Vidradhi (Abscess)

Vidradhi (Abscess) (classification and management)

1. Vidradhi (Abscess) DR. ALOK KUMAR PhD SHALYA TANTRA NEIAH, SHILLONG

2. overview References Definition Type Clinical feature Principle of management Complications

3. References Vidradhi nidan ……………… Su.Ni . Chapter 9 Vidradhi chikitsa……………..Su. Chi. Chapter 16

4. Definition “ स वै शीघ्रविदाहित्वाद्विद्रधीति निरुच्यते”- (च. सू. १७ ) त्वग्रक्तमांसमेदांसि प्रदूष्यास्थिसमाश्रिताः | दोषाः शोफं शनैर्घोरं जनयन्त्युच्छ्रिता भृशम् || महामूलं रुजावन्तं वृत्तं चा(वाऽ)प्यथवाऽऽयतम् | तमाहुर्विद्रधिं धीरा, विज्ञेयः स च षड्विधः || Due to various factors, when vitiated doshas goes in to dhatus like twak , rakta, mansa , meda and Asthi and slowly-slowly produces, pain and severe swelling (sotha). When this sotha became deep, painful, oval, large, broad base and reach to pakwavastha then it called vidradhi. This is of 6 types.

5. Types पृथग्दोषैः समस्तैश्च क्षते ना प्यसृजा तथा | षण्णामपि हि तेषां तु लक्षणं सम्प्रवक्ष्यते || Three from different doshas, one Sannipataj, one Kshataj (traumatic) and one raktaj these are six types of vidradhi. As per Acharya charak vidradhi are two types Bahya (External) and Abhyantar (Internal).

6. Clinical features Vataj कृष्णोऽरुणो वा परुषो भृशमत्यर्थवेदनः | चित्रोत्थानप्रपाकश्च विद्रधिर्वातसम्भवः || Pittaj पक्वोदुम्बरसङ्काशः श्यावो वा ज्वरदाहवान् | क्षिप्रोत्थानप्रपाकश्च विद्रधिः पित्तसम्भवः || Kaphaj शरावसदृशः पाण्डुः शीतः स्तब्धोऽल्पवेदनः | चिरोत्थानप्रपाकश्च सकण्डुश्च कफोत्थितः ||

7. Sannipataj नानावर्णरुजास्रावो घाटालो विषमो महान् ||१०|| विषमं पच्यते चापि विद्रधिः सान्निपातिकः | Kshataj तैस्तैर्भावैरभिहते क्षते वाऽपथ्यसेविनः ||११|| क्षतोष्मा वायुविसृतः सरक्तं पित्तमीरयेत् ज्वरस्तृष्णा च दाहश्च जायते तस्य देहिनः ||१२|| एष विद्रधिरागन्तुः पित्तविद्रधिलक्षणः Raktaj कृष्णस्फोटावृतः श्यावस्तीव्रदाहरुजाज्वरः [ १ ] ||१३|| पित्तविद्रधिलिङ्गस्तु रक्तविद्रधिरुच्यते

8. Site of Abhyantar vidradhi “ गुदे बस्तिमुखे नाभ्यां कुक्षौ वङ्क्षण योस्तथा | वृक्क योर्यकृति प्लीह्नि हृदये क्लोम्नि वा तथा | ” These are site of abhayntar vidradhi Guda Vast Nabhi Kukshi Vankshana Vrikka Ykruta Pleeha Hrudya K lome

9. Clinical features अधिष्ठानविशेषेण लिङ्गं शृणु विशेषतः || गुदे वातनिरोधस्तु बस्तौ कृच्छ्राल्पमूत्रता | नाभ्यां हिक्का तथाऽऽटोपः कुक्षौ मारुतकोपनम् || कटीपृष्ठग्रहस्तीव्रो वङ्क्षणोत्थे तु विद्रधौ | वृक्कयोः पार्श्वसङ्कोचः प्लीह्न्युच्छ्वासावरोधनम् || सर्वाङ्गप्रग्रहस्तीव्रो हृदि शूलश्च दारुणः | श्वासो यकृति तृष्णा च पिपासाक्लोमजेऽधिका ||

