Meaning, Symptom, Associated conditions, Treatment, Modern correlation

Article by Dr Raghuram Y.S. MD (Ay) & Dr Manasa S, B.A.M.S

Parikartika – It is a painful condition which has been mentioned in more than couple of instances in Ayurveda treatises. But it has not been given an independent status as a disease and has not been explained in a separate context of its own.

The meaning of Parikartika shall be understood from its ‘root meaning’. The place of the body in which it occurs can also be assumed by the contextual explanation / mention of this word in the texts.

Meaning of Parikartika

The word Parikartika has two terms in it:

• Pari – which means all around
• Kartika – this term comes from kartana which means ‘to cut’.

The word ‘Parikartika’ has the term ‘kartana’ in it. Kartana means ‘to cut’. It defines ‘cutting pain in the anal region’. Here Kartana or Kartika shall be read as ‘Kartanavat Peeda’ i.e. pain as if the organ (anal region in this context) is being cut or sawed. While not being limited to all around the guda (anal region), the excruciating cutting type of pain seems to be experienced all around  the basti / basti shirah (head or fundus of urinary bladder) and nabhi (navel region) also.

This term parikartika has also been mentioned as a complication of ‘vamana – therapeutic emesis’ and ‘virechana – therapeutic purgation’ and also as a complication of wrongly introduced enema nozzle. Parikartika has been mentioned among the symptoms of Vataja Atisara, Vataja Grahani and Purisha Udavarta.

It has also been mentioned among the complications of various diseases including Vatika Jwara (fever of predominantly vata origin) and Vatika Pakvatisara (chronic diarrhea of vata origin), Arsha Purvarupa (premonitory symptom of piles / hemorrhoids), Udavarta (disease marked by abnormal upward movement of vata) and also as Garbhini Vyapad (disorders of pregnancy).

The treatment principles of these conditions shall be considered in treating anal fissure.

A condition called as Parikartika mentioned in different contexts in Ayurveda treatises can be closely compared to ‘anal fissures’.

Nidana – Causative Factors

Most of the diseases or the subtypes of diseases in which Parikartika has been mentioned as a symptom are predominantly caused by aggravated vata. So, vata increasing and kapha decreasing foods, activities and habits will play an important role in causation and manifestation of parikartika. Here we need to remember the etiological factors for cause (vata increase or vataja diseases) and effect will be the same (symptoms of increased vata or vataja diseases – parikartika in this context). Vata increase and kapha decrease might take place simultaneously. Separate etiological factors may be responsible or each condition can cause the other condition i.e. vata increase can cause kapha decrease and vice versa. Since guda – rectum and anus are located in the zone belonging to Apana Vata i.e. the lower portion of the body, apana vata vitiation should be mainly considered as causal for parikartika.

Samprapti – Pathogenesis

Both these i.e. vata increase and kapha decrease are responsible for many pathological changes in the body, including the colon, rectum and anal region which are the territories (residence, abode) of vata and its functioning. Excess dryness in the body caused due to vata increase (and or kapha decrease) may cause excessive dryness of feces leading to constipation. When there is severe or chronic constipation or hard bowel movement the person strains at defecation. Constipation and straining are the main causes of fissures as well.

Involvement of pitta in the samprapti of parikartika

Apart from vata, aggravated pitta too would be sometimes involved in the causation of parikartika. Ashayapakarsha is a pathological condition wherein the aggravated vata displaces normal pitta or kapha from their normal seats. When aggravated vata pulls down normal pitta (displacing it from its seat) into the lower zone of the body (which belongs to vata), especially colon (including rectum and anus), it would cause cutting pain (like parikartika – though the term has not been mentioned in the context of ashayapakarsha) in the anal region and also inflammatory condition in the anal region. This can cause conditions like arshas, bhagandara and parikartika.

Involvement of Ama and Mandagni

Due to less strength of digestive fire (mandagni), lot of ama is formed (intermediate products of erroneous digestion which are sticky in nature and tends to cause blocks and clogs in the body). Association of ama with doshas (sama doshas) is a vicious combination. These sama doshas would cause blocks in the body, in the passages and channels of the body, including the gut. This would eventually cause conditions like constipation. If there are signs of low digestion power or symptoms of ama, they should be addressed before any other interventions.

