Fistula

Anal Fistula
 Ano-rectal disorders

are progressively increasing in the society. Few important causes out of a number of them are; sedentary life style, irregular and inappropriate diet, prolonged sitting and/or standing and psychological disturbances like anxiety, depression etc. Ano-rectal problems coupled with psychological manifestations are the causes, inter-related to each other. As per Ayurveda, these above mentioned causes result in derangement of ‘Jatharagni’ (the digestive power) which leads to constipation and other associated symptoms. Constipation leads to generation of hard stool (fecolith) which when expelled leads to trauma in anal canal and ultimately generates Anal fissure. Constipation increases the back pressure onto haemorrhoidal vessels to produce Piles/Haemorrhoids. Crypto-glandular infection leads to ano-rectal abscess and Fistula-in-ano. Thus constipation seems to be the very important cause for most of these disorders. The fast food culture has again worsen the condition as these foods are devoid of dietary fibres.

These disorders are utterly embarrassing to the patient. The peri-anal skin is one of the most pain sensitive region in the body due to rich nerve endings. So, even a mild form of disorder can produce great discomfort to the patient. It has been observed that in the initial stages of the disease, most of the patients avoid consulting to the physician and explaining their problem particularly because they feel ashamed. They try to prevaricate it. This tendency is still more in females. This ultimately leads to manifold increment in their problem and the disease. When they visit to doctor for consultation, they are too mentally disturbed to lose the interest in life. They become very much anxious, many go in depression and few of them even try to attempt suicide.
Among the list of ano-rectal disorders, following are commonly seen;

    Piles (Haemorrhoids)
    Fissure-in-ano (Anal fissure)
    Fistula-in-ano (Anal fistula)
    Ano-rectal abscess


WHAT IS AN ANAL FISTULA?
Anal fistula, or fistula-in-ano, is an abnormal connection or channel like structure, between the surface of the anal canal and the exterior perianal skin.

Anal fistulae originate from the anal glands, which are located between the two layers of the anal sphincters and which drain into the anal canal. If the outlet of these glands becomes blocked, an abscess can form which can eventually point to the skin surface. The tract formed by this process is the fistula.
Ancient Ayurveda surgeon, Susruta has described five types of Bhagandara(Sataponak, Ustragriwa, Parisrabi, Sambukawarta, Unmargi). They have been classified according to the vitiation of the three doshas and the shape & site of the fistula tract.
  
CAUSES OF FISTULA?

Anal fistulas commonly occur due to an anal abscess.

An abscess is a collection of pus and infected fluid. An anal abscess usually develops after a small gland, just inside the anus, becomes infected with bacteria.

A fistula may occur if an abscess has not completely healed, or if the infected fluid has not been entirely drained away.

An anal fistula may also develop as a result of:

    a growth or ulcer (painful sore)
    a complication from surgery
    a congenital abnormality (a health problem that you were born with)

Anal fistulae are also a common complication of conditions that result in inflammation of the intestines. Some of these conditions include:

    Irritable bowel syndrome (IBS): a chronic (long-term) disorder that affects the digestive system, causing abdominal pain, diarrhoea and constipation.
    Diverticulitis: the formation of small pouches that stick out of the side of the large intestine (colon), which become infected and inflamed.
    Ulcerative colitis: a chronic condition that causes the colon to become inflamed and can cause ulcers to form on the lining of the colon.
    Crohn's disease: a chronic condition that causes inflammation of the lining of the digestive system.

SYMPTOMS OF FISTULA

Anal fistulae can present with many different symptoms such as:

    Pain
    Discharge - either bloody or purulent
    Pruritus ani– itching around the anus
    Systemic symptoms if abscess becomes infected

DIAGNOSIS OF FISTULA

Diagnosis is by examination, either in an outpatient setting or under anaesthesia. The examination can be an Anoscopy.

Possible findings:

    The opening of the fistula onto the skin may be seen
    The area may be painful on examination
    There may be redness
    A discharge may be seen
    It may be possible to explore the fistula using a fistula probe (a narrow instrument) and in this way it may be possible to find both openings of the fistula

AYURVEDA TREATMENT OF FISTULA
Kshara Sutra is utilized in the treatment of fistula in Ayurveda.

KSHARA SUTRA

Kshara Sutra is a seton thread medicated with organic alkalis,such as Apamargakshara(Achyranthesaspera), Arkakshara(Caltropisgigantea) or Snuhikshara (Euphorbia lingularia). The alkali is repeatedly coated on the seton thread 15 – 21 times. Apart from this, natural antibiotic like haridra powder, guggulu, etc are also used to make Ksharasutra. The mechanical action of the threads and the chemical action of the drugs coated , collectively do the work of cutting, curetting, draining, and cleaning the fistulous track, thus promoting healing of the track/ wound. This also acts both as the antiseptic and fibrotic agent to induce healing. The process of healing starts from deeper tissues and moves towards the periphery. This can be applied and changed periodically till the thread cuts the fistulous tract. Since the sphincter heals by fibrosis, there is no incontinence.

Under local anaesthesia, the kshara sutra is inserted into the tract and the two ends of the thread are tied forming a loop. The alkalis coated on the thread are continuously released throughout the length of the track there by cutting, curetting, draining cleansing and healing the track. This therapeutic action of the thread lasts for seven days. The old thread is then replaced with a new thread following the same procedure. Depending on the length of the tract and the extent of damage, the kshara sutra may be changed up to 5 times. The changing of the thread is a simple procedure taking about 1 to 2 minutes and requires no anaesthesia.

