It is an attempt to explore more about the kshar sutra (medicated thread) standardization and its preparation in more scientific way.

1. KSHAR SUTRA
PREPARATION
STANDARDISATION
&
APPLICATION
By
Dr. Sameet Masand
Dept. Of R.S. & B.K. R.G.G.P.G. Ayurveda
College Paprola
Kshar Sutra
Dr. Sameet Masand

2. Definition
Kshar sutra is a medicated thread prepared with a linen
thread of specified physical characteristics, to meet the
quality of the finished product described ahead, by coating
it with layers of materials obtained from plants as
mentioned.
KSHAR-SUTRA
 KSHAR + SUTRA = Ksharsutra
 Kshar is an alkaline salt of plant origin
 Sutra is thread
 Ksharsutra is an Alkaline Medicated Thread.
Kshar Sutra
Dr. Sameet Masand

3. References
 Suhruta Samhita, Cikitsasthana-17 / 26-30
 Astang Hridya – 30 / 35
 Chakradatta, Arsha Cikitsa -148
 Ras Tarangini, 24 trang 527-530
 Ras Kamdehnu, Arsha chikitsa 126-128
 Bhavaprakasha (16th A.D.)
 Ayurvedic Pharmacopeia of India
Kshar Sutra
Dr. Sameet Masand

4. History of rebirth of Kshar Sutra
 In 1964 by Prof. Dr. P. J. Deshpande assisted by : Dr. P. S.
Sankaran & Dr. S. N. Pathak.
 The first ever known published report was published in
Nagarjun, January 1965 on ten successfully cured patients.
 ‘Role of Ksharsutra in the treatment of Bhagandara (Fistula-in-
ano), the first postgraduate thesis by Dr. K. R. Sharma,
supervised by Prof. Dr. P. J. Deshpande submitted in the
department of Shalya-Shalakya, B.H.U., Varanasi.
 The first exposure to the Ksharsutra therapy at international
level was a study of 200 cases in “The American Journal of
Proctology, Febuary 1973”
Kshar Sutra
Dr. Sameet Masand

5. Ingredients of Kshar Sutra
S. No. Name of
ingredient
Botanical
name
Part used Ratio
1. Linen Thread of 20 gauge, of suitable length
2. Snuhi
Ksheer API
Euphorbia
neriifolia
Fresh Stem Q.S. Latex
3. Apamarga
Kshar API
Achyranthes
aspera
Water
soluble ash
of Pl.
Q.S.
4. Haridra API Curcuma longa Rz. Q.S.
Kshar Sutra
Dr. Sameet Masand

6. Different references of Kshar Sutra
Preparation
Kshar Sutra
Dr. Sameet Masand

7. Method of Preparation Acc. To
A.F.I
 Spread the surgical linen thread of size 20 throughout the length and
breadth of the hanger of the specially designed cabinet known as
Kshar sutra (K.S.) Cabinet.
 Smear the thread with latex, uniformly and carefully, all around the
thread, with the help of clean gauze piece soaked in the Snuhi ksheer.
 After smearing and hanging of all the threads on the hanger, place
the hanger in the Kshar sutra cabinet for drying.
 Close the cabinet properly and dry at 500C leaving it overnight.
 Close all the outlets of the Kshar sutra cabinet properly in order to
prevent the entry of moisture into the cabinet.
Kshar Sutra
Dr. Sameet Masand

8.  After eleven such coatings with Snuhi Ksheer, repeat the
process on next day for the 12th coat of Snuhi Ksheer and then
pass the wet thread through a heap of finely powdered
Apamarg kshar immediately.
 After smearing all the threads with Kshar, shake the hanger
gently allowing the excess particles of Kshar to fall down.
Place the hanger in the Kshar sutra Cabinet and dry.
 Repeat this process till seven coatings of Snuhi Ksheer and
Apamarg kshar are achieved, thus completing the 18 coatings
on the thread.
Kshar Sutra
Dr. Sameet Masand

9.  Perform the remaining 3 coatings with Snuhi Ksheer and fine
powder of Haridra as per the above said procedure making a
total 21 coatings on the thread.
 Put on the ultraviolet lamp of the Kshar sutra cabinet daily for
20-30 minutes to maintain sterile atmosphere right from the 1st
day of coating.
 Cut the threads of a uniform length i.e. 29-31 cm for packing as
directed.
 Put the sealed Glass Tube in a cabinet and expose it to
ultraviolet radiation.
Kshar Sutra
Dr. Sameet Masand

