1. Welcome U All

2. JOURNAL PRESENTATION PRESENTATION BY Dr. S. KAMALAKAR 1ST YEAR PG DEPARTMENT OF SAMHITA SIDDANTA 3. International Ayurvedic Medical Journal AYURVEDIC PERSPECTIVE OF DUSTAVRANA(NONHEALINGULCER) Dr.Prem Chandra Dr.Hemantha Kumar Dr.P. Gopikrishna B. J. Dr.Pathak Avnish Dr.Pratibha K. Dept. of Shalya Tantra, SDM College of Ayurveda and Hospital, Hassan, Karnataka 4. AIM OF THE ARTICLE Management of Dusta Vrana 5. METHOD EMPLOYED BY AUTHOR Vrana Shodhaka and Vrana Ropaka methods in the management of Dushta Vrana. 6. AUTHOR LANGUAGESTYLE AND EXPRESSION Very simple, Easily understandable language Gramatically correct,straight to point Has systematically arranged the information under proper headings 7. Introduction Definition of dusta vrana Dusta vrana lakshanas Ayurveda management of dusta vrana Authors conclusion Further understanding of dusta vrana My conclusion CONTENTS 8. A common and oftenly encountered problem in day to day practice by a medical practitioner is Dushta Vrana. Wound healing is the major problem in today practice. For these, the most fearful is infection. Due to infection, Vrana becomes complicated. The presence of Dushta Vrana worsens the condition of the patient with different complications and may become fatal. INTRODUCTION 9. As the scar of wound never disappears even after complete healing and its imprint persisting life long, it is called as Vrana. As it causes destruction of the tissue or damage of body part, so it is termed as Vrana. Vrana which has foul smell, continuously flowing putrefied pus along with blood, with cavity, since long time andVrana lakshanas are high in intensity. DEFINITION 10. Foul smelling , purulent discharge ,Black coloured oozing Ulcer edges are elevated or deep Elevated surface floor Healing is delayed abnormally The ulcer is apparently closed but pus will be getting accumilated day to day .so probing through the mouth of the ulcer, emits pus and discharge Hardness of the surrounding skin Highly soft with a sponge consistency indicating gangrene and sloughing of the tissue Too hot or too cold(heat indicates combustion of tissue and coldness indicates gangrene formation) Maggots formation LAKSHANAS 11. Ayurvedic management Shasti Vranopakarmas Urdhwa Shodhana by Vamana, Shirovirechana, Adho Shodhana by Virechana, Basti followed by Langhana, Katu-Tiktaka, kashaya Ahara then Raktamokshna. 12. Dustavranatreatment broadly classified into twoheadings Medical management: Apatarpana, Aalepa, Parisheka, Abhyanga, Sweda, Vimlapana, Upanaha, Pachana, Sneha, Vamana, Virecana etc. Surgical management: Astavidha sastra karmas and Kshaarakarma, Agnikarma, 13. vranaShodhana Abhyantara Shodhana Bahirgata Shodhana 14. Vamana: Vrana which are situated above Nabhi Pradesha with Kapha Pradhana Lakshana are better treated with the Vamana Karma. Virechana: The Vrana which are affected by Pitta Dosha and situated middle portion of the body and non-healing wound with long duration, in such cases Virechana plays a better role in healing. Basti: Vrana which is having Vata Pradhana Dosha, and Marga avarana janya Vrana and Vrana situated in lower extremities are better treated with Basti Chikitsa. Shirovirechana: Vrana which are situated in Urdvajatrugata area and Kapha pradhana conditions, this procedure is beneficial. 15. Raktamokshana:The Vrana which is predominant of Pitta and Rakta and in Margavarana conditions. Vrana Prakshalana :Aragwadhadi kashaya, Sursadigana kashaya, Lakshadigana kashaya, Panchavalkala kashaya Vrana Pichu :Jatyaditaila/ghrita, Kshara taila , Nimbadi taila, Sursadi taila, Doorvadi ghrita, Hingulamrutadi malahara Vrana Lepa :Tilakalkadi Vrana basti : jatyadi taila 16. Ropana means a factor, which promotes or quickens the healing process. At present the modern system of medicine could not find such karma which promotes the process of healing except anti-infective and debriding agents. Ropana process in the form of Kalka, Kashaya,Varthi, Ghrita, Taila, Choorna etc. Eg: Jatyadi ghrita, Ropana ghrita, Ambasthadi ghrita. vranaRopana 17. This is the case of Dustavrana in left leg and it was treated by the prakshalana with Panchavalkala kashaya and of Hingulamrutadi Malahara. CASE BT DT AT 18. The Vrana should be protected from Dosha Dusthi and from various micro-organisms, which may afflict the Vrana and delay the normal healing process. For the early and uncomplicated healing of Vrana, treatment is necessary. Number of patients were having Dushta Vranas on lower extremities than any other parts of the body so