Lakshana – Symptoms 

Symptoms of Parikartika – The name of the disease itself indicates its main symptom also i.e. ‘presence of excruciating cutting pain in the anal region and also in the region of urinary bladder and umbilicus’.

Parikartika as a Symptom / Premonitory symptom

Parikartika is also mentioned as a symptom of few diseases. They are –

• Vataja Atisara / Vataja Pakvatisara (Cha.Chi.19/5)
• Vataja Grahani (Cha.Chi.15/62)
• Purishaja Udavarta (Su.Ut.55/8)
• Sahaja Arshas (Cha.Chi.14/8)
• Arsha Purvarupa (Su.Ni.2/9)

Parikartika as a complication of therapies

• Vamana-Virechana Vyapat – as a complication caused due to excessive administration of emesis and purgation therapy or administration of quick acting emesis and purgation medicines / recipes (Cha.Si.6/61-63)
• Vasti Vyapat – as a complication caused due to administration of enema prepared with un-unctuous and sharp acting herbs / ingredients (Cha.Si.7/54-57)
• Vasti Netra Vyapat – as a complication of erroneously / quickly introduced enema nozzle into the anus / rectum (though the word parikartika has not been mentioned in these contexts, symptoms indicating injury to the anal canal have been mentioned)

Etiology and signs and symptoms of Parikartika caused as complication of (emesis and) purgation therapy  

स्निग्धेनगुरुकोष्ठेनसामेबलवदौषधम्|
क्षामेणमृदुकोष्ठेनश्रान्तेनाल्पबलेनवा||६१||
पीतंगत्वागुदंसाममाशुदोषंनिरस्यच|
तीव्रशूलांसपिच्छास्रांकरोतिपरिकर्तिकाम्||६२||
If a person who is oleated, who has costive bowel and who is afflicted with Ama or if a person who is weak, who has lax bowel, who is fatigued and who has taken a quick acting medicine for purification, then the recipe reaches the rectum to cause excruciating sawing kind of pain accompanied with slimy and bloody discharge. This is called as Parikartika. (This parikartika should be considered as a complication of erroneously administered purgation therapy. In erroneously administered emesis therapy similar cutting pain may be experienced in the throat instead of anus).

Etiology, signs and symptoms of Parikartika caused by administration of un-unctuous and sharp enemas

मृदुकोष्ठाल्पदोषस्यरूक्षस्तीक्ष्णोऽतिमात्रवान्|
बस्तिर्दोषान्निरस्याशुजनयेत्परिकर्तिकाम्||५४||
त्रिकवङ्क्षणबस्तीनांतोदंनाभेरधोरुजम्|
विबन्धोऽल्पाल्पमुत्थानंबस्तिनिर्लेखनाद्भवेत्||५५||

If enema with un-unctuous and sharp ingredients is given to a patient who has laxed bowel and who has less of aggravated Doshas, then it immediately eliminates Doshas to cause partikartika (sawing pain), pricking pain in the lumbar region, groins and the region of urinary bladder and pain in the lower abdomen below the umbilical region. Because of the scraping effect of enema, the patient suffers from constipation and frequent voiding of stool in small quantities.

Management of PARIKARTIKA

Parikartika shall be treated with the help of below mentioned principles.

Treatment of Vata –

Since aggravated vata is the main cause of parikartika and its symptoms, vata shall be handled with the help of vata balancing measures including diet, lifestyle changes, medicines and therapies. Medicated oils and ghee shall be used for oral consumption and as enemas.

Vasti – Lubricating enemas i.e. anuvasana / matra vasti will act as vatanulomana i.e. regularize the movement of vata and control its activities and hence addresses vata aggravation effectively. This would help healing the fissure / wound, lubricating the anal passage, relieving constipation, local spasm, pain and discomfort caused by parikartika.

Pichcha Basti – Slimy medicinal enemas shall be administered if there is discharge of mucus, slimy material or blood from the anus in the presence of anal fissures.