10. Clinical features Guda - obstruction of flatus/stool Vasti - oligouria and dysuria Nabhi - hiccough, aatop (distension in abdomen) Kukshi - marutkopanam (Vitiation of Vata)(excessive flatus) Vankshana - spasm in back (lumbar and thoracic) Vrikka - pain in renal angle (lateral bending) Ykruta - dyspnea, thirst Pleeha - dyspnea Hrudya - severe pain and spasm in body Klome - excessive thirst

11. Differences between gulma and vidradhi विशेषमथ वक्ष्यामि स्पष्टं विद्रधिगुल्मयोः ||२८|| गुल्मदोषसमुत्थानाद्विद्रधेर्गुल्मकस्य च | कस्मान्न पच्यते गुल्मो विद्रधिः पाकमेति च || २९|| Both vidradhi and gulma are originated from same dosha, but vidhardi became pakwa gulma doesn’t ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,the possible reseaon behind this are…. न निबन्धोऽस्ति गुल्मानां विद्रधिः सनिबन्धनः | गुल्माकाराः स्वयं दोषा विद्रधिर्मांसशोणिते ||३०|| विवरानुचरो ग्रन्थिरप्सु बुद्बुदको यथा | एवम्प्रकारो गुल्मस्तु तस्मात् पाकं न गच्छति ||३१ || मांसशोणितबाहुल्यात् पाकं गच्छति विद्रधिः | मांसशोणितहीनत्वाद्गुल्मः पाकं न गच्छति || ३२|| गुल्मस्तिष्ठति दोषे स्वे विद्रधिर्मांसशोणिते | विद्रधिः पच्यते तस्माद्गुल्मश्चापि न पच्यते || ३३||

12. Principle of management उक्ता विद्रधयः षड्ये तेष्वसाध्यस्तु सर्वजः | शेषेष्वामेषु कर्तव्या त्वरितं शोफवत् क्रिया Su.Chi 16/3 Sannipataj vidradhi is considered as asadhya rest apakva vidradhi should be treated as treatment of sopha (Apkwa) (upakrama 1-11) नोपगच्छेद्यथापाकं प्रयतेत तथा भिषक् || Su.Chi 16/ 38 Surgeon should try first with conservative approach to avoid suppuration (Pak) in vidradhi by various medicine and parasurgical procedure. स चेदेवमुपक्रान्तः पाकायाभिमुखो यदि | तं पाचयित्वा शस्त्रेण भिन्द्याद्भिन्नं च शोधयेत् Su. Chi 16/7 Even after trying upakrama if vidradhi shows lakshana of pakwa then it must be explored and treat like wound.

13. Conservative measures Aptarpana Aalepa Upnaaha Parisheka Abhyanga Swedana Raktamokshana Jalukavcharana Siravedha Virechana Vamana

14. Shalya Karma मर्मसिरास्नायुसन्ध्यस्थिधमनीः परिहरन्, अनुलोमं शस्त्रं निदध्यादापूयदर्शनात्, सकृदेवापहरेच्छस्त्रमाशु च; महत्स्वपि च पाकेषु द्व्यङ्गुलान्तरं त्र्यङ्गुलान्तरं वा शस्त्रपदमुक्तम् Su .Su. 5/7 तत्रायतो विशालः समः सुविभक्तो निराश्रय इति व्रणगुणा : Su .Su. 5/8 Every incision must be have the properties like it must be enough long, wide with equal clean margin and no pockets left. आयतश्च विशालश्च सुविभक्तो निराश्रयः | प्राप्तकालकृतश्चापि व्रणः कर्मणि शस्यते Su .Su. 5/9 The ideal incision is that which have, Enough length, wide, clean margins, brakes all the pus pockets and made on correct time.

