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Effects of Aloe vera cream on chronic anal fissure pain, wound healing and hemorrhaging upon defection: A prospective double blind clinical trial

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Aloe vera is a medicinal plant that promotes wound healing in burn injuries. A prospective clinical trial was conducted to evaluate the effects of a topical cream containing 0.5% Aloe vera juice powder in the treatment of chronic anal fissures. The aloe cream was applied by the patients to the wound site 3 times per day for 6 weeks following the instructions of a physician. Pain was assessed with a visual analog scale before treatment and at the end of each week of treatment. Wound healing and the amount and severity of bleeding were examined and evaluated before and at the end of each week of treatment. There were statistically significant differences in chronic anal fissure pain, hemorrhaging upon defection and wound healing before and at the end of the first week of treatment also in comparison with control group (p < 0.0001). In this study, a topical cream containing aloe vera juice was an effective treatment for chronic anal fissures. This is a promising result indicating that further comparative studies are justified.
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Effects of Aloe vera Cream
on Posthemorrhoidectomy Pain and Wound Healing:
Results of a Randomized, Blind, Placebo-Control Study
Fariborz Eshghi, M.D.,
1
Seyed Jalal Hosseinimehr, Ph.D.,
2
Nasrin Rahmani, M.D,
1
Mohammad Khademloo, M.D.,
1
Mohammad Sina Norozi, M.D.,
1
and Omolbanin Hojati, M.D.
1
Abstract
Objective: Aloe vera is an herbal medicine, which has wound healing effects in burn injury. This study assessed
the effects of Aloe vera cream in reducing postoperative pain, postdefection pain, and its promotion of wound
healing after open hemorrhoidectomy.
Design: A prospective, randomized, double-blind, placebo-controlled trial was conducted comparing the effects
of a cream containing Aloe vera versus a placebo cream on posthemorrhoidectomy pain. The study preparations
were applied by patients to the surgical site 3 times per day for 4 weeks after hemorrhoidectomy. Pain was
assessed with a visual analog scale immediately postoperatively and at hours 12, 24, and 48 after surgery and at
weeks 2 and 4. Wound healing was examined and evaluated at the end of 2 and 4 weeks. The use of analgesics
was recorded.
Results: Forty-nine (49) patients were randomly assigned to receive aloe (n¼24) or placebo (n¼25). Patients in
the topical aloe cream group had significantly less postoperative pain at hours 12, 24, and 48 hours and at 2
weeks. Aloe cream reduced the pain after defecation in 24 and 48 hours postsurgery ( p<0.001). Wound healing
at the end of the second postoperative week was significantly greater in the aloe group compared with the
placebo group ( p<0.001). Patients required fewer additional analgesics posthemorrhoidectomy ( p<0.001).
Conclusions: Application of Aloe vera cream on the surgical site is effective in reducing postoperative pain both
on resting and during defecation, healing time, and analgesic requirements in the patients compared with the
placebo group.
Introduction
Hemorrhoids are one of the most common chronic
anorectal diseases known. Hemorrhoids grade III and
IV require an operative hemorrhoidectomy to eliminate
hemorrhoidal symptoms.
1–3
Hemorrhoidectomy is associated
with significant pain in the postoperative period. Both open
and closed hemorrhoidectomy resulted in postoperative
pain.
4,5
Continuous internal anal spasm is considered a major
factor in the inducing of pain.
6,7
The patients mainly required
narcotic and nonnarcotic analgesics in the early period post-
hemorrhoidectomy for reducing pain.
6
With regard to the
effect of pain on discomfort of patients, several pharmaco-
logical agents were assessed for relieving pain in patients,
including diltiazem ointment,
8
lidocaine and prilocaine
creams,
9
sucralfate cream,
10
glyceryl trinitrite ointment,
11
and
ropivacaine.
12
Recently we showed that patients who applied
topical metronidazole had significantly lesser postoperative
pain than those in the placebo group up to day 14.
13
Some
studies have shown that reduced postoperative spasm of the
internal anal sphincter is effective in reducing pain associated
with sphincter spasm.
8,11
Patients applied topical glyceryl
trinitrite for reducing posthemorrhoidectomy pain and had
headaches.
11
Therefore, patients sought a safe topical drug
with natural origin and with less toxicity.
Aloe vera (family: Liliaceae) has been used in traditional
medicine for a long time. It is one of the most recognizable
herbs in the world and the medicinal part is the succulent
leaves. A topical skin gel provides wonderful healing
support for the skin. Aloe vera contains many important
nutrients for the body, including amino acids, B vitamins,
and other nutrients that support general health. It also has
1
Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran.
2
Faculty of Pharmacy, Traditional and Complementary Medicine Research Center, Mazandaran University of Medical Sciences, Sari, Iran.
THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE
Volume 16, Number 6, 2010, pp. 647–650
ªMary Ann Liebert, Inc.
DOI: 10.1089/acm.2009.0428
647
pharmacological properties including antioxidant, wound
healing, antibacterial, antifungal, and immunomodulating
effects.
14
Burn wound healing is one of the major indications
of Aloe vera gel use in several in animal and clinical studies.
15
Realizing the potential use of Aloe vera in wound healing,
we examined the effects of Aloe vera cream versus placebo in
reducing postoperative pain and pain on defection after open
hemorrhoidectomy.
Methods
This clinical trial was registered by Iranian Registry of
Clinical Trials as a code IRCT138711131627N1. After ob-
taining approval from the Ethical Committee at Mazandaran
University of Medical Sciences, this clinical trial was carried
out in Imam Hospital, Sari, Iran. This study was a random-
ized, double-blind, prospective, placebo-controlled trial
comparing aloe cream with placebo cream. All patients who
were enrolled this study had symptomatic III and IV degree
hemorrhoidal diseases and met criteria for surgical hemo-
rrhoidectomy. All patients underwent open hemorrhoi-
dectomy. Exclusion criteria were pregnancy, anal fissure,
and heart and liver diseases.
Preparation of aloe cream
Liquid white paraffin, sterile alcohol, cetyl alcohol, solid
white paraffin, and propylene paraben were mixed and he-
ated to the boiling point as the oil phase. Aloe vera powder
(Zarband, Phytopharmaceutical Company, Iran) mixed with
deionized water was added to a mixture of propylene glycol,
sodium lauryl sulfate, and methylparaben. The mixture was
heated as the aqueous phase. These two separate phases
were mixed continuously while being cooled. Thus, after
cooling, the uniform cream that was produced was placed in
an aluminum package similar to a placebo tube, weighing
50 g. The cream contained Aloe vera gel powder 0.5%. Placebo
creams were prepared according to similar protocol without
aloe powder. Our experimental research and formulations
were carried out under sterile conditions. The final creams
were tested for any probable contamination microbes, which
were not detected during the applications.
Patients and study procedure
In this study, 49 patients were randomized in two groups.
Patients had creams applied (aloe or placebo) immediately
after surgery and 12 hours after hemorrhoidectomy. This
treatment was continued on the surgery site 3 times a day up
to 28 days postoperatively. Study patients applied approxi-
mately 3 g of aloe cream to the wounds outside. Control
patients applied the same quantity of placebo cream in a
similar fashion. The initial application of cream was per-
formed as a part of the postoperative dressing. For blinding,
the aloe and placebo creams were coded and both the nurse
and patients were blinded as to which cream was used
during examination. Patients were discharged from the
hospital 24 hours after surgery. Patients were instructed to
apply the cream with the tip of the index finger to the
wounds three times daily. All patients were supplied with
analgesic drugs as needed. The patients were followed up
after discharge from the hospital. Postoperative pain was
evaluated by using a visual analog scale (VAS), which was
scored as 0 (no pain) to 10 (very severe pain). Pain score were
obtained immediately postoperatively and at 12 hours, 24
hours, and 48 hours after surgery and at days 14 and 28. Pain
on defecation was also recorded using the VAS. The patients
recorded their analgesic requirement. At the end of 2 and 4
weeks postoperatively, an expert surgeon examined the
healing of patients’ wounds. Wound healing was defined as
complete epithelial covering as observed by physical exam-
ination. Wounds were classified as grade I (severe and fresh
wound with inflammation), grade II (granulation tissue on
wound), and grade III (completed layer of epithelial covering
on wound).
Statistical analysis
Data were analyzed using the ttest and w
2
, as appropriate,
to compare patients’ demographics, pain score, wound
healing, and analgesic drug use. P<0.05 was considered a
significant difference. Statistical analysis performed using
SPSS software (version 12, SPSS Inc., Chicago, IL).
Results
Forty-nine (49) patients were randomly assigned to receive
aloe cream (n¼24) or placebo cream (n¼25) after hemor-
rhoidectomy. Both groups were predominately female (aloe
group 16 female; placebo group 14 female). The groups were
similar with respect to age, gender, and extent of preopera-
tive hemorrhoid diseases. The number of patients with III
and IV degrees of hemorrhoids was 10 and 14, 11 and 14 for
aloe and placebo groups, respectively. Pain scores immedi-
ately after hemorrhoidectomy were 9.29 0.81 and
9.24 0.66 in the aloe and placebo groups, respectively. The
VAS scores were not significantly different between the two
groups in the time immediately after hemorrhoidectomy.
