Evaluation of Anti microbial properties of Guggulu

Dr. Manoranjan Sahu* Dr. Gopal Nath** Dr. Sanjay Kumar Singh***

*Head of Department Of Shalya-Shalakya, Institute Of Medical Sciences, B.H.U, Varanasi
**Sr. lecturer dept. of Microbiology, Institute of Medical sciences, B.H.U., Varanasi.
***Junior Resident -3, Institute Of Medical Sciences, B.H.U., Varanasi.
Publish in Journal of Ayurvedic Pharmaceutics and pharmacology, Vol 1, No. 1 July 2003. Nagarjuna rasa Bhaishajya Parishada, Department of Rasa Shastra, College of Ayurveda & Research Center, Sec. No. 25 Pradhikaran, Nigdi, Pune – 44, Maharashtra.

Abstruct

Kshara Sutra therapy is an original research contribution of the department of Shalya Shalakya I.M.S., B.H.U. Majority of the works has been done on Snuhi based Apamarga Kshara Sutra. Though, this Kshara Sutra is highly effective in the management of Fistula-in-ano. But pain irritation, difficulty in manufacturing process has limited its use. Thus, various type of Kshara Sutra tried with their efficacy in different angle. In this present study effort will be made to define the probable mode of action of Guggulu Kshara sutra in Fistula-in-Ano. This is equally effective with less painful and easy to prepare. The present paper deals with the efficacy of Guggulu Based Kshara Sutra especially on its antibacterial effect.
Key words: Recurrent High anal Fistula, Bacteria, Kshar Sutra, Guggulu, Haridra, Apamarga, Bhagandara.

Introduction:

Fistula-in-Ano is a grave disease.  In modern medical science, the description of Fistula is available long back from time of Hippocrates 6 B.C. But in Ayurvedic classical texts Fistula-in-Ano has been widely described as name of Bhagandara along with treatment, before the time of Hippocrates. There we found Bhagandara also treated by Kshara sutra. It is a medicated thread, which is prepared by repeated coating of various medicinal plants over the thread. In 1964, a scientific study was carried out in the dept. of Shalya-Shalakya, IMS, BHU, Varanasi by Deshpande et. al[1],[2]. and it was found that Snuhi based Kshara sutra is very effective in the management of anal fistula with least complications[3] i.e. recurrent 1-2%.  In comparison of the operative methods, which are not free from complications. Recently H. Ortiz[4] has also been shown high recurrent rate. This Kshara sutra in spite of good result was having some local irritation, inflammation, pain and few difficulties in processing. Therefore, since then the department of Shalya Shalakya, faculty of Ayurveda, Institute of Medical sciences, has been engaged in developing a well-accepted good quality Kshara sutra, which also has easy in processing. Several types of Kshara sutra with different modification were tried. These modifications can be classified in two heading 1. Modification in Kshara material i.e. Yava, Borax.etc. 2. Modification in Binding material i.e. Snuhi gum, Udumber Ksheer, Papaya Ksheer etc. By trial and error Sahu et. al. found that the Guggulu based Kshara sutra[5],[6] is equally effective as Snuhi based Kshara sutra and having less pain, irritation, inflammatory reaction and easy in processing. Now Guggulu based Kshara sutra is being in use since 1998. Following hypothesis were given in favors of action of Guggulu Kshara sutra: (1) Kshara Sutra removes the fibrous tissue by chemical cauterization of fistulous tract. (2) The thread creates the passage for continuous drainage of pus. Thus facilitates the healing process. (3)  Kshara Sutra may posses anti bacterial properties which may control the infection of the tract and promote healing. The present study was planned to see the antibacterial effect of Guggulu Based Kshara Sutra contents and effect of Kshara Sutra was study in primary and recurrent high Anal Fistula. 

Material & Methods

Materials & Methods: Present study was planned in two phase; in 1st phase, 80 cases ( 25 primary and 55 recurrent high anal fistula) were taken for study. Since, the therapy takes a long time i.e. 7 to 8 month for completion and during the limited period of  present study only 48 cases were could completed the therapy. Hence, 48cases were selected for evaluation of antibacterial effect of Guggulu Kshara Sutra in high anal fistula. The cases were divided in two groups:  Group I (Primary cases) and Group II (Recurrent cases) containing 9 and 39 patients in each group respectively. Both the group were treated with Guggulu Kshara sutra and no antibiotics were used during the therapy. Before starting the therapy, proper anorectal examintation was carried out  with or without local anesthesia Anal canal and the lower rectum were carefully examined for internal opening by inspection and pressure from out side to see if pus could be demonstrated. The pus smear was taken from the fistulous opening by sterile cotton swab and sent to dept. of microbiology, in sterile container, and where pus culture and sensitivity was done. Pus swab was inoculated on Blood agar and Mac-Conkey’s agar medium. Pus smear was taken before, during and after the therapy.   The procedure of applying Kshara Sutra is very easy, in most of the cases it was done under  local anaesthesia and only few cases were required spinal anesthesia. Changing of Kshara sutra was done by railload method i.e. the new one medicated Kshara sutra was tied at previous Kshara sutra, this sutra is cut and pull out thorough fistulous opening and new one placed. The cutting rate of fistulous tract was recorded by measuring the length of Kshara sutra on subsequent changing. In second phase of study, the different contents of Guggulu Kshara sutra were taken and following protocol were adopted for antibacterial study.

