patient had 15 follow ups, once every week to change the Kshama sutra and also for examination by the physician. One primary threading and 13 Ksharasutra were applied before the patient got a complete relief from his condition.

Clinician-based assessment; On examination, the wound had healed completely. There is no pain or pus discharge. 

Patient-assessed; Not relevant

After undergoing one and half months of Ayurvedic treatment, there was a significant reduction in the symptoms- itching followed by bleeding observed rarely. After 5 months, the patient is completely free from all the symptoms. On examination, the skin is normal. There is no scaling or swelling. She is still continuing the Ayurvedic medicines.

Image 3. Endpoint Sonofistulogram dated April 2022 added below

Intervention adherence and tolerability – The patient adhered to the prescribed treatments and tolerated the treatments well. 

Method of assessment- Sonofistulogram before and after ayurvedic treatment were the primary methods of assessment. 

Adverse and unanticipated events; None reported

DISCUSSION ; 

The patient had been suffering from complaints since 2 years. He had undergone 2 surgical procedures - Incision and drainage and Seton replacement 4 months back, but the pus discharge persisted. After undergoing Ksharasutra treatment for 4 months, pus discharge completely stopped. The primary treatment modality Ksharasutra helped in draining the tract and healing the wound completely. Internal medicines like Triphala guggulu and Gandhaka Rasayana were given to help the healing process. 

PATIENT’S PERSPECTIVE

Not available. 

LEARNING POINTS/TAKE HOME MESSAGES 

This case report narrates the successful management of a case of complex anal fistula in a patient who had already tried 2 surgical procedures but did not get complete relief. With 1 primary threading and 13 kshara supported with Ayurvedic medicines, the tract was completely cut through and healed. A follow-up Sonofistulogram revealed no evidence of fistula or intersphincteric abscess.

INFORMED CONSENT

Written consent obtained from patient. 

ACKNOWLEDGEMENTS

None

CONFLICT OF INTEREST

None declared.

FUNDING

None

REFERENCE

1. Seow-Choen F, Nicholls RJ. Anal fistula. Br J Surg. 1992 Mar;79(3):197-205. doi: 10.1002/bjs.1800790304. PMID: 1555083.

2. Ahmad Mir, *Shaheen, & Kumar, P. H. (2017). Bhagandara and its management in Ayurveda: A conceptual study. International Journal of Ayurveda and Pharma Research, 5(8). Retrieved from http://ijaprs.com/index.php/ijapr/article/view/753