Patients in the aloe group experienced significantly less pain
at 12, 24, and 48 hours and 2 weeks postsurgery ( p<0.001)
(Table 1). Patients who received aloe cream were found to
have significantly lower pain on defecation on 24 and 48
hours after hemorrhoidectomy ( p<0.001), but no significant
difference was observed at 2 and 4 weeks (Table 2).
Aloe cream significantly helped wound healing in patients
at 2 weeks postsurgery ( p<0.001) (Table 3), but no signifi-
cant difference was observed at the end of 4 weeks. All
wounds in the aloe group showed grade III wound healing
with epithelial covering, but wound healing was grades I
and II in the placebo group at 14 days (Table 3).
Table 1. Postoperative Pain Scores in Aloe vera
and Placebo Groups
Time
Aloe (n¼24)
mean SD
Placebo (n¼25)
mean SD p-value
Immediately
after surgery
9.29 0.81 9.24 0.66 0.807
12 hours 5.75 0.9 8 0.71 <0.001
24 hours 3.2 0.83 6.3 0.70 <0.001
48 hours 1.8 0.64 5.2 0.91 <0.001
Week 2 1.16 0.38 2.56 0.50 <0.001
Week 4 1 0.00 1.04 0.20 0.332
Pain scores ranged from 0 (no pain) to 10 (very severe pain).
SD, standard deviation.
648 ESHGHI ET AL.
The narcotic consumption in the aloe group was signifi-
cantly less compared with the placebo group at 12 hours after
hemorrhoidectomy ( p<0.001). At 12 hours postsurgery, the
percentages of patients who required narcotic analgesic drug
(tramadol injection) were 21% and 76% in the aloe and control
groups, respectively. No narcotic consumption was observed
at 24 hours after hemorrhoidectomy. Nonnarcotic analgesic
medications were significantly lower in the aloe group 2
weeks after hemorrhoidectomy (Table 4) ( p<0.001).
No mortality was encountered. No side-effects or allergic
reactions were observed in patients who received creams.
Discussion
This prospective, randomized study has demonstrated
that application of Aloe vera cream provided significant pain
relief through the 48 hours post open hemorrhoidectomy.
Aloe cream led to significant wound healing at 14 days
postsurgery. Compared with the placebo group, lower an-
algesic consumption in the aloe cream group confirms the
improved pain management following a hemorrhoidectomy.
Various factors believed to be responsible for the pain
after hemorrhoidectomy include spasm of the internal
sphincter, and inflammation and bacterial colonization of the
hemorrhoidectomy site.
14–16
Another reason for pain could
be the healing of wounds, which was extended up to the
anorectal ring.
10
There are several reports that pharmaco-
logical agents with different mechanisms contribute to re-
ducing pain, include antispasmodic effects such as glyceryl
trinitrate ointment,
11
calcium channel blocker ointment,
8
botulinum toxin injection,
7
antimicrobial effects such as
metronidazole ointment,
14,15
and diminishing tissue edema,
such as sucralfate cream.
10
Aloe vera preparations have many biological effects in-
cluding antidiabetic, immunomodulatory, antiinflammatory,
antioxidant, and wound-healing effects.
17
A recent review of
clinical trials investigating the effect of Aloe vera on burn
wounds found that Aloe vera significantly shortened the
wound healing time compared to control.
8
Aloe contains
various carbohydrate constituents. Polysaccharides, man-
nose, and acemannan were identified in the aloe prepara-
tion.
17
Polysaccharides are known to have an effective
property in skin wound repair.
17,18
Antiinflammation is the
first step in wound healing, and this effect of aloe prepara-
tions is believed to play a direct role in facilitating rapid
healing.
18
Wound healing involves biological processes such
as inflammation and granulation tissue formation. Collagen
is the major protein in the extracellular matrix and provides
strength and integrity to the dermis and other supporting
tissues.
19–21
Aloe vera enhances the production of collagen.
20
Glycoprotein fraction is the major component of aloe that is
involved in wound healing with cell proliferation and mi-
gration and promotes the growth of dermal fibroblasts.
22,23
The glycoprotein fraction of Aloe vera stimulated cell prolif-
eration, accelerated recovery of an artificial wound on the
monolayer of normal keratinocytes, and enhanced thicken-
ing of the epidermal covering. Another study found that Aloe
vera increased the collagen content of the granulation tissue
as well as the degree of cross-linkage. It is thought that the
enhanced collagen content promotes stimulation by aloe in
collagen synthesis or increases the proliferation of fibroblast
synthesis of collagen, or both.
24
In this study, aloe cream significantly improved the
wound healing posthemorrhoidectomy. Since inflammation
is one of the main causes of pain in patients in the early
postsurgery time,
25
the antiinflammatory effects of aloe
contribute to relief of postoperative pain in patients treated
with aloe cream. Aloe has an antimicrobial effect; this effect
is related to its constituents including anthraquinones and
aloe-emodin.
