|Year : 2021 | Volume
| Issue : 3 | Page : 125-130
Effectiveness of anal infiltration with Murivenna oil, internal administration of Triphala choorna, sitz bath, and fiber diet protocol in acute and chronic anal fissures: A retrospective observational study
Pratap S Kizhakke Meladam, Pratibha P Nair, Gayathri Sureshkumar, Devarakonda Sudhakar
NARIP, Cheruthurthy, Kerala, India; CCRAS, Ministry of AYUSH, Govt of India, New Delhi, India
|Date of Submission||25-Jul-2021|
|Date of Acceptance||08-Feb-2022|
|Date of Web Publication||22-Mar-2022|
Dr. Pratap S Kizhakke Meladam
F2, Space Karuna Appartments, Puthur, Palakkad, Kerala.
Source of Support: None, Conflict of Interest: None
BACKGROUND: Anal fissure (fissure in ano) is an excruciating manifestation among common anorectal presentations. The condition inflicts significant personal and social ill health causing considerable morbidity. This study aimed at documenting the effect of Murivenna oil infiltration and Triphala choorna oral use along with sitz bath and fiber diet protocol in the management of fistula in ano. MATERIALS AND METHODS: Retrospective analysis of 15 cases diagnosed with primary fissure in ano who underwent prescribed conservative Ayurvedic treatment between March 2018 and February 2019 at the National Ayurveda Research Institute for Panchakarma, Cheruthuruthy, is reported. All patients were managed with anal infiltration of Murivenna oil (30 ml), internal administration of Triphala choorna (10 g), sitz bath, and fiber diet. Retrospective outcome analysis of recorded change in each case on study variables, viz. pain, bleeding per rectum (BPR), anal discharge, inflammation and tenderness, and healing of fissure, was recorded in structured proforma, was carried out using the Statistical Package for the Social Sciences. A Friedman test for repeated measures, followed by Wilcoxon post hoc test, was conducted on the study variables. Results with P-value<.01 were considered significant. RESULTS: Data of 15 patients was used for analysis. Complete healing of the fissure was documented in 93% of patients by the end of their respective 30th day. There was significant relief in symptoms of inflammation, tenderness, anal discharge, and bleeding per rectum (BPR) in most of the patients within their first 7 days of treatment. Median pain level assessed on VAS was significantly reduced from 9 (on the 1st day) to 1 (on the 7th day) and eventually to 0 on the 30th day. Statistically significant difference was observed in the percentage healing of fissure measured on the 8th day (78 ± 11.464), 15th day (91.33 ± 9.904), and 30th day (99.33 ± 2.582). CONCLUSION: The observatory report provides significant elementary evidence on the effectiveness of an Ayurvedic conservative treatment in managing acute and chronic primary fissure in ano.
Keywords: Ayurvedic conservative treatment, fissure in ano, observatory report
|How to cite this article:|
Kizhakke Meladam PS, Nair PP, Sureshkumar G, Sudhakar D. Effectiveness of anal infiltration with Murivenna oil, internal administration of Triphala choorna, sitz bath, and fiber diet protocol in acute and chronic anal fissures: A retrospective observational study. J Res Ayurvedic Sci 2021;5:125-30
|How to cite this URL:|
Kizhakke Meladam PS, Nair PP, Sureshkumar G, Sudhakar D. Effectiveness of anal infiltration with Murivenna oil, internal administration of Triphala choorna, sitz bath, and fiber diet protocol in acute and chronic anal fissures: A retrospective observational study. J Res Ayurvedic Sci [serial online] 2021 [cited 2022 Aug 13];5:125-30. Available from: http://www.jrasccras.com/text.asp?2021/5/3/125/340289
| Background|| |
Fissure in ano or an anal fissure is a prevalent proctologic condition wherein a longitudinal tear is manifested in the skin of anal canal below the dentate line. Clinically, a primary anal fissure presents with symptoms such as severe pain while defecation that may range from an initial few minutes up to several hours, bleeding per rectum (BPR), anal discharge and swelling. Acute primary anal fissure is more severe in intensity than a chronic variety. Primary anal fissure is usually managed with conservative therapies such as an increased dietary fiber, bulk agents, stool softeners, warm sitz bath, botulinum toxic injections or topical ointments like glyceryl nitrate, and calcium channel blockers. Untoward events such as toxicity, headache, giddiness, and itching have at times been reported with topical ointments. Studies have reported that botulinum toxic injections can cause heart block, skin and allergic reactions, postural hypotension, temporary incontinence of flatus and stool, and perianal hematomas.,, Normally, if 4–8 weeks of conservative management proves ineffective, then surgical interventions are adopted. Further, common surgical corrections such as Lord’s dilatation, sphincterotomy, and fissurectomy have their own risks of incontinence to flatus and feces, nonhealing external wound, and abscess and fistula formation. Therefore, pharmacological ways of treating primary anal fissures are highly explored these days. In Susruta Samhita, a surgical compendium among traditional Ayurvedic literatures, the author had mentioned specific iatrogenic clinical conditions, namely Parikartika (cutting pain in the rectum) and Gudakshata (anal ulcer), which refer to complications arising from an inappropriately administered enema therapy. The author advocated the traumatic wound treatment principle in such patients., This observational documentation aimed at reporting the effectiveness of an Ayurvedic conservative management strategy in acute and chronic primary anal fissure.