adequate care is needed to lower limbs for any type of Vrana before its converted into Dustavrana . Before starting the treatment we must to assess which type of Vrana, level of Dusthi, predominance of Dosha, involvement of Dhatu, site and size of the Vrana, Sadhyaasadhyata of Vrana. When wound will be completely free from discharge, slough, foul smell, burning sensation, itching, then healing can be achieved very well. CONCLUSION 19. Vrana is defined as the condition where in tissue undergo destruction Vrana causes not only tissue destruction but also causes discolouration of the affected region Vrana is a condition, which even after complete healing , leaves a scar over the area,which stays as long as the person is alive Definition 20. DIFFERENCE B/W WOUND&ULCER Wound Breach in the continuity of skin or mucous membrane Ulcer Persistent breach in the continuity of skin or mucous membrane associated with cell death 21. Vrana has 6 roots of vitiation: Vata, Pitta, Kapha, Rakta, Sannipataja and Agantuja 8 sites for localisation of dosa: Skin,Muscles,Vessels,Ligaments,Joints,Bones, Abdomen and Vital organs 5 features of identification: Shape,Pain,Color,Odour,Discharge Can be managed by 60 Measures Can be succesfully treated if the 4 necessities of the theraupeutics Points to remember 22. EXAMINATIONOF AN ULCER 23. Vrana pariksha Shape of the ulcer (aakrithi) Odour (gandha) Colour (varna) Discharge (srava) Pain (vedhana) 24. SURROUNDING AREA FLOOR DISCHARGE EDGE SHAPE SIZE SITE NUMBER ASSOCIATED DISEASES DISCHARGE PAIN DURATION ONSET PRASNASPARSANADARSANA TENDERNESS BASE DEPTH SKIN Methods of examination 25. History : 1.Mode of onset: A.Secondary to trauma - AAGANTUJA B.On its own(spontaneously)-NIJA Traumatic Ulcers heal on their own ,when the trauma causing agent is removed. But if trauma continues, the ulcer becomes chronic. Ulcer which occur spontaneously, generally occur secondary to a swelling, which may be a infected lymphnode, tubercular lymphnode, malignant growths. Varicose ulcer secondary to a Varicosed limb 26. 2.Duration: Acute, Chronic 3.Pain: Ulcer with associated pain indicate inflamation Ulcer with no pain occur when there is associated nerve diseases. EX.Trophic ulcers Ulcer with mild pain. EX.Tuberculosis ulcer 4.Discharge : Nature and quantity of discharge 5.Associated Disease: Diabetis, Tuberculosis etc 27. ` Inspection: 1.Number : Whether ulcer is single or multiple 2.Site : This provide a clue for the provisional diagnosis Ulcer on the medial malleolus: Varicose ulcer Ulcer on the upper part of the face: Rodent Ulcers in the neck axilla inguinal region: Tuberculous Ulcers on the heel: Trophic ulcers 3.Size : Exact size has to be recorded ,to foretell the time required for healing. Bigger ulcers will obviously heal over longer periods of time 28. 4.Shape : Tuberculous ulcers: Generally oval Syphilitic ulcers: Circular Varicose ulcers: Vertically oval Malignant ulcers: Irregular 5.Floor : Floor denotes exposed surface of the ulcer. Floor covered by red granulation tissue indicates healing; Pale granulation tissue- indicates slow healing 29. 6.Edge : Mode of union between the floor and margin of the ulcer 7.Discharge :The quantity and odour of discharge is to be noted Inflammed ulcer :Has purulent discharge Healing ulcer : Scanty serous discharge Tuberculous ulcer: Sero-sanguinious discharge 8.Surrounding area: Has to be checked for signs of inflamation viz.redness,odema,glossiness. The sorrounding area is hyper pigmented and eczematous in varicose ulcer HEALING ULCERS TROPHIC ULCERS TB ULCERS RODENT ULCERS MALIG ULCERS 30. 2.Palpation: 1.Tenderness : An acutely inflammed ulcer will be very tender. Chronic ulcers are slightly tender. Neoplastic ulcers are never tender 2.Base : Base is the area on which ulcer rests. indurated base is a characteristic feature of chronic ulcers. very significant induration is a feature of squamous carcinoma 31. 