Management of rectal prolapse (Guda Bhramsa) through Kshara Karma (chemical cauterisation): a case study / Manejo do prolapso retal (Guda Bhramsa) usando Kshara Karma(cauterização química): um estudo de caso

Abstract Rectal Prolapse is a condition where the rectum protrudes beyond the anus. The explanation of this condition can be traced back to ancient Ayurveda text like Susruta Samhita, Ebers Pappyrus of 1500 B.C., etc. The exact cause of rectal prolapse is unclear but it is predominant on female gender and on people having constipation, previous anorectal surgeries etc. Both partial and complete varieties of rectal prolapse are extremely debilitating because of the discomfort of the prolapsing mass and variety of symptoms like rectal bleed, intermittent constipation or fecal incontinence. Although, diverse modalities of surgical management of rectal prolapse are present, no single optimal procedure is proved and the choice of operation is determined by the patient's age, sex, degree of incontinence, operative risk, as well as by the surgeon's experience. In Ayurveda, Guda Bhramsa (Rectal prolapse) is explained by Acharya Susruta under Kshudra Rogas (chapter of minor diseases) and has elaborated it's conservative management very beautifully. In this case, a female with partial rectal prolapse was treated with Kshara application and managed without complications. So, Kshara application can be a safe and effective alternative for the management of rectal prolapse.

Resumo O prolapso retal é uma condição em que o reto se projeta para além do ânus. A explicação desta condição foi relatada em antigos textos Ayurveda como Susruta Samhita e Ebers Pappyrus, datados de 1500 aC. A causa exata do prolapso retal não é clara, mas essa condição é predominante no sexo feminino e nas pessoas com constipação e histórico de cirurgias anorretais anteriores. Tanto o prolapso retal parcial quanto total são extremamente debilitantes devido ao desconforto da massa prolapsante e da variedade de sintomas como sangramento retal, constipação intermitente ou incontinência fecal. Embora diversas modalidades de tratamento cirúrgico para corrigir o prolapso retal tenham sido relatadas na literatura, nenhum procedimento é consensual; a escolha da operação é determinada pela idade, sexo, grau de incontinência, risco operatório e experiência do cirurgião. Na Ayurveda, Guda Bhramsa (prolapso retal) é explicado por Acharya Susruta no Kshudra Rogas (capítulo de doenças menores) e seu manejo conservador é descrito de forma bastante completa. No presente caso, uma paciente do sexo feminino com prolapso retal parcial foi tratada com aplicação de Kshara e administrada sem complicações. Assim, a aplicação de Kshara pode ser uma alternativa segura e eficaz para o manejo do prolapso retal.

Anorectal conditions: rectal prolapse.

Rectal prolapse, the protrusion of the layers of the rectal wall through the anal canal, may be partial (mucosal) or complete (full thickness). Although prolapse is most common among older women, it affects individuals of all ages, including children. Associated fecal incontinence and constipation are typical. Urinary incontinence and uterovaginal/bladder prolapse also may coexist. Some patients may have rectal ulcers. Diagnosis is predominantly clinical; visualization of the prolapse may require the patient to strain while sitting or squatting. Imaging studies, including fluoroscopic or dynamic magnetic resonance defecography, can confirm the prolapse if the diagnosis is uncertain, and endoscopy can aid in detecting other colonic/extracolonic pathology. Nonsurgical management (eg, increased fiber intake, fiber supplements, biofeedback) often is therapeutic in minor (first- or second-degree) mucosal prolapse and can help alleviate constipation and incontinence before and after surgery for patients with full-thickness prolapse. However, for full-thickness prolapse, transabdominal procedures are the most effective management and are favored for healthy patients, irrespective of age. Perineal procedures (eg, rubber band ligation, mucosal excision) can be used for patients with full-thickness prolapse who are not candidates for transabdominal surgery and for those with second- and third-degree mucosal prolapse.

Comparative effects of different sclerosing agents used to treat rectal prolapse: an experimental study in rats.