| Materials and Methods|| |
This is a retrospective observational report of 15 patients diagnosed with primary anal fissure (acute and chronic) treated at the Outpatient Department of NARIP, Cheruthurthy, between March 2018 and February 2019 and underwent Ayurvedic conservative management. All the patients were treated with anal infiltration of a medicated oil (Murivenna oil) [Table 1] once daily (30 ml) and oral administration of 10 g of Triphala choorna (combination of Indian herbal drugs, namely Terminalia chebula Retz. var. typica, Terminalia bellirica Gaertn. Roxb., and Emblica officinalis Gaertn. in a powdered form) with hot water at bedtime for 7 days. The patients were advised sitz bath (with Triphala decoction) and were also put on a fiber diet such as green beans, pomegranate, ash gourd, cabbage, carrots, green beans, bananas, apples, spinach, and lettuce. As most of the patients took low-fiber diet, they were advised to take high-fiber foods, and this was ensured during the assessment periods. Those patients who did not get considerable relief in the first 7 days were continued with anal infiltration on alternate days for 2 more weeks along with aforesaid prescribed medicine and dietary regimes. Assessments were carried out at baseline (Day 1), day 8, and day 15 based on changes in signs and symptoms [Table 2], and healing of fissure. The patients were followed up to 12 months (30th day, 90th day, after 6 months, and after 12 months) for reporting recurrences if any.
Observations on signs and symptoms of anal fissure
Observations were made as per signs and symptoms of anal fissure such as pain, BPR, anal discharge, inflammation, and tenderness. Inflammation and tenderness were assessed through physical examination and graded [Table 2]. Assessment of fissure healing was carried out by physical examination and interrogation (absence of signs and symptoms and presence of granulation tissue in fissure bed were considered as healing). Percentage of healing was assessed clinically with these criteria.
After management, periodical follow-up of respective patients was done on their 30th day, 90th day, after 6 months, and after 12 months of treatment advocacies. Reappearance of symptoms was considered as the recurrence.
| Observation and Results|| |
The demographic representations along with observed lifestyles of the 15 documented cases are demonstrated in [Table 3]. [Table 4] denotes specific characteristics of the observed group.
|Table 3: Distribution of observations based on age, gender, and occupation|
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Statistical analysis for assessment of effectiveness of treatment was done using the Statistical Package for the Social Sciences. A Friedman test for repeated measures, followed by the Wilcoxon post hoc test, was conducted for the study variables, namely pain, BPR, anal discharge, inflammation, and tenderness and healing of fissure. The results showed a significant improvement in each of the symptoms, namely pain (= 41.00, P.05), BPR (= 36.00, P.05), and discharge (= 39.00, P.05), inflammation and tenderness (= 45.00, P.05), and healing of fissure (= 27.89, P.05) as on the 1st day, 8th day, 15th day, and 30th day. All symptoms resolved by the 30th day [Table 5]. On further analyzing the data using the Wilcoxon post hoc test [Table 6], significant improvements were observed in pain, BPR, discharge, and inflammation and tenderness scores by the 8th day (baseline to 8th day, P<0.001), with pain scores significantly dropping further on the 15th day (8th day–15th day, P=.002) and percentage healing of fissure showing significant improvement at each level, in particular. Further, these improvements observed were maintained throughout (8th day–30th day, P<0.001).
