Pilonidal sinus treated with Kshara sutra therapy

Pilonidal sinus treated with Kshara sutra therapy

1. 1 WELCOME

2. CASE PRESENTATION 2 DR NEHARU MANDOLI BAMS, MS, FRHS, D,Pharma Surgeon , Proctologist Assisstant professor Dept of PG studies in Shalyatantra Shri Kalabyraveshwara Swamy Ayurvedic Medical College and Hospital, Vijayanagar , Bangalore 104

3. ATURA PARICHAYA: Name- Mr . XYZ Age/Sex – 35 years/ male Occupation – Street Vendor Religion – Muslim Marital status – Married Address – Shyamanna garden, Bangalore DOC – 01/04/2015 OPD No – C 8896 Source of data- Patient Socio economic status – Lower economic status Education – 7th standard CASE TAKEN ON- 13/05/2015 3

4. PRADHANA VEDANA: Pain and foul smelling discharge from low back region between the buttocks since 15 years. 4

5. ANUBANDHA VEDANA Nothing significant

6. 6 VEDANA VRUTTANTA: The patient was apparently normal before15 years. Then gradually he noticed mild swelling at natal cleft with intermittent dull aching pain which was there for 6 days . Later he noticed foul smelling pus discharge associated with mild itching in that area . He used to feel discomfort in this region during sitting and bending. He neglected it even though it used to interfere with his daily activities. Whenever there was little injury to the area, pain and bleeding was noticed for which he consulted a local physician to get rid of pain.

7. Two years before again he noticed mild swelling at right side of natal cleft with intermittent dull aching pain which was there for one week followed by foul smelling pus discharge. Symptoms used to aggravate by travelling on his bike and profuse sweating . when the pain and foul smelling blood mixed pus discharge increased considerably, the local physician advised him to consult at higher center. So he approached Shalyatantra OPD in SKAMCH & RC.

8. 8 PURVA VYADHI VRUTTANTA: No H/O any other illness.

9. KAUTUMBIKA VRUTTANTA: No H/O of similar complaints in the family . 9

10. 10 VRUTTI VRUTTANTA: W orking as a Street Vendor, he pushes heavy cart from morning 9am to 6 pm. Travelling on his bike for 05-08 kms daily

11. VAYAKTIKA VRUTTANTA: Diet – Mixed Sleep – Undisturbed Bowel – 1 – 2 times per day, Micturition – 3-4 times per day . Habit - tea twice a day. Addiction - Nil 11

12. SAMANYA PAREEKSHA: Built Moderately. Nourishment- Moderately nourished Pallor – Absent Edema - Absent Cyanosis - Absent Clubbing - Absent Icterus - Absent Lymphadenopathy - Absent 12

13. B.P - 110/80 mm of Hg Pulse- 74/min, regular R.R - 19/min, regular Temperature - Afebrile Wt - 72kgs Ht - 166 cms

14. ASHTASTHANA PAREEKSHA: नाडी - 74/min मूत्र - 3-4 times per day मल – 1-2 times per day जिह्व - Alipta शब्द – Prakrutha स्पर्श – Prakruta दृक् - P rakrutha आकृति - Madhyama 14

15. DASHAVIDHA PAREEKSHA: 1) प्रक्रुति – Vatha kaphaja 2) विक्रुति – Madhyama 3) सार – Madhyama 4) संहनन - Madhyama 5) सात्म्य – P ravara 6) प्रमाण - Madhyama 7) सत्व - Madhyama 8) आहारशक्ति : Abyavaharana shakti - M adhyama , Jarana shakti - Madhyama 9) व्यायाम शक्ति - Madhyama 10) वय - Madhyama 15

16. SYSTEMIC EXAMINATION RESPIRATORY SYSTEM Inspection : Bilaterally symmetrical . Palpation : Trachea-centrally placed Percussion : Resonant sound heard except the area of cardiac dullness. Auscultation : Normal vesicular breath sounds.   CARDIOVASCULAR SYSTEM S 1 S 2 heard, No Murmurs. 16

17. GASTRO INTESTINAL SYSTEM ABDOMEN Inspection – U mbilicus is centrally placed Palpation – T enderness absent Percussion – Tympanic sound heard Auscultation – B owel sounds (++) 17

18. ANO RECTAL EXAMINATION: INSPECTION – No signs of inflammation around the anus No external pile mass or sentinel pile mass No external opening in the peri -anal region PALPATION – No tenderness in the perianal region. DIGITAL EXAMINATION Sphinchter tone- normal No spinchter spasm 18

19. P2 S1 S2 S3 S4 P1 Anus Imaginary vertical line NATAL CLEFT INSPECTION 1) Number of sinus 6 Sinuses 2) Position of sinus 2 Primary openings in the midline of natal cleft just above the buttocks. 4 Secondary openings seen right laterally . 3) Opening of the sinus Presence of tuft of hairs seen Margin – normal. STHANIKA PAREEKSHA:

20. 4) Discharge Pus discharge present 5) Surrounding Skin Inflammation - present. Scars – Absent 7 ) Smell Foul smelling discharge. 20

21. PALPATION: Tenderness Present Mobility Present Lump Absent in the surrounding area 21

22. SINUS PROBING: P osition: K nee elbow position Painting done with Betadine solution. Xylocaine gel applied on the probe and around the sinus. Probe was introduced in the primary sinus in the middle line. Then probe was introduced from primary sinus in to the secondary sinus. Findings: Two primary sinuses were inter connected with a depth of 2cms directed downwards. The secondary sinuses right laterally were connected to the primary sinuses and inter connected with each other. There was blood mixed pus and hair on withdrawal of the probe. 22 Knee elbow position