BACKGROUND/PURPOSE: Sclerosing agents injected into the rectal submucosal area produce an inflammatory response and scar that prevent rectal prolapse. This study aimed to investigate the histopathological changes following submucosal injection of different sclerosing agents in rats. METHODS: Rats (n=35) were divided into control, sham, and five experimental groups, each treated with a different sclerosing agent: cow's milk, 30% saline solution, 30% dextrose solution, 70% ethyl alcohol, and 5% phenol in almond oil (PAO). All agents were injected into the submucosal area. After 4 weeks, all animals were sacrificed. Histopathological evaluation was performed according to a semi-quantitative fibrosis scoring system (grades 0 to 3), by using Masson trichrome and hematoxylin and eosin staining. RESULTS: Histopathological changes in the 5% phenol in almond oil group were significantly different from other groups (p=0.0001). Prominent submucosal fibrosis (grade 3), lymphatic vascular dilation, foreign body reaction, and lipogranuloma were observed in the 5% PAO group (p=0.007). No significant histopathological differences were seen between the 30% saline, 30% dextrose, and 70% ethyl alcohol groups. Significantly increased mucosal fibroblast proliferation (grade 2) was seen in 60% rats of the 30% dextrose group (p=0.026). The cow's milk and ethyl alcohol groups had mucosal erosions and congestion (grade 1) which were significantly different from the control group (p=0.024). No statically significant difference was observed between the 30% saline group and the control group. CONCLUSIONS: In this study we showed that 5% PAO can induce some histopathological changes in the submucosal area that increase the mucosal tightness of the mucosa, which are necessary for the treatment of rectal prolapse.

The surged faradic stimulation to the pelvic floor muscles as an adjunct to the medical management in children with rectal prolapse.

BACKGROUND: To assess the role of the surged faradic stimulation to the pelvic floor muscles as an adjunct to the conservative management in the children of idiopathic rectal prolapse. STUDY DESIGN: Prospective. SETTING: Pediatric Surgery Department, Pt BD Sharma, Post Graduate Institute of Medical Sciences, Rohtak. SUBJECTS: 47 consecutive children with idiopathic rectal prolapse attending the Pediatric Surgery out patient department from July 2005 to June 2006. METHODOLOGY: The information pertaining to duration and the extent of rectal prolapse, predisposing or associated medical conditions, results of local clinical examination were noted. Surged faradic stimulation using modified intraluminal rectal probe, was given on the alternate days. The conventional conservative medical management was also continued. The extent of relief and the number of the sittings of faradic stimulation required were noted at various stages of follow-ups. STATISTICAL METHODS: Mean values between those completely cured and others; poor responders and others were compared with t-test and proportions were compared with Chi square test. The p-value < 0.05 was considered statistically significant. RESULTS: The mean number of sittings in the completely cured group (n = 28(64%)) was (12.4 +/- 7.8) and was comparable with very poor responder (n = 6(13%). There was higher percentage of relief (76%) at the first follow up (at 15 days) in completely cured Vs other (37%) and also the poor responders showed (20%) Vs other (68%) and was statistically significant. CONCLUSION: With use of faradic stimulation, even the long-standing rectal prolapse can be fully cured. The follow up visit at 2 weeks is very important to gauge the likely success of this modality in treatment of the patients with rectal prolapse. Those showing poor response at this stage may require alternative treatment or take a long time to get cured.

Aluminum potassium sulfate and tannic acid injection in the treatment of total rectal prolapse: early outcomes.

PURPOSE: No surgical method for repair of total rectal prolapse has been established as optimal. We describe a new technique that uses ALTA (aluminum potassium sulfate and tannic acid) injection as a simple perianal procedure for total rectal prolapse. METHODS: Fourteen patients with total rectal prolapse were treated with sclerosing therapy by using ALTA injection. Via a perianal approach, 0.5 to 1 ml of ALTA solution was injected along a linear track into the submucosa at 30 to 80 different sites, totaling 20 to 60 ml. RESULTS: All 14 patients treated with injection sclerotherapy were cured, with no intraoperative or postoperative complications. One patient required a repeat injection after two months to be cured. No exacerbation of constipation has resulted, and no stenosis has been evident on rectal examination. In seven of ten patients presenting with fecal incontinence, this complaint resolved after therapy. CONCLUSIONS: ALTA sclerotherapy yielded satisfactory results in total rectal prolapse, causing no alteration in neurophysiology of bowel function. Injection sclerotherapy should be recommended as the first procedure for treatment of total rectal prolapse.

Rectal prolapse of intussusception--a single institution's experience.