(A) Screening of antimicrobial effect of component of Guggulu based Kshara Sutra by Broth[7] dilution method

Where grading was done on the basis of following entering:

≥ 1000 colonies / plate : ++++

> 100 – 1000 “ “ : +++

>1 – 10 “ “ : ++

1 – 10 “ “ : +

0 “ “ : -

(B) Screening of the antimicrobial activity of component of Guggulu based Kshara Sutra by disc diffusion method[8]:  The components of Guggulu Kshara Sutra were dissolved in normal saline and methanol (white spirit) and in the concentration of 400mg/ml was made. The Guggulu Kshara Sutra, Apamarga Kshara Sutra were of 4cm taken and dissolved in 1 ml Normal Saline and supersaturated Guggulu gum also taken for the study. The Whatman filter paper no.1 discs were added into all the solution and these were kept for 48 h. to assume that the active principle would be absorbed by the paper disc. After 48 h. it was observed that the white spirit was evaporated and disc were dry. Standard strain of Escherichia coli , Enterococcus faecalis and Pseudomonas aeruginosa were taken for the culture and dissolved into the 1ml of normal saline, and turbidity was matched with the Mc Farland standard, to ensure that the conc. was 1,00,000 bacteria per ml.. The swab stick were soaked into the bacterial suspension and wet stick was spread over the Muller Hinton plate. Now Guggulu Kshara Sutras and its component containing Whatman filter paper no.1 discs (6mm)were placed on bacterial lawn. The number markings were given to every component behind the Petri disk and disks were kept at the temperature of 370c for 24 h.

+ : (Zone of inhibition present > 8 mm)

± : (Zone of inhibition 6 - 8 mm)

- : (No Zone of inhibition)

Escherichia coli and Staphylococcus aureus were further kept in incubator to find out further changes. In disk of Escherichia coli, it was observed that discs which contained the Apamarga Kshara, Guggulu mixed, Guggulu Kshara Sutra, and concentrated Guggulu gum dissolved in Methanol, were not contaminated. Rest of the discs which were dissolved in the water along with the control disc of ciprofloxacin got heavily contaminated   In Staphylococcus aureus, the discs, which were having Kshara, Guggulu and mixed, were not any contamination. However, rest of the disc along with the control got contamination. Observation:

Table No. 1
Distribution of cases according to change in bacterial trend in Group I in before and during the therapy :

 Out of 9 cases before therapy 33.3% (3/25)case of Escherichia coli, each of 22.2% (2/9) cases Staphylococcus aureus and Proteus mirabilis and each of 11.1%(1/9) cases of Escherichia coli & Enterococcus fecalis and Escherichia coli & Enterococcus  species respectively In mid of therapy out of 9 cases, 66.7 %(6/9), 22.2%(2/9) , 11.1%(1/9) cases were of Escherichia coli , Proteus mirabilis and Sterile respectively. In post - therapy out of 9 cases, 100.0 %( 9/9) cases were of Escherichia coli. Table No. 2

Distribution of cases according to change in bacterial trend in Group II in before, during and after the therapy(fig. – 2):

Out of 39 cases, before therapy, 48.7% (19/39), 7.7% (3/39), 15.4 %( 6/39) cases were of Escherichia coli, Staphylococcus aureus and Escherichia coli & Staphylococcus aureus respectively. each of 5.1 %( 2/39) cases were of Citrobactorspecies, Morganella morgani respectively and each of 2.6 %( 1/39) cases were of Klebsiella pneumonae, Proteus mirabilis, Enterococcus fecalis, Enterococcus species, Escherichia coli & Enterococcus fecalis and Escherichia coli & Acinetobacter. Out of 39 cases during the therapy, 74.4% (29/39), 5.1 %( 2/39), 10.3 %( 4/39) cases of Escherichia coli, sterile and Escherichia coli & Staphylococcus aureus and 2.6 %( 1/39) cases were of Klebsiella pneumonae, Proteus mirabilis, Escherichia coli & Enterococus fecalis and Klebsiella pneumonae & Enterococcus fecalis. In post - therapy out of 39 cases, 82.05 %( 32/39), 7.7 %( 3/39), Escherichia coli Aeromonas and each of 2.6 %( 1/39) cases were of Klebsiella pneumonae, Proteus mirabilis, Citrobactorspecies and Enterobacter respectively.