3.Depth : Depth of the ulcer is recorded to asses the amount of tissue involved/necrosed and to understand the prognosis of the disease. Neurogenic ulcers are very deep and may even reach the bone 4.Surrounding skin : Incresed temperature and tenderness around indicates accute inflammation Fixity to deeper structures .Malignant lesions Loss of sensation or motor functions Nerve lesionsTrophic ulcers Pulsations of surrounding arteries..Absent/decreased pulsation .Ischaemic ulcers Associated varicosityVaricose ulcers 32. Special investigationS Blood TC,DC,Hb,ESR,FBS-PLBS Urine CUE,ALB Swab from the wound for culture and sensitivity Mx test Chest xray X ray of bone and joints Biopsy from the edge of the ulcer 33. Clean {Suddha vrana} Healing {Ruhyamana vrana} Healed {Ruda vrana} Infected {Dusta vrana} 34. Suddha vrana: Edges should be greyish Granulation tissue in the ulcer should be of the same level as the surrounding. Not associated with pain and any discharge Ulcer floor should be red like a clean tongue Is soft Smooth Regular Such a ulcer is considered clean or healthy and has a good chance to heal 35. RUHYAMANA VRANA : Edges are Dark Ulcer area is free of moisture The tissues in the site and around are stable area is covered by small out growth (granulation tissue) In a healing ulcer the edge if traced from the red granulation in the centre towards periphary, will show a blue zone (due to thin growing epithelium) and a white zone due to fibrosis of the scar Floor covered by red granulation tissue indicates that the ulcer is healthy and healing 36. RUDA VRANA: No swelling No hard ness No scar tissue No pain Color of the site should be like that of the surrounding skin 37. Dusta vrana: Ulcers in people who dont have control over senses When a person with Vrana follows unwholesome diet and regimen, If Vrana in a person who follows proper diet etc but is wrongly treated by a quack, Then the vrana becomes severly vitiated and is called a Dusta vrana. Such vrana are very difficult or impossible to treat. 38. FACTORS WHICH PRODUCE DEFECTIVE OR DELAYEDHEALING 39. Increased untous applications, Increased moistness Improper bandinging When hairs are present between the healing tissue Increased use of strong or pungent applications Greater depth of ulcer Condition of indigestion in the patient Infected by maggots Excessive diet Fracture of underlying bones Virudhha bhojana, Asatmya ahara Presence of poision, foreign body Excessive sorrow, Excessive exercise Fast spreading, Excessive cohabitation Excess anger, Day sleep When vrana breaks open due to contact with nail When opposite edges or surfaces of wound constantly rub with each other Increased fluid in bloodvessels 40. Reasons for a healed wound to break: Aggravate dosha Exercise Trauma Excessive laughter Excessive anger Fear 41. Clinical 1. Spreading 2. Healing 3. Chronic Pathological 1. Specific - 2. Malignant 3. Non-Specific - Tuberculosis Syphilis Arterial Venous Trophic Infective Tropical Diabetic 42. s.n o Spreading ulcer Chronic ulcer Healing ulcer 1 No granulation tissue Pale granulation Red granulation 2 Plenty of discharge Serous discharge Minimal serous discharge 3 Excessive and offensive slough Slough present Slough is absent 4 Surrounding area is inflammed and odematous Induration at the base ,edge and surrounding area Minimal signs of inflammation 5 Purulent smell present Purulent smell can be present Purulent smell absent 43. WHAT ARE THE COMMONTYPE OF PATHALOGICAL NON HEALING ULCERS (DUSTA VRANAS)IN PRESENT PRACTICE???? 44. Varicose ulcers Occurs due to increased venous hydrostatic pressure. Generally manifests on medial side of lower 1/3rd of the leg {long saphanous vericosity} & also ocassioanally lateral aspect of lower leg region {short saphanous vericosity}. It is generally shallow & superficial edge is sloping. Never penetrates deep fascia , floor is covered by pale granulation. Occurs secondary to many years of venous disease. Discomfort, pigmentation, odema & tenderness of skin exists for months prior to ulceration. 45. Arterial ulcer They are painful occur commonly in tips of finger & toes. Ulcer is dry , punched out & penetrates deep fascia. Diagnosis is based on presence of signs of ischaemia in the region around the ulcer. Ulceration is secondary to peripheral arterial disease & poor peripheral circulation. 46. Neurogenic ulcer Repeated trauma over an anesthetic limb results in such ulcers the causes of nueropathy are Diabetic neuropathy, Leprosy, Alcholic nueropathy, Nerve injuries. Ulcers manifest over various pressure points, heal, gluteal region Eg;Bed sore. It penatrates deeper tissue , edges are punched out May involve the underline bone causing osteomilitis. 47. Bed sores A chronic ulcer of the skin caused by prolonged pressure on it (as in bedridden patients) They appear and sometimes spread rapidly within short notice in bed ridden patients 48. Diabetic gangrin Necrotic tissue; A mortified or gangrenous part or mass . The localized death of living cells (as from infection or the interruption of blood supply) It caused mainly due to Trophic changes secondary to peripheral neuritis. Ischaemia due to atheromo of arteries Reduced resistence due to sugar laden tissues Neuritis impairs sensation to a site, which makes the person neglect minor injuries ,thus the damage occuring to the tissues. 