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\def\RunningAuthor{Alok Kumar Diwedi et al.}
\firstPage{1423}
\articleType{Case Report}
\receivedDate{25 Jun 2020}
\acceptedDate{06 Aug 2020}
\revisedDate{28 Jul 2020}
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\title{\textbf{A contemporary treatment approach for fissure in ano: A case report of 38 year old patient }}
\author{Alok~kumar~Diwedi\textsuperscript{*},  
            Kiran~Khandare, 
            Pooja~Shrivastav~\\[5pt]{Department of Shalyatantra, Mahatma Gandhi Ayurved College Hospital and Research Centre, Salod (H), Datta Meghe Institute of Medical Sciences, Wardha 442001, Maharashtra, India}}

\begin{abstract}
Anal Fissure is one of the major causes for pain at anal region. We are presenting case report of 38 year old male patient came to Shalyatantra OPD with chief complains of pain during and after defecation, bleeding per rectum, itching since 30 days. Intervention-In this case report patient is treated by using chakramarda ghrita for the management of acute fissure in ano chakramarda ghrita was used for local application along with sitz bath. The effectiveness of Charamarda was assessed by pain bleeding itching and healing. The patient has found effective relief from pain, bleeding, itching at perianal region using chakramarda ghrita which has anti-inflammatory activity, antibacterial, antifungal scavenging activity, antiulcer, anti-proliferative activity, antioxidant activity. The outcome of this management is that \textit{Chakramarda is effective in the management of Fissure in ano}. Patients who take all follow-up after treatment will have less chance of symptom reoccurrence.  
\end{abstract}\def\keywordstitle{Keywords}

\begin{keywords}Fissure in ano,\newline Chakramarda Ghrita,\newline Ayurveda,\newline Antifungal
\end{keywords}
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\makeatletter{\raggedright\textsuperscript{*}Corresponding Author\par Name:\ Alok~kumar~Diwedi~\\ Phone:\ ~\\  Email:\ alokd663@gmail.com 
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\section{Introduction}
In the age of fast food, there is a shift in the habit of taking food and its timings as well as in the lifestyle that has become sedentary. Both of these causes produce disturbance in the digestive system that leads to many diseases including anorectal disorders such as piles, fissure, fistula, prolapsed etc. 

Anal Fissure is one of the major causes for pain at anal region \unskip~\citep{907138:20534606}. The fissure-in-ano is categorized into two types depending on the clinical symptoms \& durations of the disease; viz. Acute and Chronic \unskip~\citep{907138:20534610}. The two primary signs of this disorder are, bleeding and pain; pain is often unbearable \unskip~\citep{907138:20534605}. In long-standing instances, sentinel tag and haemorrhoids can be associated with this. Pruritus ani can be another symptom of this disorder \unskip~\citep{907138:20534607}. In males anal fissure typically occurs in the midline posterior- 90 percent and 10 percent much less frequently. Subsequently, female fissures on the anterior midline are somewhat more common than before \unskip~\citep{907138:20534608}. 

Sources on Parikartika are available from all Bruhatrayi and corresponding writers of A\textit{yurveda. The factors responsible for the causation of Parikartika can be found in various ayurvedic texts such as Vamana {\textendash} VirecanaVypada, Basti Karma vypada and Upadrava of Atisara, Grahani, Arsa,Ud{\selectfont\={a}}vta. In this regard, Acharya Sushruta stated the aetiopathogenesis of disease that if a anyone is impaired, with Mrudukoshta (mild digestive power), Mandagni (poor appetite) in these circumstances, more intake of food has the quality of Rukshna(dry), Ushna(hot), Lavana(salty) etc. }Diet which is having such quality will vitiate Vata \& Kapha \& leads to Parikartika. Parikartika also has symptoms such as pain in the penis, anus, neck of the urinary bladder and umbilical region with flatus cessation. In Kashyap Samhita, in the chapter \textit{Garbhini Chikitsa}, we receive \textit{doshik} classification, aetiology, symptomatology and treatment of \textit{Parikartika. }Acharya Charaka further mentioned fissure in ano as a Vataj Atisara complication. In ayurveda chakramarda is used for the treatment of kandu, pamma, kusta, vrana, latin name of chakramarda is \textit{cassia tora}
    
\section{Case Report}
We are presenting case report of 38 year old male patient came to shalya tantra OPD with chief complains of pain during and after defecation, bleeding per rectum, itching since 30 days. The patient has previous history of hypertension for which he went to local practitioner and he was prescribed with Amlodipine 5 mg once a day till next consultation. Presently, the patient vitals were as follows pulse was 76/min, Blood pressure 130/70 mm hg, respiratory rate 18/min, temperature 96.5F. His cardiovascular examination and Respiratory examination was normal. On per rectum examination Fissure in ano was present at 6 and 12 o~clocks, spasm Grade 1, with no active bleeding was present (Figure~\ref{f-7f89ecfdbe4c}).

Investigation: Hb-10.2 gm\%. TLC: White blood count (WBC) 7600/mm3. Kidney function test was normal. Liver function test was normal. Human immunodeficiency virus-l (HIV-l) testing was negative and Hepatitis B surface antigen, non reactive (Figure~\ref{f-417d2b1cea7e}).

Intervention-In this case report patient is treated by using chakramarda ghrita for the management of acute fissure in ano chakramarda ghrita was used for local application along with sitz bath. The effectiveness of Charamarda was assessed by pain bleeding itching and healing. Assessment was done on 1\ensuremath{^{st}} day, 7\ensuremath{^{th}} day, 14\ensuremath{^{th}} day follow up was taken on 45\ensuremath{^{th}} day. 


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\caption{\boldmath {Fissure in ano 1\ensuremath{^{st}} day}}
\label{f-7f89ecfdbe4c}
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\caption{\boldmath {Fissure in ano 30\ensuremath{^{th}} day}}
\label{f-417d2b1cea7e}
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\section{Discussion}
In\textit{ Ayurveda Chakramarda }is used for the treatment of \textit{Pama, Jwara, Kasa, Kandu, Dadru. Rasapanchak} of \textit{Chakramarda} is Rasa-\textit{Katu, Guna-Laghu, Ushna, Virya-Ushan, Vipaka-Katu, Karma -Vata-Kaphasamak}. It is known for\textit{ Vranaropak} properties. Fissure in ano is longitudinal tear in the anoderm distal of anal canal. In contemporary sciences surgical treatment available for fissure in ano are sphincterotomy, lord's dilatation, fissurectomy, but these surgical procedure having adverse effects such as bleeding, infection, incontinence. \unskip~\citep{907138:20534609} The methanolic extract of cassia tora having antioxidant activaity. \unskip~\citep{907138:20534604} Chakramarda is effective in subsiding the symptom of Fissure in ano such as pain \& bleeding per rectum, itching. \unskip~\citep{907138:20534611} To sort out these problem we need treatment which is easily applicable and non surgical
    
\section{Conclusions}
The patient has found effective relief from pain, bleeding, itching at perianal region using chakramarda ghrita which has anti-inflammatory activity, antibacterial, antifungal scavenging activity, antiulcer, anti-proliferative activity, antioxidant activity. The outcome of this management is that \textit{Chakramarda is effective in the management of Fissure in ano}. Patients who take all follow-up after treatment will have less chance of symptom reoccurrence.  

\textbf{Conflict of Interest}

The authors declare that they have no conflict of interest for this study.

\textbf{Funding Support}

The authors declare that they have no funding support for this study.
    

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