10. Images of Kshar Sutra Preparation
Kshar Sutra
Dr. Sameet Masand

11. Standardization of Kshar Sutra
 Linen Thread of 20 gauge of suitable length.
 Snuhi Ksheer API Euphorbia neriifolia ( Fresh Stem
Latex) Q.S.
 Apamarga Kshar API Achyranthes aspera (Water soluble
ash of Pl.) Q.S.
 Haridra API Curcuma longa (Rz.) Q.S.
Kshar Sutra
Dr. Sameet Masand

12. Linen Thread of 20 gauge
 Linen thread is a spun thread , typically in a thicker gauge than
that used for fabric garments. It may be waxed to increase the
durability and resistance to mildew. Traditionally this thread is
used for leather luggage and hand bags accessories.
 20 Gauge – Gauge means length of thread in kilometers
required to weigh 1 kilogram. So, 20 gauge means 20 kg of
thread has the weight of 1kg.
 Length of thread - 29 to 31 cm
 Weight - 0.9 to 1 g
 Diameter/Thickness - 1.75 to 2.0 mm
 Tensile Strength - Breaking load not less than
5 kg
Kshar Sutra
Dr. Sameet Masand

13. Snuhi Ksheer(Euphorbia neriifolia)
 Snuhi consists of stem of Euphorbia neriifolia Linn. (Fam.
Euphorbiaceae), a large branched, erect, glabrous, succulent,
xerophytic shrub occurring wild on rocky ground throughout
central India and extensively grown as a hedge plant.
 DESCRIPTION
Stem, green, cylindrical, showing, spiral ridge portion only,
dried stem, tough with pairs of sharp stipular thorns, with
hollow space in centre containing white reticulate mass, taste,
acrid.
Powder - Cream yellow, under microscope shows, vessels,
fibres and cortical cells, starch and calcium oxalate crystals
absent.
Kshar Sutra
Dr. Sameet Masand

14.  IDENTITY, PURITY AND STRENGTH
Foreign matter - Not more than 2 percent.
Total Ash - Not more than 8 percent.
Acid-insoluble ash - Not more than 1 percent.
Alcohol-soluble extractive - Not less than 5 percent.
Water-soluble extractive - Not less than 15 percent.
 CONSTITUENTS - Resin, gum and triterpenes.
 PROPERTIES AND ACTION
Rasa : Katu, Tikta
Guna : Guru, Tikshna
Virya : Ushna
Vipaka : Katu
Karma : Bhedana, Tikshan virecana, Amakaphavatahara
 THERAPEUTIC USES - Sotha, Gulma, Kustha, Meha, Udararoga.
 DOSE - 125-250 mg of the drug in powder form.
Kshar Sutra
Dr. Sameet Masand

15. Collection of Snuhi Ksheera
 Selection of the Plant
 Collection of Snuhi Ksheera
 Criteria for Selection of Snuhi
Kshar Sutra
Dr. Sameet Masand

16. Selection of the Plant
 Botanical Name : Euphorbia Neriifolia
 Family : Euphorbiaceae
 Size of the Plant : 2-3 yrs. Old
Kshar Sutra
Dr. Sameet Masand

17. Collection of the Latex
 The Snuhi ksheer should be collected early in the morning before
sunrise to get the maximum yield.
 Slit the Snuhi branch vertically from down to upward 5mm deep,
keeping the collecting jar under the slit.
 As soon as the cut is made, a milky substance (ksheer) starts dripping
down.
 After sufficient amount is collected the ksheer should be transferred
to a glass bottle with airtight seal to prevent the coagulation of
ksheer.
 Care to be taken so that the pieces of bark and dust should not come
along with latex.
 Snuhi ksheer should be always used freshly.
Kshar Sutra
Dr. Sameet Masand

18. Kshar Sutra
Dr. Sameet Masand

19. Apamarga Kshar (Achyranthes aspera)
 Apamarga kshar AFI, Part-I, 10:2
Apamarga kshar is an off-white alkaline preparation made with the ingredients in the
Formulation composition given below.
 Formulation composition:
 Apamarga bhasma (Apamarga) Achyranthes aspera (API-Vol:2/7) (Pl. ) 1 Part
 Water Water 6 Parts
Kshar Sutra
Dr. Sameet Masand