23. FINDINGS ON PROBING: P2 S1 S2 S3 S4 P1 P = Primary sinus S = Secondary sinus P1- P2 interconnected P1- S1interconnected P2-S4 interconnected S1-S2interconnected S3-S4interconnected Anus Imaginary vertical line

24. PRAYOGASHALA PAREEKSHA: 11/04/2015 Haemoglobin – 15.9 Gms % RBS- 118 mg/dl HIV 1 & 2 – Non reactive HBsAg – Non reactive 24

25. NIDANA PANCHAKA: निदान Ati sweda Ashuchitwa Ati roma Ati Yaana Bhaara harana पूर्वरूप Ruja and kandu रूप Ruja R akta mishrita durgandhayukta puya srava 25

26. SAMPRAPTI: Due to Ati sweda , ashuchitwa , ati roma , ati yaana , bhaara harana Tridosh vikriti S opha Pakwa sopha & prachura puya srava Incomplete drainage of puya Puya abyantaram pravishyati Atimatra gamanat Nadi vrana 26

27. SAMPRAPTI GHATAKA: दोष tridosha दूष्य Twak , Rakta , mamsa अग्नि Rasa, Rakta and Mamsa dhatwagni स्रोतस् Rasavaha , Raktavaha , M amsavaha , स्रोतोदुष्टि Sanga,vimarga gamana व्यक्तस्थान Kati pradesha अधिष्ठान Twak , Mamsa रोगमार्ग Bahya साध्यासाध्यत Kashta sadhya 27

28. VYAVACHEDAKA NIDANA: INCLUDED EXCLUDED OSTEOMYLITIS OF COCCYX: Tract at midline of natal cleft just above the buttocks. pain Pus discharge Sinus is mobile No sequestrum on probe FISTULA IN ANO: Opening with pain and discharge at just above the buttocks. No internal opening felt on P/R examination

29. PILONIDAL SINUS: INCLUDED AND DIAGNOSED Tract at midline of natal cleft just above the buttocks with secondary sinus openings at right laterally . With pain and foul discharge O/E tuft of hair at opening of the sinus

30. INCLUDED EXCLUDED UNMARGI BHAGANDHARA: Due to Shalya H/O Kshata Presence of pidaka with puya rudhira srava Asthi Shalya at nadi No vata mutra purisha srava KAPHAJA VIDRADHI: H/O Shotha Sheeta Chirottana prapak Sakandu H/O Kshata Absence of baala Na nadivat bahati

31. SHALYAJA NADIVRANA: INCLUDED AND DIAGNOSED Rakta mishrita Puya srava Sahasa saruja sa nityam Sankandu Presence of baala as a shalya H/O Kshata N adivat bahati

32. VYADHI VINISHCHAYA: SHALYAJA NADI VRANA PILONIDAL SINUS 32

33. CHIKITSA : 01/04/2015 Primary threading was done under Aseptic precaution Orally Triphala Guggulu 2-0-2 for 1month Gandhaka rasayana 2-0-2 with milk after food 4/04/2015 Apamarga kshara sutra ligation under Aseptic precaution P2 S1 S2 S3 S4 P1 Anus Imaginary vertical line Kshara sutra

34. Regular Shaving of the area Maintain hygiene Rest Avoid -Bike riding During treatment -Strenuous work Changing Apamarga kshara sutra once a week.

35. PATHYA: More of vegetables Laghu ahara Liquids APATHYA: Spicy, o ily, deep fried Non veg food

36. 01/04/2015 Primar y threading under aseptic precaution Triphala Guggulu 2-0-2 Gandhaka rasayana 2-0-2 Tuft of hair seen Burning pain with blood mixed pus discharge. 04/04/2015 Apamarga kshara sutra ligation under Aseptic precaution. Tuft of hair less than previously seen Burning pain with pus discharge noticed 08/04/2015 c/o pain and discharge from tract. Pus discharge was cleaned and advise to continue same treatment Tuft of hair seen DATE TREATMENT OUTCOME

37. 11/04/2015 Apamarga kshara sutra changed under Aseptic precaution Tuft of hair not seen Burning pain with mild pus discharge noticed. 18/04/2015 Apamarga kshara sutra changed under Aseptic precaution P1 and P2 Primary tracts Were opened Mild burning p ain and pus discharge reduced 29/04/2015 Apamarga kshara sutra changed under Aseptic precaution Mild Burning pain with pus discharge DATE TREATMENT OUTCOME

38. 06/05/2015 Apamarga kshara sutra changed under Aseptic precaution Mild burning p ain and pus discharge absent 13/05/2015 Apamarga kshara sutra changed under Aseptic precaution Burning pain with pus discharge absent 20/05/2015 Dressing with Jatyadi taila S3 -S4 S1 and S2 tracts were opened pain and pus discharge absent DATE TREATMENT OUTCOME

39. COURSE OF HEALING: 39 11/04/15

40. 18/04/2015

41. 13/05/2015

42. 20/052015

43. FOLLOW UP: Regular Shaving of the area maintain hygiene Rest, Avoid -Bike riding -Strenuous work Once in every two weeksto observe healed tract for any recurrence till 6 months.

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