Pichu – Small pads of sterile cotton dipped in medicated ghee or oil, kept inside the anal canal in close contact with the wound (fissure wound) acts like a protective layer and causes soothing of anal canal. It relieves pain, burning sensation and risk of bleeding. It also helps in wound cleansing and hence is effective in wound (fissure) healing). It doesn’t allow formation of unhealthy granulation tissue. Jatyadi Taila / Ghrta or Jivantyadi Yamakam / Yashtimadhu Taila shall be used for the purpose.

Gudavarti – herbal suppositories mentioned in the contexts of udavarta and adhmana shall be used in parikartika too.

Avagaha Sweda – Tub fomentation or sitz bath in a tub filled with hot / warm water should be used by the patient after every bowel movement. Instead of plain warm water, herbal decoctions like warm dashamula kashaya should be used in the tub. The patient should sit waist deep in the tub for 10-20 minutes. Apart from ‘after defecation’ the patient can use this as and when needed. This would soothe pain and relax spasm of anal sphincters and would also cleanse the wound (fissure).

Treatment of Pitta –

If symptoms of pitta aggravation are seen in parikartika pitta balancing measures should be included in the treatment of Parikartika.

Treatment on the basis of Ashayapakarsha –

Pitta symptoms in the anal region may be due to hyperactivity of vata which would pull normal pitta into the anal region. Here aggravated vata should be treated promptly which will in turn take care of pitta and its symptoms.

Treatment of Mandagni and Ama / Sama doshas –

If symptoms of mandagni or ama or sama doshas are present they should be promptly treated before starting any other interventions. In this direction langhana (lightness producing measures), pachana (ama digesting medicines and measures) and rukshana (dryness producing measures) shall be skillfully used as and when required, only until these conditions are resolved. If these procedures are done for longer time without monitoring the patient’s condition they would cause more dryness and worsen constipation and symptoms of parikartika.

Arsha Bhagandara Chikitsa –

Parikartika shall be treated on the lines of treating arsha – piles and bhagandara – fistula in anus. All these conditions occur in the anal region. It should be mainly treated on the lines of treating shushkarsha – dry or non-bleeding piles or bahya arsha – sentinel piles.

Master Sushruta has described fourfold approach (modalities) in treating arshas. They are –

1. Bheshaja prayoga – use of medicines / conservative treatment
2. Ksharakarma – use of alkali cautery
3. Agnikarma – use of fire cautery
4. Shastrakarma – use of surgical methods

Among these, leaving out agni karma, the other three shall be skillfully implemented for effectively treating parikartika.

Kshara Sutra Therapy

Kshara Sutra means thread smeared or impregnated with herbal alkalis. In this procedure, the alkali thread is inserted and knotted into the fistula, pile mass, sinus in anal region or fistula in anal region and left in place for few days. The alkali, by the virtue of its intense and deep penetrating action and by the virtue of its hot potency, burns the pathological area (cauterization effect) and eliminates them from the base. Ksharasutra is a minimal invasive Ayurvedic para-surgical procedure and time-tested Ayurveda technique in the management of Anorectal disorders. Sentinel pile masses are commonly associated with fissures, vis-à-vis parikartika. Ligation of alkali threat to these masses will ensure that they fall off within few days.

Related Reading – Ksharasutra

Kshara Lepa – Application of alkali paste (pratisaraniya kshara) over chronic fissures have shown considerably good results in terms of fissure healing. Alkali imparts scraping action which reduces the fibrous tissue formation (and clears that which has been formed) over and around the fissure bed. On the other hand, anal sphincters would relax.

Agnikarma – Fire cautery / electro-thermal cautery is also a para-surgical procedure. It has been successfully used for treating many complicated conditions especially by the ancient surgical schools of Ayurveda. In conditions of parikartika, the arsha surrounding it (sentinel piles present in the vicinity of fissures) can be dealt with so as to mark relief and prevent recurrence.

Bheshaja and Pathya Apathya – Medicines and modulations in dietetic regimen and lifestyle activities shall be the same as for arshas and bhagandara.

Treatment of Koshtabaddhata

Koshtabaddhata or constipation is the main cause for parikartika. This is caused by vata imbalance in the colon. Here too laxatives and mild purgatives which can cleanse bowel shall be given in the form of ‘laxative oils’. Gandharvahastadi Eranda Taila or Nimbamrutadi Eranda Taila can be used for this purpose.