20.  Method of Preparation:
 Take ingredients of pharmacopoeial quality.
 Cut whole plant of Apamarga into small pieces and dry it
completely and than burn to ash (Bhasma).
 Add 6 parts of water to the Bhasma, stir well and keep
over night.
 Next morning decant the clear liquid and filter through a
three-layered muslin cloth. Repeat the filtering process till
a colourless filtrate is obtained. Transfer filtered material
to a stainless steel vessel and heat to evaporate the water.
Collect Kshar deposited as flakes from the bottom of the
vessel and grind it to a fine powder.
 Pack it in tightly closed containers to protect from light
and moisture.
Kshar Sutra
Dr. Sameet Masand

21.  Description:
Fine powder, passing through sieve number 100; hygroscopic,
odour faint and taste saline; freely soluble in water.
 Identification:
An aqueous solution yields the reactions characteristic of
sodium and potassium.
 Physico-chemical parameters:
Loss on drying at 1100 : Not more than 4 percent.
Acid-insoluable ash : Not more than 1 percent.
pH (10%aqeous solution) : 10 to 11
 Assay:
Sodium : Not less than 4 percent.
Potassium : Not less than 29 percent.
Iron : Not less than 1.2 percent.
Kshar Sutra
Dr. Sameet Masand

22.  Storage: Store in a cool place in tightly closed containers,
protected from light and moisture.
 Therapeutic uses :
Gulma (Abdominal lump)
Udara sula (Pain in the abdomen)
Grahani (Malabsorption syndrome)
Visuchika (Gastroenteritis with piercing pain)
Ajeerna (Dyspepsia)
Aruchi (Tastelessness)
Arsha (Piles)
Ashmari (Urinary calculus)
Karimi (Helminthiasis)
Antarvidradhi (Hernia)
 Dose : 125 to 500 mg daily in divided dose.
 Anupāna : Water.
Kshar Sutra
Dr. Sameet Masand

23. Haridra Curcuma longa
 Haridra is the dried rhizomes of Curcuma longa Linn. (Fam.
Zingiberaceae), a perennial herb extensively cultivated in all
parts of the country, crop is harvested after 9-10 months when
lower leaves turn yellow rhizomes carefully dug up with hand-
picks between October-April and cured by boiling and dried.
Kshar Sutra
Dr. Sameet Masand

24.  IDENTITY, PURITY AND STRENGTH
Foreign matter - Not more than 2 percent.
Total Ash - Not more than 9 percent.
Acid-insoluble ash - Not more than 1 percent.
Alcohol-soluble extractive - Not less than 8 percent.
Water-soluble extractive - Not less than 12 percent.
Volatile oil Not less than - 4 percent.
 PROPERTIES AND ACTION
Rasa : Katu, Tikta
Guna : Ruksha
Virya : Ushan
Vipaka: Katu
Karma : Karimighna, Kusthaghna, Varnya, Vishghna,
Kaphapittaghna, Pramehanashna.
Kshar Sutra
Dr. Sameet Masand

25.  THERAPEUTIC USES – Pandu
Prameha
Vrana
Vishvikara
Kustha
Tvagroga,
Sitapitta
 DOSE - 1-3 g of the drug in powder form.
Kshar Sutra
Dr. Sameet Masand

26. Standards of Kshar Sutra Acc. To
A.F.I
 Description : A dark brown coloured thread, with a dry coat of
medicament that remains intact on handling and smooth to touch. The
thread used is of linen consisting of processed pericyclic fibres from
stems of Linum usitatissimum, complying with microscopy given
below.
 Microscopy:
1. Chloroform and 10% aqueous solution Sodium carbonate test
a) Fibers with cell walls very thick with uniformly narrow lumen
and tapering to a very fine point.
b) Fine, oblique or transverse markings present on the walls,
sometimes crossing one another.
2. 0.5 g Copper carbonate and Ammonia test
No bulbous swelling is present (distinction from cotton).
Kshar Sutra
Dr. Sameet Masand

27.  Physico-chemical Characters
Length of thread : 29 to 31 cm.
Weight : 0.9 to 1 g
Diameter/Thickness : 1.75 to 2.0 mm
Tensile Strength : Breaking load not less than 5 kg
Loss on drying at 1050 : Not more than 5 percent.
Water-soluble extractive : Not less than 85 percent.
Hexane-soluble extractive : Not less than 6 percent.
Sulphated ash : 80 to 82 percent.
pH (1% aqueous solution) : 9.3 to 10.5.
Total alkalies : Not less than 20% w/w*
(calculated as carbonates)
For these tests and assays, collect sufficient quantity of the
coated material from a set of kshar sutra, by scraping gently
with a spatula.
Kshar Sutra
Dr. Sameet Masand