15. Principle of counter incision एकेन वा व्रणेनाशुध्यमाने नाऽन्तरा बुद्ध्याऽवेक्ष्यापरान् व्रणान् कुर्यात् भवति चात्र- Su. Su . 5/11 If the one incision is not enough to drain the complete cavity , surgeon should examine and wisely made other incision to drain the pus completely. यतो यतो गतिं विद्यादुत्सङ्गो यत्र यत्र च | तत्र तत्र व्रणं कुर्याद्यथा दोषो न तिष्ठति S u. Su 5/12 “If there is swelling due to collection of pus, make the incision to drain it”.

16. Incision 1. Straight ( Tiryak ) तत्र भ्रूगण्डशङ्खललाटाक्षिपुटौष्ठदन्तवेष्टकक्षाकुक्षिवङ्क्षणेषु तिर्यक् छेद उक्तः Su. Su 5/13 2. Circular (Chandrakaar) चन्द्रमण्डलवच्छेदान् पाणिपादेषु कारयेत् 3. Semicircular (Ardh-chandrakaar) अर्धचन्द्राकृतींश्चापि गुदे मेढ्रे च बुद्धिमान् Su. Su 5/14

17. Drugs Pakwa vidradhi should be treated as like pakwa sopha. That include vrana patana, sodhana and Ropana karma. In sodhana and Ropana various drug/ yog should be used keep in mind the doshaghntwa of drug. Vrihatpanchmool , bhadradarvadi gana , kakolyadi gana ----Vata Mulethi , sariva , ksheerkakoli , jeevniya gana , karanjjadi ghrita ---Pitta Danti , D rvanti , Nishotha , tilvaka , sendhanamak ---- kapha Varukadi gana , uskadi gana – Apkwa Antravidradhi

18. Special treatment Siravedhan in kaphaj vidradhi Majjagatvidradhi .—considered as ashadya but treat with sodhana and Shalya karma after paak .

19. ABSCESS An abscess is circumscribed area of inflammation or Collection of pus in an abnormal cavity in body (after suppuration).

20. Classification There are two types of classification for abscess are found:- A- 1. P yogenic abscess 2 . P yaemic abscess 3. Cold abscess B- 1 . Acute or hot abscess 2.Chronic or cold abscess 3.Superficial abscess 4.Deep abscess 5.Embolic abscess 6.Pyaemic or metastatic abscess

21. Pyogenic abscess This is commonest variety. The causative organism( bacteria) are mostly- Sterptococcus spp Staphylococcus spp Pseudomonas aeruginosa Actinomyces bovis Actinobacillus lignieresi Retained foreign body (RFB) and parasite also may develops abscess. Organism may spread by direct due to penetrating trauma , local extension of adjacent focus , via lymphatic or via Blood stream .

22. PATHOGENISIS Any breach in skin and mucous membrane Invasion of Pyogenic organism Formation of pyogenic membrane Body immunity fails to fight (suppuration) Finally formation of pus (abscess develops)

23. Pus When suppurative organism dominates the body’s defense mechanism, then due to toxins of pyogenic organism both tissue cells and those exudate are killed, and liquefied by proteolytic enzymes released from dead polymorphonuclear leucocytes. The resulting yellow alkaline fluid is called “ pus ” which contains disintegrating and living leucocytes and plus dead and living bacteria . Sometimes due to continuous long time use of antibiotics in abscess the cavity became firm and contains sterile pus, known as “Antibioma” . The firmness is due to thickness of cavity wall. The lump became very hard and may mimic as tumor/carcinomatous lump.

24. C linical features All the five features of inflammation. ( R , C , D , T , LOF ) Collection of pus can be detected by- Brawny pitting oedema and induration Fluctuation test positive

25. INVESTIGATION Clinical diagnosis is most important. In superficial abscess physical examination may reveals the depth of cavity but in internal abscess special diagnostic tools may required for eg . X-Ray ( Lung Abscess, subphrenic Abscess) Ultrasound (Abscess of liver, spleen, gall bladder empyema) CT ( to differentiate Abscess to tumor) Other investigation.

