A case report on management of recurrent pediatric fistula in ano with an udumber ksheersutra

Fistula-in-ano and Perianal abscess are common findings in infants and children. The perianal abscess is usually a manifestation of a fistula-in-ano. Although surgical treatment is an extensively standard remedy for fistula-in-ano, it was recently advised that fistula-in-ano in toddlers is a time-confined disease and fistulotomy or fistulectomy must be avoided. However, it should be noted that conservative treatment of fistula leads to prolonged hospital stay, prolonged antibiotic use and additional pain. Although recurrence of a perianal abscess or fistula abscess after treatment is possible, there should be undue evidence of suspected Crohn’s disease in older young people who wish to relapse. We aimed to present the optimal management of fistula-in-ano in order to reduce or even eliminate the risk of recurrence. It was also dis-covered that udambara ksheera heals vital recurrent anal fistulas by acting on its shodhan (wound clean-ing) and ropan (wound healing) properties. So present case study of reccurrent fistula in ano in pediatric patient was carried out in outpatient department of Shalya Tantra at Mahatma Gandhi Ayurved College, Hospital and Research Centre, Salod (Hirapur) under Datta Meghe Institute of Medical Sciences, which was successfully treated.


Introduction
According to Acharya Sushruta, Bhagandar was considered as one of the Ashtamahagad, this demonstrates the seriousness of the disease. It appears as Pidika at first, then becomes Pakwa to form Bhagandar in Bhaga , Guda, and Basti Pradesh, it causes Daran [1]. it can be co releated with fistula in ano in morden science. Anal fistulas are relatively common conditions in the pediatric population, especially in infancy.
Inflammation of the glands located in abnormally deep Morganini's crypts is the cause of development of perianal abscesses and fistulas [2]. Inflammation is initiated in the crypts and spreads to the surrounding tissues, leading to inflammation and formation of an abscess in that area. In most patients, perianal abscess is a symptom and consequence of anal fistula running from the crypt on the top of the anal canal to the skin. The largest group of patients comprised male infants without other chronic conditions. There are disagreements among numerous researches approximately the charges of recurrence of anal fistula in ano. Some researchers [3] encouraged lively probing for underlying fistula in ano in all children undergoing surgery. It is found in present day surgical technological know-how maximum common surgery followed with inside the treatment of fistula in Khandare K, et al. Pediatr Urol Case Rep. 2021;8(6): 134-137 135 ano are fistulectomy, fistulotomy, flap advancement, LIFT, glue, and seton. These surgical control includes numerous complications like frequent harm to the anal sphincters muscles, faecal soiling, rectal prolapse, anal stenosis, not on time wound healing, or even after entire excision of tract there are possibilities of recurrence [4].
In earlier studies it is reported that the latex expressed from certain plants can be very well used to prepare the ksheer sutra which is having very good effect in fistula-in ano [5] by reducing the pain with the usual advantages of kshara sutra, Lack of consensus in the treatment of this disease makes choosing treatment difficult and in infants it is very difficult to manage the pain, inflammation, infection therefore in this present study udumber ksheersutra varti is used in this case of recurrence fistula in ano.

Case report
A six month old male infant was brought to Shalyatantra No other medicine was prescribed in this case except the regular mother breast feeding. Fistula tract was completely healed without any discharge (Fig 1 and  2), later the patient was followed up for a period of 6 months and no recurrence of symptoms was observed.

Results and Discussion
The glands of hermann and desfosses, which are located within the thickness of the anal canal, open into the canal at the dentate line. Infection of these anal glands leads to the formation of abscesses and/ or fistulas. If these manifests as an abscess, emergency drainage of the infected cavity is required [6]. Anal sepsis in children ranges from perianal abscess to fistula. It is mainly determined in children under 2 years of age. Most are running conservatively. In contrast, anal sepsis in older children is clearly similar to that in adults, and is mainly treated with surgery. Fistulas can be treated with fistula incision or fistula resection, both of which are related to the reasonable possibility of fistula recurrence [7]. The plan of care proceeded with Udumber ksheer varti and sitz bath which helps in maintaining the hygiene of perineal and peri-anal area and reducing the inflammation, pain and relaxed the spasm of sphincter muscles [8]. Udumber ksheer has activities including wound healing, antidiabetic, antibacterial, anti-inflammatory, hepatoprotective, and antimicrobial activities [9]. Udumber ksheer is having shodhana and ropana properties. When applied topically, Shodan medicine can reduce pain, discharge and swelling of surrounding tissues [10]. These drugs initially act as cleansers, removing exfoliated and necrotic materials from the wound, and ultimately promote clean and clear healing. They reduce wound contamination by bactericidal action on drug-impregnated shodhana dressings, and provide a moist environment to supplement epithelial formation and prevent exfoliation, which is beneficial to inflamed wounds with resistant bacteria. After 3 sitting of application wound was found healthier and reduced the pain and discomfort [11].

Conclusion
This case report is an attempt to show the effectiveness of udumber ksheersutra varti in management of recurrent fistula-in-ano in pediatric patient. The patient has been effectively treated without the need for any surgical intervention. The condition and progress of the patient have been properly documented photographically.
Reduce pus, healthy granulation tissue and fully healed cavity. Udumber ksheer varti has the properties of Shodhana and Ropana, as well as an antibacterial effect that promotes blood vessel formation and cavity healing.