28.  Assay
Sodium : Not less than 1 percent.
Potassium : Not less than 35 percent.
Curcumin : Not less than 0.05 percent.
Turmeric : Not less than 4 percent.
Euphol : Not less than 3 percent.
 Packing, Labeling and Storage: Giving a single fold,
keep the thread inside a polythene sachet, pack in a glass
tube, and seal it along with a silica bag (as desiccant).
Label each pack as per requirement.
 Storage : Keep in moisture free condition, away from
direct sunlight & heat.
Kshar Sutra
Dr. Sameet Masand

29. Some studies related to kshar used
for the preparation of Kshar Sutra
 Comparative study of use of Palash Kshar and Apamarg Kshar
in fistula in ano shows that Palash Kshar is much effective in
managing pain, inflammation, irritation and wound healing.
 Effect of kadali Kshar Sutra in the management of Fistula in
Ano shows Kadali Kshara Sutra can be considered as a better
alternative in place of Apamarga Kshara Sutra because it has
more acceptability, easily available, less burning sensation and
better wound healing property after cut through.
 Various plants used as the alternate of Apamarga kshar - Kutaj,
Palash, Ashwakaran, Paribhadra, Aragwadh, Bibhitak, Patla,
Putrak, Chitrak, Putika, Asphota, Mushka, Gunja, Aganimantha
etc.
Kshar Sutra
Dr. Sameet Masand

30. Kshar Sutra and some important
conditions of Ano rectal region
 Fistula in ano
 Piles
 Fissure
 Ischio- rectal Abscess
Kshar Sutra
Dr. Sameet Masand

31. Therapeutic indications and
Contra-indications of Kshar Sutra
Therapeutic indications Contra-indications
 Bhagandara (Fistula-in-ano and other
fistulae of perianal region)
 Nadivaran (sinuses)
 Arsha(haermorrhoids)
 Dushta nadivarana(chronic-infected,
non-healing ulcers)
 Vrana (ulcers)
 Vidradhi (abscesses of different location,
Pilonidal sinus, Injection sinus)
 Arbuda (tumor)
 Adhimamsa (external growth of muscle
and skin)
 Yoni arsha (vaginal polyps).
 The sinuses which are connected with
the following lesions away from the
anorectal canal
 Osteomyelitis of pelvic bones
 Osteomyelitis of femur
 Tuberculosis of hip joint
 Tuberculosis of spine
 Intra abdominal cold abscesses
 Chronic/acute ulcerative colitis
 Regional ileitis
 Appendicitis
 Intestinal & pelvic malignancies
 Venereal diseases
 Strictures of urethra causing urethral
sinuses
 Cases of RVF and VVF
 Cron’s disease etc.
Kshar Sutra
Dr. Sameet Masand

32. Advantages And Benefits Of Kshar
Sutra Therapy
1. It is a simple, safe and sure treatment for fistula –in-ano
(95% success rate)
2. Ksharsutra is - chemical fistulectomy rather than surgical
fistulectomy
3. It is a simple minimum invasive surgical technique
4. Recurrence is negligible (3-5%)
5. Performed in Minor O.T. conditions
6. No damage to anal sphincter and chances of incontinence is
practically Nil
7. It is an Ambulatory procedure, no hospitalization required
8. Only local/topical anesthesia required
Kshar Sutra
Dr. Sameet Masand

33. 9. No antibiotic coverage is required.
10. Ksharsutra is very safe in patients who are otherwise not
fit for surgery e.g. Diabetics, Cardiac patients,
Hypertensives elderly and weak patients.
11. Cost effective – very Low cost treatment as compared to
surgery.
12. Fully Ayurvedic management, associated medicines for
Internal and External use has many benefits
13. Minimum scar formation at the wound site
Kshar Sutra
Dr. Sameet Masand

34. Application of Kshar Sutra
 FISTULA IN-ANO (Bhagandar)
 Fistula-in ano is a chronic inflammatory condition having a tubular
structure, which communicates with the ano-rectal canal at one end
and surface of perineum or peri-anal skin on the other end.
 Classical fistula has two openings, one internal (in ano-rectal canal)
and other external (in the skin of peri-anal area).
 Chronic pus discharging opening in the peri-anal area indicates –
fistulous opening.
 Pain off and on, pus discharge from an extra opening, sometimes it
closes itself and again opens after the pus formation.
 Deep seated abscess is the source of pus which later on converts into
Fistula-in ano.
Kshar Sutra
Dr. Sameet Masand

