|Year : 2015 | Volume
| Issue : 1 | Page : 68-71
Unusual occurrence of stony hard material in posterior anal fistula (bhagandara)
Pradeep S Shindhe, Sunny Mathew, N Dongargoan Tajahmed, S Killedar Ramesh, YM Santosh, Amruta A Wali
Department of Shalyatantra, KLEU's Shri B M Kankanawadi Ayurveda Mahavidhyalaya, Shahapur, Belagavi, Karnataka, India
|Date of Web Publication||5-Jun-2015|
Dr. Pradeep S Shindhe
Reader, Department of Shalyatantra, KLEU's Shri B M Kankanawadi Ayurveda Mahavidhyalaya, Shahapur, Belagavi, Karnataka
Source of Support: None, Conflict of Interest: None
The occurrence of stony material in the anal fistulous tract is a very rare clinical presentation; till today there are only three evident citation in pubmed indexed journals. Anal fistula (bhagandhara) is a chronic inflammatory tubular structure connecting the anorectal canal with peri-anal skin. A 66-year-old male patient presented with complaints of persistent pain in the perianal region and soiling of the undergarments with stool and constipation since 2 years. The case was diagnosed as posterior low anal fistula by per rectal digital, proctoscopic, and by fistulogram. It can be correlated to agantuja/unmargi bhagandhara. In the present case, "stasis" and "infection" might the reasons for the formation of stony hard material. Patient was successfully treated by the excision of whole tract with the unusual stone under local anesthesia. The presence of stony hard material in the fistulous tract is a very rare presentation and was successfully managed.
Keywords: Anal fistula, bhagandara, goodsall′s rule, stony hard material
|How to cite this article:|
Shindhe PS, Mathew S, Tajahmed N D, Ramesh S K, Santosh Y M, Wali AA. Unusual occurrence of stony hard material in posterior anal fistula (bhagandara). Indian J Health Sci Biomed Res 2015;8:68-71
|How to cite this URL:|
Shindhe PS, Mathew S, Tajahmed N D, Ramesh S K, Santosh Y M, Wali AA. Unusual occurrence of stony hard material in posterior anal fistula (bhagandara). Indian J Health Sci Biomed Res [serial online] 2015 [cited 2019 May 19];8:68-71. Available from: http://www.ijournalhs.org/text.asp?2015/8/1/68/158248
| Introduction|| |
Human body is an ideal and favorable "breeding ground" for the formation of "stones" particularly in the bladder, kidney, liver, salivary gland, gall bladder, etc. If these stones stay longer in our body, may trigger our health problem and their existence may even life-threatening if immediate medical treatment is not given.  However, stone in the fistulous tract is very unusual, there is only one evident citation regarding the occurrence of stony material within the anal fistulous tract.  Suśruta samhitā elaborately describes bhagandara (anal fistula). The condition is termed bhagandara as it does dāraṇā (tears) of bhaga (perineum), guda (rectum), and basti pradeśa (pelvis). The causative factors are attributed to the dosha viz., vāta, pitta, śleṣma, sannipāta, and āgantu.  Suśruta has given the name unmargi for āgantu bhagandhara and states the clear pathology of the condition as; particles of bones, eaten with (cooked) meat by an imprudent, greedy, gluttonous person, may be carried down with the hard and constipated stool by the Apána Váyu (into the rectum), thus scratching or abrading the margin of the anus, or burrowing into the rectum in the event of their being evacuated in improper directions through (transverse or horizontal postures). The scratch or abrasion is soon transformed into a fetid and putrid ulcer, infested with worms and parasites, as a plot of miry ground will soon swarm with a spontaneous germination of similar parasites. These worms and parasites eat away the sides of, or largely burrow into, the region of the anus, and jets of urine, fecal matter, and flatus (Vαyu) are found to gush out of these holes. 
Contemporary medicine describes the causes of anal fistula as, abscess in one or more potential spaces, source of infection from anal fissure, an ulcer at the root of the pile mass, inflamed anal crypt, infection from hair follicle, infected sebaceous gland, infected sweat gland, inflamed/thrombosed pile mass, retained sutures after hemorrhoidectomy, foreign body penetrating from outside. Systemic diseases may also cause fistula-in-ano like tuberculosis of intestine, ulcerative colitis, regional ileitis, recurrent appendicitis, urinary tract infections, prostatic infection, pilonidal sinuses, pott's spine and osteomyelitis of pelvic bones. Generally the external openings of the tract are found around the perianal area. In the present case, the external opening was located at the posterior anal wall below the 6 o'clock position and leakage of the fecal matter was observed through the opening.