AIM: The objective was to study the clinical presentation and outcome of intussusceptions prolapsing rectally. METHODS: A retrospective analysis was done of 198 children who presented with intussusception at a single institution over a 5-year period. Of this group, the data of children with intussusception prolapsing rectally was studied. RESULTS: The incidence of prolapsing intussusception in this series was 8%. All 16 patients were infants with an average age of 5 months. The most common presenting features were rectal bleeding and abdominal mass. Only 56% of children had abdominal pain. 4/16 children had abdominal distension and 4 had dehydration. The duration of symptoms was less than 48 hours in 14/16 patients. Air enema reduction (AER) was attempted in 14/16 patients and was successful in 8 patients. The success rate of AER was 57%. One patient developed a perforation during AER. Manual reduction was done in six patients who failed AER and in two patients in whom AER was not attempted because of prolonged duration of symptoms (> 48 hrs). There were no recurrences in this series. CONCLUSION: The incidence of intussusceptions prolapsing rectally is high in this series. It can present in the absence of the cardinal symptoms of intussusception. A high index of clinical suspicion is necessary to make the diagnosis. AER is often successful and must be attempted in children who do not have contraindications for this procedure.

The treatment of rectal prolapse in children with phenol in almond oil injection.

PURPOSE: The treatment of rectal prolapse in children is controversial. We report the results of injection sclerotherapy in children using phenol in almond oil (PAO) and discuss the occurrence of complications after the injection of PAO. METHODS: Nine children with rectal prolapse, aged from 2 years and 6 months to 14 years, were treated by PAO injection sclerotherapy between 1993 and 2000. The outcome of PAO injection sclerotherapy and the presence of complications were investigated from the point of anorectal function using anorectal manometry. RESULTS: All of the nine patients were cured after one to three injections without any complications. The manometric study showed that normal anorectal reflex and other parameters of the anorectum were found after injection sclerotherapy. Two of the 4 who had complained of constipation no longer had constipation after the therapy. CONCLUSIONS: PAO injection sclerotherapy is simple and should be recommended as a first method of treatment for rectal prolapse in children. PAO as a sclerosing agent did not cause any complications.

Treatment of prolapse of rectum with acupuncture combined with TCM drugs in 38 cases.

Prolapse of rectum usually occurs in the children with insufficient qi and blood, in the elders with declined qi and blood or deficiency of qi in the middle jiao (burner), in the women who made qi exhausted during labor resulting in deficiency of qi and blood, and in those with chronic diarrhea, habitual constipation and long-standing cough. All these may cause sinking of qi in middle jiao and induce the disorder. Therefore in treating the disorder, the primary causes should also be treated simultaneously.

Tratamiento homeopatico de prolapsos rectales en cerdos / Homeopathic terapy of rectal prolapse in pigs

Un estudio clinico fue realizado para evaluar el efecto curativo de la terapeutica homeopatica en casos de prolapso rectal en cerdos, cuya prueba se desarrollo en una granja comercial de Mexicali, Baja California, Mexico. Siete de los ocho animales tratado con homeopatia en este estudio, se curaron en un tiempo promedio de 13-4.86 dias. Cuatro casos adicionales constituyeron el grupo control; en estos cuatro casos el prolapso persistio por mas 22 dias, por lo que dichos animales fueron enviados a sacrificio. La diferencia en la proporcion de curaciones fue significativa (p<0.05). Se encontro una predisposicion genetica, pues todos los animales afectados fueron descendencia directa de un semental de raza hampshire propiedad de la misma granja. El manejo alimenticio fue similar al del resto de los cerdos que se encontraban en la etapara de engorda de dicha explotacion. Ademas, la presentacion de prolapsos rectales no pudo ser asociada con factores como constipacion, diarrea o tos, ya que ninguno de estos sintomas se observo durante el estudio

Tratamiento homeopatico de prolapsos rectales en cerdos / Homeopathic terapy of rectal prolapse in pigs

Un estudio clinico fue realizado para evaluar el efecto curativo de la terapeutica homeopatica en casos de prolapso rectal en cerdos, cuya prueba se desarrollo en una granja comercial de Mexicali, Baja California, Mexico. Siete de los ocho animales tratado con homeopatia en este estudio, se curaron en un tiempo promedio de 13-4.86 dias. Cuatro casos adicionales constituyeron el grupo control; en estos cuatro casos el prolapso persistio por mas 22 dias, por lo que dichos animales fueron enviados a sacrificio. La diferencia en la proporcion de curaciones fue significativa (p<0.05). Se encontro una predisposicion genetica, pues todos los animales afectados fueron descendencia directa de un semental de raza hampshire propiedad de la misma granja. El manejo alimenticio fue similar al del resto de los cerdos que se encontraban en la etapara de engorda de dicha explotacion. Ademas, la presentacion de prolapsos rectales no pudo ser asociada con factores como constipacion, diarrea o tos, ya que ninguno de estos sintomas se observo durante el estudio