35. Images of Application Of Kshara
Sutra
Kshar Sutra
Dr. Sameet Masand

36. Mode of action of the Kshara
sutra
Mechanical action
Chemical cauterization
 K.S is Capable of dissolving the tough fibrous tissues and
finally drains it out creating a healthy base for healing . Its
gradual and sustainable chemical action not only removes the
debris from the site of fistula but also helps in encouraging
fresh healthy granulation thereby reducing long awaited
healing pattern in the depth of tissue.
Kshar Sutra
Dr. Sameet Masand

37. Mechanism of Kshara Sutra
Wire on ice block
bearing weight
both side
Wire cutting
through by
pressure
Ice block
reform and
healed block
Kshar Sutra
Dr. Sameet Masand

38. 1. Latex of Euphorbia (Snuhi) is proteolytic, therefore, dissolves the
fibrous tissue of Fistulous tract.
2. Apamarg Kshar is a Alkali, which clears the fistulous tract and
liquefies the thick pus. It keeps the tract clean and helps in
drainage of pus. It causes chemical fistulectomy.
3. Turmeric powder is anti-allergic, anti septic and a wound healer.
4. Special linen thread holds the medicines with the help of latex for
3-4 days in the fistulous tract.
5. Physical presence of Ksharsutra in the fistulous tract keeps the
passage patent and helps in the drainage of pus.
6. Ksharsutra legation exerts mechanical pressure along with
chemical cauterization. Therefore, in the initial 3 days there is
cutting of the tract.
Kshar Sutra
Dr. Sameet Masand

39. 7. After cutting the fistulous tract by Ksharsutra in initial days
the follow-up of 3-4 days is the healing time for the wound.
Therefore, cutting and healing of fistular tract per week is
achieved.
8. As cutting and healing go side by side, there is no gap or
recess for accumulation of pus in the cavity.
9. In case the abscess cavity is large - Ksharsutra can be
packed in the cavity till all the accumulated pus is drained
out and wound is clean for healing.
10. Keeping in view the healing progress of the tract – surgeon
can tight or loose the Ksharsutra ligation.
11. Alkali of Ksharsutra when applied with medicated oil it
forms cleaning and antiseptic sol. , which cleans the tract.
Kshar Sutra
Dr. Sameet Masand

40. The effect of kshara sutra on local tissue
Active granulation with capillary formation
Fibroblastic proliferation with collagen formation
Epithelial hyperplasia
Endorses early necrosis followed by active granulation
is possible only with the novel drug delivery system of
kshara sutra
Kshar Sutra
Dr. Sameet Masand

41. Chemical Composition of Kshar
Sutra
 The main chemical constituents which are responsible for the
proteolytic action of Snuhi (Latex)
1)Euphol Activity:- Anti inflamatory ,Antibacterial, Antifungal
2)Neriifolin Activity:- Antibacterial, Antifungal, wound healing
and immuno-modulatory
Kshar Sutra
Dr. Sameet Masand

42.  Water soluable ash of Apamarga (whole plant) ,the main
constituents which takes part for the preparation of kshara are
1)Betaine Activity:- Basic substance used as kshara, Antibacterial
and Antifungal
2) Oleanolic acid Activity:- Anti microbial and wound healing
activity
Kshar Sutra
Dr. Sameet Masand

43.  In the modern scientific investigation different medicinal
values like anti inflammatory, antibacterial, anti fungal, anti
infective, analgesic and anti pruritic effect of the rhizome of
Haridra has been established. Significant chemical compounds
which are responsible for the above medicinal values are
1)Curcumin Activity:- Anti inflammatory, Anti infective,
Antibacterial, Antifungal and cytotoxic
2) Caprylic acid Activity:- Antifungal property
CH3(CH2)6COOH
Oil - b.p 239.70C
Kshar Sutra
Dr. Sameet Masand

44. 3) d-Borneol Activity:- Pharmaceutic aid (cooling effect) Topical
analgesic & topical anti pruritic
4) α-Phellandrene Activity:- Absorbed through skin/may act as
carrier of other useful chemical compounds to penetrate the
skin.
5) Cineol Activity:- Pharmaceutic aid (cooling effect) topical
analgesic & topical anti pruritic
Kshar Sutra
Dr. Sameet Masand

45. Thanks
Kshar Sutra
Dr. Sameet Masand