Complete healing of fissure was observed in 93% of the subjects by the end of their respective 30 days of treatment. There was a statistically significant difference in healing of fissure measured on the 8th day (78 ± 11.464), 15th day (91.33 ± 9.904), and 30th day (99.33 ± 2.582). The average time taken to heal was 1.5 ± 0.5 weeks. Complete remission of all the symptoms were observed in 80% of the cases. Recurrence was recorded in 20% of the cases during the follow-up period up to 12 months.
Comparing the median score for the symptoms, most significant improvement was found in tenderness and inflammation scale levels and there was complete relief of symptoms of inflammation, tenderness, anal discharge, and BPR within the first 7 days [Graph 1]. On comparing the median pain levels (out of 10), pain level significantly reduced from 9 (on the 1st day) to 1 (on the 7th day). Complete pain relief was observed by the 15th day in almost 80% of the subjects. No pain was reported by the subjects while assessment on the 30th day [Graph 2].
|Graph 1: Relief of symptoms (BPR, discharge, inflammation, and tenderness)|
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| Discussion|| |
Fissure in ano is considered as the disease of adults. Raj and Kadam had reported 43.33% and 36.67% of acute and chronic fissure in ano cases, respectively, to be occurring within the age group of 21–30 years. This was reflected in this observatory report as well, where out of 15 patients observed, the maximum number of patients were adults (67%), coming out of the age group 21–40 years and the mean age was estimated as 35.87 ± 9.49 years [Table 3] and [Table 4].
Panigrahi and Giridhar et al. in their respective studies on anal fissure reported a male dominance (62.5% and 56.6%, respectively)., This study too reported a male upper hand with 67% males.
Hananel and Gordon observed that dominant presenting symptoms in diagnosed cases of fissure in ano were pain in 90.8% patients and BPR in 71.4% patients. Sajith Babu et al. studied 165 patients with acute fissure in ano and reported that 100% had symptoms of pain and 86.1% of cases had BPR. In compliance with the abovementioned studies, it was observed that pain (100%) and BPR (80%) were the chief complaints in the observed group.
Lock and Thompson reported that tenderness and hypertonic sphincter were present in 69% of patients. Sajith Babu et al. observed that 100% of cases had tenderness and hypertonic sphincter. Panigrahi also observed that 95% of cases had high sphincter tone. In agreement to aforesaid statistics, it was observed that 80% of the reported cases had hypertonic sphincter tone. Patel and Dudhamal observed in their study that 16.67% of cases had anal discharge, whereas 87% of cases presented with anal discharge in the observational group. Pain and anal discharge might be two significant reasons why people with anal fissure turn up for an Ayurvedic consultation. Inappropriate anal hygiene and dampness might be the causes for anal discharge in most of the cases.
Treatment of anal fissure should focus on breaking the cycles of pain, spasm, and ischemia.Sushruta Samhita, a treatise on surgical and parasurgical treatment strategies, advocates treatment principles of traumatic wounds; measures to pacify the Pitta Dosha, the one which is crucial in all inflammatory symptoms manifestation; and the use of oil irrigation/infiltration as treatment methods to be adopted in anal fissure. Majority of anal fissures will heal with conservative management using sitz bath, laxative, high-fiber diet, topical anesthetics, or anti-inflammatory ointment.Murivenna oil is a time-tested medicated oil that is used externally for various types of exogenous and endogenous types of ulcers, inflammatory swellings, sprains, and fractures. The drugs in Murivenna oil, namely A. vera, P. glabra, B. hispida, A. racemosus, and M. oleifera are known for their analgesic and anti-inflammatory properties. Most of the drugs mentioned in the yoga are having Katu, Tikta, Madhura Rasa, and Katuvipaka. Tikta Rasa and Sitavirya have Dahaprasamana action (pacifying burning sensation). Katu Rasa and Katuvipaka are Vranavasadana (reduce the hypergranulation of wounds), thus resulting in wound healing and is Sothahara (anti-inflammatory) too. Oil by its nature pacifies pain and spasms, and lubricates the anorectal area. Anal infiltration with Murivenna oil thus helps in reducing the increased sphincter tone and associated symptoms. Triphala choorna not only acts as a laxative but also promotes wound healing, reduces discharge, and cures diseases of tainted blood origin. The healing property may be attributed to the antimicrobial and debridement property of tannic acid present in Triphala.