Treatment of Udavarta (Anaha, Adhmana)

Udavarta too should be taken care of, mainly the abnormal upward movement of vata caused by forcible withholding of urges of fart and feces. People should be trained not to withhold any of the body urges and to address them as and when they get manifested. Purishaja Udavarta i.e. vata aggravation and abnormal upward movement due to forcible withholding of defecation reflex has been mentioned as one of the chief causes for parikartika (parikartika is a symptom of this condition). Likewise Anaha – flatulence and Adhmana – distension of abdomen wherein vata (and ama) are the main causes too should be addressed. They may coexist with udavarta or manifest independently.

Here, in parikartika, the treatment principles of all these three conditions explained in the classics shall be adopted.

Treatment of Atisara and Grahani

Atisara i.e. diarrhea and Grahani i.e. small bowel disorders including inflammatory bowel disorders should be promptly treated and so also dysentery. In diarrhea there will be fluid loss leading to dryness and vata vitiation. In grahani there will be alternating episodes of diarrhea and constipation. In dysentery there will be lot of straining. All these will constantly irritate the rectum and anus and would cause parikartika.

Vrana Chikitsa

Parikartika shall be treated on the lines of treating vrana i.e. ulcers or wounds as explained in Ayurveda treatises.

Treatment of Parikartika caused as complication of emesis and purgation therapy

लङ्घनंपाचनंसामेरूक्षोष्णंलघुभोजनम्|
बृंहणीयोविधिःसर्वःक्षामस्यमधुरस्तथा||६३||

आमेजीर्णेऽनुबन्धश्चेत्क्षाराम्लंलघुशस्यते|
पुष्पकासीसमिश्रंवाक्षारेणलवणेनवा||६४||
सदाडिमरसंसर्पिःपिबेद्वातेऽधिकेसति|
दध्यम्लंभोजनेपानेसंयुक्तंदाडिमत्वचा||६५||
देवदारुतिलानांवाकल्कमुष्णाम्बुनापिबेत्|
अश्वत्थोदुम्बरप्लक्षकदम्बैर्वाशृतंपयः||६६||
कषायमधुरंशीतंपिच्छाबस्तिमथापिवा|
यष्टीमधुकसिद्धंवास्नेहबस्तिंप्रदापयेत्||६७||

In this condition associated with Ama, the patient should keep fasting; take Pachana (digestive stimulants) and food which is un-unctuous, hot and light for digestion.

If the patient is weak, then all the nourishing therapies and recipes containing drugs having sweet taste are taken.

Recipes for Parikartika
If Parikartika (sawing pain) continue even after the Ama (product of improper digestion and metabolism) gets cooked intake of alkaline, light to digest and sour foods are beneficial.

If there is predominance of vayu (aggravated), the below mentioned recipes are useful:

• Ghee along with pomegranate-juice added with Puspa-kasisa or alkalies or salt
• Food and drinks containing sour curd mixed with the skin of the pomegranate;
• Paste of Devadaru and Tila should be given for drinking mixed in hot water.
• Milk boiled and processed with Ashwattha, Udumbara, Plaksha and Kadamba should be given for drinking.
• Cold enemas prepared with astringent and sweet tasting herbs or Pichcha Basti type of enema shall be administered.
• Anuvasana Basti with oil / ghee prepared with paste and decoction of Yashtimadhu.

Treatment of Parikartika caused by administration of un-unctuous and sharp enemas

स्वादुशीतौषधैस्तत्रपयइक्ष्वादिभिःशृतम्|
यष्ट्याह्वतिलकल्काभ्यांबस्तिःस्यात्क्षीरभोजिनः||५६||
ससर्जरसयष्ट्याह्वजिङ्गिनीकर्दमाञ्जनम्|
विनीयदुग्धेबस्तिःस्यात्व्यक्ताम्लमृदुभोजिनः||५७||

Milk is boiled by adding sweet and cooling ingredients like sugarcane, etc. To this medicated milk, the paste of Yastimadhu and Tila is added. Enema is given with this recipe keeping the patient on milk diet.