49. Tropical ulcers Aggrevating factors are poor status of nutrition, humid climate, ill health & poor immunity. Starts a pustule with extensive inflammation. The pustule bursts resulting in formation of ulcer. This ulcer spreads rapidly causing destruction of surrounding tissue. 50. Cellulitis An inflammation of body tissue (especially that below the skin) characterized by fever and swelling and redness and pain It is a non-suppurative inflammation spreading along the sub cutaneous tissue & connective tissue planes,& across intracellular spaces. Varying degree of pyrexia & toxaemia The site is swollen & tender Diabetic patients have greater tendency of getting it. Regional lymph nodes are enlarged & tender. There is a wide spread sweling & redness at the site. 51. Syphilitic Treponema Pallidum papule appears on the skin that devolop into a Hard Chancre(A small hard painless nodule at the site of entry of a pathogen- Ext Genitals Painless, indurated (hard)base(button Like) Nipple, lip, tongue, anal canal Secondary- Mucus patches Tertiary Gummatous (A small rubbery granuloma) 52. MANAGEMENT OF DUSTA VRANA 1.SODHANA 2.ROPANA Sodhana means cleaning.This is done with instruments ,with douches by application of sodhana dravyas Sodhana is indicated in durgandha,klinna,pichila vranas . this is done after vrana is opened The ulcers which are deep seated, foul smelling and covered with thick slough should be managed by sodhana dravyas Sodhana converts a dusta vrana into suddha vrana Healing will never take place when a vrana is in a stage of dustavrana .By sodhana sloughs, pus etc will be completely washed away and the floor of this ulcer appears just like a surface of tongue with bright,clean and red margins. 53. Ropana Which promote healing process. Once procedures of sodhana are over and the ulcer has become clean, then one should adopt ropana measures to ensures its healing for this purpose i. Decoction of various drugs like vata etc which promote healing, can be used for irrigation ii. Wicks prepared of ropana drugs can be placed in deep ulcers iii. A paste of tila and madhu can be applied iv. A paste of tila and ropana drugs v. A paste of tila madhu and gritha can also be applied Barley can also be mixed with above pastes 54. In ulcers caused by vitiated Pitta Rakta Visha and foreign objects and other extrinsic causes- healing is promoted using gritha prepared with ksheera and Ropana drugs In ulcers, predominately vitiated by kapha and vata- healing is promoted using taila prepared with Ropana drugs In ulcers, which are situated over joints or area where bandaging cannot be done- Ropana drugs along with both the varieties of haridra is made in to Rasa kriya and applied For vataja vrana Drugs of laghu and brihath pancha mula are used In pithaja vrana Nyagrodhadhi and kakolyadhi ghana drugs are used In kaphaja vrana- Aragvadhadhi ghana drugs used For promote healing lepa of sharapunkha with madhu 55. Important healing drugs Ashwagandha, Rohini, Lodhra , Khatphala., Madhu yashti, Samanga , Dhathaki pushpa, Arjuna , Udumbara, Jambhu, Ashwatha 56. Dr Pankaj.B.Patil PG Scholar Dept of Shalya Tantra 57. Name:Govinda Patel Sex/Age: M/67yrs Occupation: Buisnessman Date: 08/04/2011 OPD/IPD No: 211031/55042 Residence: Banglore Details of the Patient: Patient presented with the complaints of non healing ulcer 5cm above left medial malleolus since 1 yr. He has a history of Varicosity. On the day of examination: There was a nonhealing ulcer, foul smelling discharge ulcer with irregular margin with irregular shape above the left malleolus. Treatment: Patient was admitted and treated with Vrana Basti by using Jatyadi Taila twice daily for 7 days .After 7 days patient was adviced Go-Ghrita for Dressing. 58. trole 59. Even though healing is a natural process, it is inhibited by various factors. Derranged Doshas cannot be treated with a single drug all the times. Therefore number of drugs of different properties is described as Vrana Shodhaka and Vrana Ropaka in the management of Dushta Vrana. At the end of Sodhana Chikitsa, Vrana becomes Shuddha Vrana and Ropana Cikitsa has to be followed further. Various causes of Non Healing Ulcer needs to be evaluated like Arterial Ulcer, Venous Ulcer, Neurogenic Ulcer, Tropic Ulcer etc and treatment is to be done accordingly. CONCLUSION 60. THANK BISHAK DRAVYA ROGIUPASTATHA