A clinical study conducted by Patel and Dudhamal to assess the effect of Yashtimadhu Ghrita in comparison with lignocaine–nifedipine ointment reported complete relief of BPR and anal discharge within first 14 days of Ayurvedic treatment compared to 7 days in the control group. They also reported that time period taken for relief of pain in patients treated with Yashtimadhu Ghrita and lignocaine–nifedipine ointment was 18.06 days and 16.88 days, respectively. Sajith Babu et al. reported considerable relief of pain after 6 weeks of treatment, whereas according to Antropoli et al. there was total pain relief in 87% of cases after 21 days of active treatment. Among the 15 patients, it was observed that there was complete relief of anal discharge and BPR within the first 7 days. In all, 80% of patients had relief from pain within 15 days, and all the subjects reported complete relief from pain on the 30th day. Analgesic and anti-inflammatory activities of Murivenna oil and antimicrobial property of Triphala may have aided this outcome.
Ayurveda while explaining the pathology of wound considers that inflammation precedes and coexist with wounds. In traumatic wounds, inflammation obviously manifests after a trauma, presenting with the features of Pitta and Rakta vitiation. Tenderness is a sign elicited clinically by the physician during the examination of anal fissure. Hence, both these features have to be considered during the assessment of treatment for fissure in ano. While comparing the median scores for the symptoms, most significant improvement was found in tenderness and inflammation scale levels and there was complete relief of symptoms of inflammation and tenderness within the first 7 days of the prescribed treatment.
Healing of ulcer refers to the total absence of symptoms and the presence of granulation tissue in the fissure bed. A randomized clinical trial conducted by Gough and Lewis observed that fissure healed in 43.6% of patients with 2% lignocaine topical application for 1 month. A retrospective study conducted by Shub et al. reported that 44% of fissure healed within 4–8 weeks of conservative treatment. Perrotti et al. have reported that the local application of nifedipine and lidocaine gel healed the fissure in 6 weeks in 94.5% of patients. In the present observatory group, it has been found that the time taken for fissure to heal was 1.5 ± 0.5 weeks.
A systematic review reported that late recurrence occurred in more than 50% of cases treated with glycerine nitrate. A high recurrence rate (42%) was also reported with the usage of botulinum toxin injection., Among the 15 cases treated here, recurrence was recorded in 20% of the cases while and after the follow-up period of 12 months, and they were subsequently treated with sphincterotomy. Several undesirable effects have been reported with topical ointments and botulinum toxin injections. There are also risks of developing several complications by undergoing surgical treatment.,,,, Here, no untoward events have been reported in any of the documented cases, making it a candidate treatment strategy in primary anal fissures.
| Conclusion|| |
This observatory report intents to disseminate primary evidence on Ayurvedic treatment approaches adopted in primary anal fissure, a common anorectal diseased condition. The conservatory treatment measure adopted here comprised anal infiltration with the medicated oil Murivenna and internal administration of Triphala choorna along with sitz bath and fiber diet that effectively relieved the symptoms and eventually lead to a healed anal fissure. No adverse events were reported in documented 15 cases in comparison to common observed side effects of topical applications. There is a definite scope of Ayurvedic Sciences in managing and curing anorectal ailments with significant patient satisfaction and decreased recurrence rate.
The authors thank Director General—CCRAS, Deputy Director General—CCRAS, and Director and Assistant Director (Ay.), NARIP Cheruthuruthy, for their immense support and guidance.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
Institutional ethical clearance
Institutional ethical clearance is not required as there is no significant alteration in the form of treatment.
| References|| |
Schlichtemeier S, Engel A. Anal fissure. Aust Prescr 2016;39:14-7.
Stewart DB Sr, Gaertner W, Glasgow S, Migaly J, Feingold D, Steele SR. Clinical practice guideline for the management of anal fissures. Dis Colon Rectum 2017;60:7-14.
Beaty JS, Shashidharan M. Anal fissure. Clin Colon Rectal Surg 2016;29:30-7.
Brisinda D, Maria G, Fenici R, Civello IM, Brisinda G. Safety of botulinum neurotoxin treatment in patients with chronic anal fissure. Dis Colon Rectum 2003;46:419-20.
Brisinda G, Maria G, Sganga G, Bentivoglio AR, Albanese A, Castagneto M. Effectiveness of higher doses of botulinum toxin to induce healing in patients with chronic anal fissures. Surgery 2002;131:179-84.
Jost WH, Schimrigk K. Use of botulinum toxin in anal fissure. Dis Colon Rectum 1993;36:974.
Gupta PG. Treatment of fissure in ano—Revisited. Afr Health Sci 2004:4:58-62.