Disscussion:   In the 1st phase of the study, two type of infective organisms found in Fistula-in-Ano i.e. skin derived bacteria and intestinal bacteria. There were fistulous tract mostly infected by the intestinal organisms and its proved the previous finding. The skin-derived organisms could not grow in the presence of Guggulu Kshara Sutra. Kshara Sutra has little effect on Escherichia coli so that it was grown through out. However, during the therapy in Group II, 5.1% (2/39) cases and in Group I, 11.1% (1/9) cases were found sterile, which were replaced by other organism in termination of therapy.   The majority of the patients who had single microorganism grown at the first culture develops several other new organisms during the course of the treatment but toward the end of the treatment, either only one organism could be grown the culture. The number of patients having Escherichia coli infection at the initial culture increased in number at the final culture but the increase was marked only in cases having two or single organism grown. The most remarkable reduction at the final culture was noticed in case of Staphylococcus aureus where 100% reduction was observed. Again, certain importance species of organism like Morganella morgani, Enterococcus fecalis, and Enterococcus species become negative in the final culture.  Another finding was that during the course of therapy sensitivity of organisms to the antibiotics varied. It may possible that these drug combination or the Ayurvedic drugs that were, consumed by the patient having some modulator property. In vitro experiment on the standard bacteria of Escherichia coli, Pseudomonas aeruginosa, Staphylococcus aureus and Enterococcus fecalis has been show that  media of Haridra has good nutrition for all four above bacteria. However, Guggulu has some antibacterial activity against the Escherichia coli, Enterococcus fecalis and Staphylococcus aureus and Apamarga Kshara have anti bacterial property against Pseudomonas aeruginosa, Enterococcus fecalis and Staphylococcus aureus. In addition, combinations of these drugs have shown inhibitory effect on Enterococcus fecalis and Pseudomonas aerugenosa. Another important finding was that Guggulu Kshara sutra after keeping in incubator at 370c did not get contaminated. Therefore, the above findings predects the antibacterial effects of Guggulu based Kshara Sutra. While, it clearly shows that some infection although persists throughout the course of Guggulu Kshara Sutra treatment and the fistula shows smooth recovery or healing in the presence of infection.  

Conclusions: Fistula-in-Ano or Bhagandara is an infective condition caused by invasion of anal glands and ducts by various pathogenic organisms. The cause of recurrence, the nidus of infection left concealed during operation. Therefore, to avoid grave complications and recurrence, Kshara sutra treatment has been tried for curing Bhagandara in Ano-rectal clinic of S. S. Hospital, B.H.U. In past 38 years a lot of work has been done by its many workers and proved the efficacy of Kshara sutra treatment has 98 to 100% cure. Now it is possible to argue here the Mechanism of action of Kshara sutra as follow: During application of Kshara sutra, there is continuous drainage of fistulous tract, which helps in healing. The ingredients used in coating over the thread, induces an effective fibrolytic action and separation & removes of debris and cleansing of the wound   through the fistulous tract and encourages healing by fresh granulation tissue formation from the base.    The role of sutra is to bind the Kshara in a particular form and to keep a desired pressure over the tissues where it is applied. The principle involved in the use of Kshara sutra as therapeutic tool is analogous to that of wire cutting through an ice block the ice still adherent after division by wire. Theoretically, by tightening the Kshara sutra and permitting it to cut through over a number of days or weeks, the resultant inflammatory cell response keeps the sphincter muscles from retracting and separating. During Kshara sutra therapy, gradual cutting and healing take place simultaneously. The contents of Guggulu Kshara sutra help the tissue by reducing the infective organisms by their antibacterial property. 

REFERENCES:

[1] Sharma, B.N.; Singh, L.M.; Deshpande, P.J.: Concept of Bhagandara and Principles of its treatment of Bhagandara (fistula-in-ano), D.Ay.M. Thesis, BHU (1968). [2] Deshpande, P.J.; Sharma, K.R.: Successful Non Operative treatment of High rectal fistula, Amer, J. Procto. 39-47, Feb (1976). [3] Tripathi, A.: Management of High Rectal Fistula with Kshara sutra, MD (Ay) Thesis, IMS, BHU (1976). REFERENCES: [4]H.Ortiz and J Marzo, Endorectal advancement repair and fistlectomy for high Transsphincteric Fistula and Suprasphincteric Fistula, Br.J.Sur. 2000, 87, 1680-83 [5] Praveen kumar: Guggulu based Kshara sutra in management of Fistula-in-Ano, MS (Ay) Thesis, IMS BHU (1998) [6] Anil yadev: Study of Guggulu based Kshara sutra in the management of high anal fistula, MS(Ay) Thesis, IMS BHU (1999) [7] Satish Gupte, Short textbook of Medical Microbiology 7th ed. 1999 , Jaypee Brothers, Medical Publishers (P) LTD. B-3 EMCA House, 23/23B Ansari Road, Daryaganj Post Box 7193, New Delhi 110002, India. [8]Gopal Nath, Basics of Microbiology for Laboratory, 1st ed. 2001, Gunjan – Gautam Publishers, 2 Vallabh Puri, Khandawa, Chunar road, Varanasi 221106.