26. Treatment 1. In initial stage before suppuration conservative approach should be taken. It includes anti-inflammatory, antibiotics and rest/elevation of affected part. 2. when the pus has been localized it should be drained. “where there is pus, let it out” Basic principle: 1. D rain the pus 2. S end the sample for C/S 3. Antibiotic

27. Drainage of pus can be obtained by Incision: 1. Free incision 2. Hilton’s method Exploration Counter-Incision Drainage Follow-up

28. Different approaches of I&D The approaches depends on the site of abscess cavity, so involved nearby structure. As abscess present in neck, axilla, inguinal region or location with involvement of major nerves and vessels or vital part should be drained cautiously. The abscess without involvement of these above vital structure should be open liberally.

29. Procedure of incision and drainage After completing pre-operative preparation patient taken in suitable position. Anaesthetize patient accordingly After draping choose the site of incision, incision site should be most prominent as well as most dependent part. If prominent part is different from dependent part then you may require counter incision. After choosing the site take a stab incision i.e. insert the 11no. Blade vertically till the pus comes out, once pus comes out the stop going vertically. Now extend the incision line to horizontally. Again take one incision perpendicular to first one to make it cruciate for complete exposure of cavity. Now debride the cavity and brake all the pus pockets, if any pus pockets remains then it may leads to recurrence. Poriment part Dependent part

30. Avoid using sharp instruments inside cavity. When the site of abscess is near vital area then be careful in taking incision and use finger to brake all the loculi instead instruments. Careful look for nerve and vessels in cavity After surgical debridement wash the cavity with hydrogen peroxide for chemical debridement followed by antiseptic solution and then tight packing with antiseptic dressings. If cavity is large it may require placing a corrugated drain. Keep the gauze dressing through if you make the counter incision, this felicitate draining of cavity. From 2 nd to tried day loos packing is helpful in starting the healing process.

31. Steps in I&D Pre-operative preparation Anesthesia Draping Incision Surgical debridement Chemical debridement Wash the cavity Pack with ASD

32. Operations in different abscess Abscess of Neck Abscess of axilla Abscess of groin Abscess of breast Abscess of Popliteal fossa Abscess of Iliac Gluteal Abscess Deltoid Abscess Abscess sole and heal

33. Pyaemic abscess Pyaemia is a condition characterized by formation of secondary foci of suppuration/infection in the various parts of body. These foci are made by lodgment of septic emboli, consisting of a clumps of organism, infected clots etc. This condition is usually associated with acute osteomyelitis, acute inflammation of intra cranial sinus and acute bacterial endocarditis . In the condition of Pyaemia multiple abscess may develop in different part of body.

34. Bacteremia Septicemia Toxemia

35. Clinical feature Generally multiple in numbers Abscess commonly in sub- fascial plan. Abscess are usually non acute i.e. no feature of acute inflammation. May have high grade fever, rigor and other feature of toxemia Such abscess may occurs in viscera like liver, spleen, kidney may be fatal if present in brain or heart.

36. Treatment Early diagnosis key to success. Search for source of infection . Suitable antibiotic as early as possible with parenteral route. Superficial may be drain.

37. Cold abscess As the name suggest , this abscess in non reacting i.e. Absence of sign of acute inflammation. Usually painless. No symptoms except lump, may be reacting after getting secondary infection. Cold abscess is almost always a sequel of tuberculosis infection. Commonly present in lymph nodes, bone and joint. Commonest site is neck and axilla, side of chest wall due to TB of ribs, loin from spinal TB, near end of long bones and joints due to TB of bone & joint.

38. Clinical feature On palpation non- tendor , soft and matted node. Common site neck, axilla, side of chest wall with Tuberculosis of Ribs. May lead to sinus formation Treatment : ATT regimen. Aspiration (In some case) If the local abscess still persist affected lymph node should be excised. An incision should bee never made for I&D for cold abcess .

39. Complications of Abscess Septicemia in acute condition Chronic ulcer Sinus formation Infection may spread to adjacent organ