Milk is added with Sarjarasa, Yastimadhu, Jingini, Kardama (mud) and Anjana (solid extract of Daruharidra). This recipe is added with sour juice and used as enema for the patient who is on soft diet.

Important formulations for treating Parikartika

• Gandharvahastadi Kashayam
• Gandharvahastadi Tailam
• Nimbamritadi Eranda Tailam
• Sukumara Ghrtam
• Dusparshakadi Kashayam
• Jatyadi Ghrta
• Jatyadi Taila
• Triphala Churna
• Triphala Guggulu
• Kaishora Guggulu,
• Shigru Guggulu
• Lakshadi Guggulu,
• Sonamukhi Churna
• Haritaki Churna
• Kalyanaka Gulam
• Nirgundi Taila
• Arshakuthar Ras
• Panchasakar Churna
• Bolabaddha Rasa
• Abhayarishta

Important herbs and things in Parikartika

• Bilwa – Aegle marmelos
• Guggulu – Commiphora mukul
• Kutaja – Holarrhena antidysenterica
• Sonamukhi
• Haritaki – Terminalia chebula
• Nagakesara – Messua ferrea
• Haridra – Curcuma longa
• Takra – buttermilk

Pathya – beneficial foods and practices

• Old red rice and paddy grown in sixty days should be taken
• Barley and horse gram are good
• Light, easily digestible foods
• Foods predominant in sweet taste
• Vata alleviating foods, drinks and activities
• Fasting, ama digesting herbs, dry and hot, light foods if ama is present
• Attend to urges of defecation and fat as and when they appear
• Avoid constipation, foods and activities which cause constipation and take care of bowel health
• Avoid straining too much during defecation
• Consume leafy vegetables
• Drink water and keep up the hydration
• Sitz Bath regularly

Apathya – unwholesome foods and activities

• Withholding urges for defecation, fart and urination
• Excessive sexual intercourse
• Excessive exercise / strenuous physical activities
• Consumption in excess of foods which are heavy to digest
• Anger
• Consumption of too much spicy foods, corrosive foods and foods having sharp and penetrating properties
• Consumption of too much salt or salty food
• Consumption of too dry and stale foods
• Any vata aggravating foods and activities
• Any pitta aggravating foods and activities

Works on Parikartika

1. A comparative clinical study of Yastimadhu Ghrita and lignocaine-nifedipine ointment in the management of Parikartika (acute fissure in ano)

2. Management of Parikartika w.s.r to Acute Fissure-in-Ano with Guduchi Taila Pichu – A case study

3. Management of Post-operative Wound of Parikartika (Chronic Fissure in Ano) by Seethodaka Thaila Pichu Followed by Dorsal Sphincterotomy – A Single Case Report

4. Comparative Study of Palashgudavarti and Diclofenac Sodium Suppository in the Management of Acute Fissure in Ano (Parikartika) – An Ayurvedic Management Protocol

5. Study of The Effect Of Chandanabalalakshadi Taila Pichu in Parikartika With Special Reference To Fissure-In-Ano: A Pilot Study

6. Acute Management of Parikartika (fissure in ano) by Tila Taila Matra Basti: Case Study

7. A Study on the Efficacy of Darvi Taila Matra Basti In The Management Of Parikartika w.s.r to Fissure-in-ano

8. Clinical Study on the effect of Dwiharidra Rasakriya Pichu in Parikartika

9. Randomized controlled clinical trial to study the efficacy of Priyangvaadi Gana Siddha Taila in the management of Parikartika w.s.r. to fissure-in-ano – An Ayurvedic Management Protocol

10. Effect of Patoli Taila in Management of Parikartika (Fissure-in-Ano) in Comparison with Jatyadi Taila: Randomized Clinical Trial

11. Comparative Study of Ksharasutra suturing and Lord’s anal dilatation in the management of Parikartika (chronic fissure-in-ano)

Modern correlation

Parikartika can be closely correlated to fissure / anal fissures explained in the modern texts. All interventions discussed in this context (of parikartika) can be skillfully and conditionally (as per situation) administered in effectively treating anal fissure cases.

Related Reading – Anal Fissures