| Case History|| |
A 66-year-old Muslim male patient presented with complaints of persistent pain in the perianal region and soiling of the undergarments with stool along with poking sensation in the anal region during sitting associated with feeling of mass per annum and constipation since 2 years. For the same patient consulted many doctors and was diagnosed as high anal fistula on the basis of fistulogram [Figure 1]. With all the reports patient approached our institute for further treatment. There was no associated history of fever or bleeding per rectum. He did not give any history of major illnesses or major surgery done in the past. Personal history of the patient revealed that he was a nonvegetarian (more intake of mutton) with irregular appetite, elderly married and farmer by occupation with no habits of tobacco and alcohol use. On examination, the patient's vital parameters were stable. On local examination, there was one visible wide external opening on the posterior anal wall approximately 2 cm away from the anal verge through which there was leakage of fecal matter with palpable hard fibrous tract extending anteriorly towards the anal canal associated with external pile mass at 11 o'clock position. The internal opening was palpable as a depression on per rectal examination at 6 o'clock position. Well lubricated slit proctoscope was inserted into the anal canal and dye was pushed from the external opening to rule out the presence of any ramification, but it was noticed that the pushed dye was coming out through single orifice in the posterior anal canal (6 o'clock position), which suggested that it was a case of posterior low anal fistula.
|Figure 1: Various views of fistulogram showing radio opaque hard stony material within the fistulous tract, shown by red arrow mark. White ring suggestive of external opening of the tract, spillage of radio opaque dye inside the rectum|
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The tract being very superficial short and palpable as hard tube extending from the anal verge to wide external opening with the stony hard material in it. Hence, chedana karma (fistulectomy) under local anesthesia was planned. The case was posted after complete preoperative analysis which included electrocardiogram, hematological, biochemical, and urine investigations.
| Treatment|| |
After adequate infiltration of local anesthesia 2% xylocaine with adrenalin, 4 finger manual, anal dilatation was achieved. Further entire tract was meticulously probed to see internal opening at 6 o'clock position. Keeping the eshani (probe) [Figure 2] in situ along with slight forward traction linear incision was taken starting from mucocutaneous junction till external opening. Further, the hard fibrous tract was separated from the underlying tissues and external sphincters by blunt dissection. Good hemostasis was achieved by Agnikarma (thermal cautery) throughout the procedure. After dissection, the tract was felt as if it is enclosed by very hard globular mass within it. On cut opening the tract, stony hard material with greyish color resembling a small pebble was observed. The wound created after fistulectomy was packed tightly with betadine soaked gauze. Postoperatively avagāha sweda (sitz bath) followed with dressing of the wound was done daily and in order to prevent surgical site infection, antibiotics were administered.
|Figure 2: Probing and confirmation of fistulous tract, probed from external opening to internal opening of fistulous tract|
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| Outcome and Follow-Up|| |
Patient was successfully treated by the excision of the whole tract with foreign body. Follow-up was done for 3 weeks, were complete wound was healed without remission of previous complaints and did not reveal any evidence of recurrence of the fistula for the period of 6 months.
| Discussion|| |
With clinical examination and Goodsall's rule.  The case was diagnosed to be a posterior low anal fistula. In fistulogram, there was presence of a radio opaque, round foreign body within the tract. On critically analyzing, the dietary habits, history, and clinical features exhibited by the patient; the condition may be better referred to Āgantu bhagandhara or Unmargi bhagandhara described in the classical texts.  Here Āgantu not refers to the external injury, but injury caused by hard bony pieces, which might be engulfed during eating which leads to the formation of posterior anal fissure; which can be a potential factor for the triggering of infection; in due course of time, food particles along with stool might have lodged in the potential space created leading to the formation of stone. Contemporary science also states that stasis, infection, reflux, and metabolic factors as the main reasons for the formation of stones elsewhere in the human body. In the present case, stasis and infection may the reasons for the formation of stony hard material.
The treatment for Āgantu bhagandhara is Shastra karma followed by Agni karma (thermal cautery) with Shalaka (red hot iron rod) and further removal of krimi or Shalya (foreign material). For low anal fistula the tract must be laid open;  but in this case as there was palpable hard fibrous tract with the presence of foreign body having chronic history and also causing much discomfort to the patient in performing his daily routines; fistulectomy was the choice of management, so that entire tract is excised giving no chance for further infection and recurrence.
Usually ks.hārasūtra therapy is widely practiced in the management of bhagandhara (fistula) but in this case the application of ks.hārasūtra was not adopted because it may take multiple sittings for the complete cutting of the hard fibrous tract and incompetent enough to remove foreign body which leads to the same previous complaints. The principle of surgery emphasis the removal of Shalya (foreign body)  irrespective of the condition. And the classical reference also emphasis the same that is, the wise surgeon should excise the complete tract along with the foreign body, followed with Agnikarma (thermal cautery) with Jambuoshta shalaka.  Hence, by taking into consideration of classical reference and the chronicity of the condition with the presence of radio opaque hard material, complete chedana (excision) of the tract [Figure 3] and [Figure 4] followed by Agni karma (thermal cautery) with Shalaka was successfully done.
| Conclusion|| |
Bhagandara is one of the "as.t.amāhāgada" (eight intricate diseases)  considering its morbidity, recurrence and social burden by its nature. Hence, meticulous planning of management is utmost essential. In this case, we came across with an unusual presentation of 9 mm × 5 mm shalya (hard stony material) [Figure 5] in the tract of posterior anal fistula which can be better referred as āgantu bhagandhara.
|Figure 5: Tract laid open to obtain the stony hard material from the well-formed sac|
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This case stands unique because we may get references of stones elsewhere in the human body, but occurrence of stone in the anal fistulous tract is incidentally unusual.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]