BENEFITS OF KSHARA SUTRA
    The procedure does not require hospitalization for more than 4 to 5 hours
    The patient requires minimal bed rest and can resume daily activities within 12 – 24 hours
    No painful dressings required
    The drugs coated on the Kshar-Sutra are slowly and gradually released into the track and the wound, leaving no abscess overseen. These abscess are drained out by the action of the drugs.
    The sphincteric muscles are not dissected and hence the possibility of incontinence is ruled out.

COMPLICATIONS OF FISTULA

Depending on the effectiveness of the treatment, fistula may result in infection or incontinence of stools.

RECURRENCE OF FISTULA

The reoccurrence rate of fistula treated with kshara sutra ligation procedure is less than 2%. This is because the medicines on the thread gradually and continually curate the payogenic membrane and fibrous tissue in the track and thus leave no pus pockets undrained.
In some cases, the fistula can reoccur despite having surgery. After having a fistulotomy, the reoccurrence rate rises to 21%. After an advancement flap procedure, the reoccurrence rate may be as high as 36%.

Ancient and modern physicians equally consider these conditions as difficult to cure. Moreover, among these three disorders, Fistula-in-ano is the most notorious one to tackle and cure. Results of surgery (fistulectomy) seem to be embarrassing as there is high recurrence in most of the cases even after complete excision of the track and meticulous post-operative dressings. There is a proverb often used by modern surgeons about this disease that “If you have enmity to a doctor, refer him a patient of Fistula-in-ano and it will never heal”.

The treatment of these disorders especially Fistula has been revolutionized after the availability of kshara sutra. Kshara sutra therapy has been scientifically standardized at BHU, Varanasi by Prof. P. J. Deshpandey and his team of co-workers.

Besides Kshara sutra, Ayurveda has a rich source of herbs based formulations mentioned in Classics, which can be effectively used to correct the gastrointestinal disturbances (disturbed agni) and  provide relief to such patient to a great extent. Moreover, the prevention from these diseases can be achieved if a person follows ayurvedic life-style and dietary regime.

Thus, proctology has been emerging as a highly specialized branch of Ayurveda since about last three decades and people are turning their faith towards Ayurveda to resolve their problems. Thus, in the interest of public, this science of healing should be propagated more and more so people can have a better health through Ayurveda.
 
Fistula-in-ano; 10 important tips you must know!

Fistula-in-ano is a disease in which there develops a track between perianal skin and/or rectum or anal canal. The main symptom that appears is mucopurulent discharge through the external opening present anywhere in the perianal area. This sometimes leads to itching and or burning sensation.

I am going to give 10 valuable tips for the patients of Fistula-in-ano which being an ano-rectal specialist doctor, I feel are necessary to be communicated to them.

1.     Many patients wander here and there in search of any doctor or medicines to cure Fistula and often waste their time, money and energy by getting trapped in the misleading advertisements, quacks etc. without any result. Remember, Fistula-in-ano is a 100% surgically curable disease. Sometimes, if fistula is due to tuberculosis then Anti-tubercular therapy can work to heal it otherwise surgical intervention is necessary in it.

2.     Beware of quacks and false claims’ advertisements like those of injection treatment, herbal treatment etc. seen commonly in media. Bengali, Chandsi, Madrasi are also not genuine and legal treatments. They can harm your health and can lead to complications like anal incontinence.
3.     Antibiotics can only temporarily reduce the symptoms like pus discharge but will not help in long term use.

4.     Conventional surgical operations for Fistula-in-ano have high recurrence rates, especially in high anal types. Fortunately, there have been excellent results obtained by Ayurveda Kshar Sutra therapy, which can be used extremely effectively to cure Fistulae of almost all the types completely, without any complication or recurrence. It has been well established and proven scientifically by various research centres in India like AIIMS, BHU, ICMR, PGI etc.
5.     One should not wait in seeking an expert physician’s/surgeon’s consultation due to shyness or hesitation. As soon as symptoms like persistent or intermittent discharge of pus, soiling of clothes, feeling of some abscess, pain in perianal region etc. appear, expert’s consultation must not be delayed.

6.     Since Ayurveda Kshar-sutra therapy is extremely effective in curing fistula-in-ano, one should prefer a qualified and experienced Ayurveda Kshar-sutra specialist doctor over other therapies physicians.

7.     Fistula patients feel pain when there is collection of pus inside the track or inside the abscess cavity. So, there must be measures to drain out the collected pus. Though kshar-sutra does the drainage by itself, patient can increase the drainage effectively by keeping themselves ambulatory. So, regular walks will help in healing of your fistula even if you are continuing the Kshar-sutra therapy.
8.      Have complete faith in your doctor. Afterall he has seen and helped many patients like you. Don’t be panic as kshar-sutra therapy sometimes takes longer times (3 months or more) to heal the fistula completely depending on the track length, type of fistula and many more factors.

9.     During the kshar-sutra therapy sometimes patient feels pain, burning sensation etc. during and/or after the weekly changing of thread. Have patience. Remember it is only temporary and ultimately you are going to get rid from this disease completely. Follow the instructions of your physician strictly.
10.     Sitz bath is a wonderful remedy in relieving the pain. It not only gives a soothing sensation and provides relief from pain but it also helps in keeping the perianal region clean. So, it should be employed correctly as per your doctor’s instructions.