Susrutha SS, Singhal GD, editors. Chikitsa Sthana. 35/32. 2nd ed., Vol. 2. Delhi: Chaukhamba Sanskrit Pratishthan; 2007. p. 488.
Susrutha SS, Singhal GD, editors. Chikitsa Sthana. 36/3. 2nd ed., Vol. 2. Delhi: Chaukhamba Sanskrit Pratishthan; 2007. p. 490.
Lalithamma K, editor. Pharmacopeia. 1st ed. Trivandrum: Govt Ayurveda College Publication Dept; 1996.
Patel JR, Dudhamal TS. A comparative clinical study of Yashtimadhu Ghrita and lignocaine-nifedipine ointment in the management of Parikartika
(acute fissure-in-ano). Ayu 2017;38: 46-51.
] [Full text]
Raj VK, Kadam MM. A study on different modalities in management of fissure in ano. Int J Sci Res 2014;3:942-8.
Panigrahi H. Clinical evaluation of Ayurvedic compound and manual dilatation of anus in the management of Parikaritika
(fissure in ano): An open perspective study. IJRAP 2012:3:792-4.
Giridhar CM, Babu P, Rao KS. A comparative study of lateral sphincterotomy and 2% diltiazem gel local application in the treatment of chronic fissure in ano. J Clin Diagn Res 2014;8:NC01-2.
Hananel N, Gordon PH. Re-examination of clinical manifestations and response to therapy of fissure-in-ano. Dis Colon Rectum 1997;40:229-33.
Sajith Babu SM, Rachna G, Lalmani S. Effectiveness of conservative management of acute fissure in ano: A prospective clinical study of 165 patients. Int Surg J 2017;4:3028-33.
Lock MR, Thompson JPS. Fissure in ano. The initial management and prognosis. Br J Surg 1977;64:355-8.
Lund JN, Scholefield JH. Aetiology and treatment of anal fissure. Br J Surg 1996;83:1335-44.
Prasanth, Rajashekar, Raiby. Clinical study to evaluate the efficacy of Janu Basti
and Janu Pichu
in Janu Sandhigata Vata
. AAMJ 2015;1:74-7.
Vagbhata. Annaswaroopa Vignaneeyam. In: Vaidya HP, editor. Astangahrdayam: Sarvangasundara Commentary by Arunadatta and Ayurvedarasayana Commentary by Hemadri. 10th ed. Sutra Sthana. 6/159. Varanasi: Chaukhambha Sanskrit Series Office; 2011. p. 118.
Vagbhata. Astanga Hrdaya. Sreekumar T (English translation & commentary). 2nd ed., Vol. 1. Sutra Sthana. 6/159. Thrissur: Harisree Hospital Publication Department; 2008. p. 206.
Antropoli C, Perrotti P, Rubino M, Martino A, De Stefano G, Migliore G, et al
. Nifedipine for local use in conservative treatment of anal fissures: Preliminary results of a multicenter study. Dis Colon Rectum 1999;42:1011-5.
Susrutha SS, Singhal GD, editors. Chikitsa Sthana. 17/14. 2nd ed., Vol. 2. Delhi: Chaukhamba Sanskrit Pratishthan; 2007. p. 161.
Susrutha SS, Singhal GD, editors. Chikitsa Sthana. 17/4. 2nd ed., Vol. 2.Delhi: Chaukhamba Sanskrit Pratishthan; 2007. p. 157.
Gough MJ, Lewis A. The conservative treatment of fissure-in-ano. Br J Surg 1983;70:175-6.
Shub HA, Salvati EP, Rubin RJ. Conservative treatment of anal fissure: An unselected, retrospective and continuous study. Dis Colon Rectum 1978;21:582-3.
Perrotti P, Bove A, Antropoli C, Molino D, Antropoli M, Balzano A, et al
. Topical nifedipine with lidocaine ointment vs. active control for treatment of chronic anal fissure: Results of a prospective, randomized, double-blind study. Dis Colon Rectum 2002;45:1468-75.
Nelson RL, Thomas K, Morgan J, Jones A. Non surgical therapy for anal fissure. Cochrane Database Syst Rev 2012;2012:CD003431.
Maria G, Brisinda G, Bentivoglio AR, Cassetta E, Gui D, Albanese A. Influence of botulinum toxin site of injections on healing rate in patients with chronic anal fissure. Am J Surg 2000;179:46-50.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]