17,18
This antimicrobial effect could be contrib-
uting to the reduction of pain and promotion of wound
healing by Aloe vera. It was demonstrated that oral or topical
antimicrobial agents such as metronidazole significantly
decreased postoperative pain after open diathermy hemor-
rhoidectomy.
15,16
The beneficial role of topical Aloe vera may
be antimicrobial, antiinflammatory properties, and positive
effects on wound healing.
Conclusions
In this study, a topical cream containing Aloe vera as herbal
medicine decreased postoperative pain and pain on defeca-
tion and enhanced wound healing after hemorrhoidectomy
Table 2. Pain on Defecation in Aloe
and Placebo Groups
Time
Aloe (n¼24)
mean SD
Placebo (n¼25)
mean SD p-value
Immediately
after surgery
9.08 0.92 9.08 0.81 0.989
24 hours 5.45 0.72 7.72 0.84 <0.001
48 hours 2.91 0.83 4.16 0.85 <0.001
Week 2 1.29 0.46 1.48 0.51 0.183
Week 4 1 0.00 1.2 0.41 0.134
Pain scores ranged from 0 (no pain) to 10 (very severe pain).
SD, standard deviation.
Table 3. The Number of Patients with Grade
of Wounds in Aloe and Placebo Groups
at the End of Week 2Posthemorrhoidectomy
Grade of wounds Aloe (n¼24) Placebo (n¼25) p-value
Grade I 0 12 <0.001
Grade II 0 12 <0.001
Grade III 24 1 <0.001
Wounds were classified as grade I (severe and fresh wound with
inflammation), grade II (granulation tissue on wound), and grade III
(completed layer epithelial covering on wound).
Table 4. Posthemorrhoidectomy Nonnarcotic
Analgesic Consumption in Aloe and Placebo Groups
During 2Weeks After Discharge from Hospital
Number of
medications
Number of
patients aloe
group (n¼24)
Number of
patients placebo
group (n¼25) p-value
Without analgesic 9 2 <0.001
One tablet per day 12 3 <0.001
Two tablets per day 3 10 <0.001
Three tablets per day 0 10 <0.001
Medication was 500-mg acetaminophen tablet.
ALOE CREAM AND HEMORRHOIDECTOMY 649
when compared with a placebo cream. The use of postoper-
ative analgesic agents was significantly decreased in the aloe
group. There were no side-effects observed related to aloe
cream.
Acknowledgments
This work was supported by a grant from Mazandaran
University of Medical Sciences, Sari, Iran. This research was
the subject of a thesis by Mohammad Sina Norozi for an
M.D. degree in the Faculty of Medicine, Mazandaran Uni-
versity of Medical Sciences, Sari, Iran.
Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Seyed Jalal Hosseinimehr, Ph.D.
Faculty of Pharmacy
Traditional and Complementary
Medicine Research Center
Mazandaran University of Medical Sciences
Sari
Iran
E-mail: sjhosseinim@mazums.ac.ir
650 ESHGHI ET AL.
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... Aloe vera gel increases collagen in the wound and changes its composition by increasing cross-linking between collagen fibers, thereby accelerating wound healing [37]. Aloe vera also prevents wound formation due to mucopolysaccharides, amino acids, and zinc, which cause skin cohesion, maintain moisture, reduce erythema, and prevents skin lesion formation [17,38]. Moreover, Aloe vera was also more effective than saline gas dressing, phenytoin, and common treatments [20,[37][38][39][40][41][42][43]. ...
... Aloe vera also prevents wound formation due to mucopolysaccharides, amino acids, and zinc, which cause skin cohesion, maintain moisture, reduce erythema, and prevents skin lesion formation [17,38]. Moreover, Aloe vera was also more effective than saline gas dressing, phenytoin, and common treatments [20,[37][38][39][40][41][42][43]. However, only one study identified no differences between the two groups, which may have been due to limited sample numbers [38]. ...
... Moreover, Aloe vera was also more effective than saline gas dressing, phenytoin, and common treatments [20,[37][38][39][40][41][42][43]. However, only one study identified no differences between the two groups, which may have been due to limited sample numbers [38]. Thus, Aloe vera reduced pain, bleeding, and healing times [42,43]. ...
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... Rahmani et al. conducted prospective clinical trials to assess the effects of a topical cream containing 0.5% AV juice powder in treating chronic anal fissures. The results showed that patients' pain in the AV cream group was dramatically relieved after one week of treatment, and wound healing time was significantly decreased compared to the non-aloe cream group [60]. Xu et al. investigated the clinical efficiency of AV on 2nd-degree burns. ...
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Chapter
The main goal of this chapter is to discuss the multiple usage of plants, one of which is its usage for medicinal and pharmaceutical applications besides their potential role in improving the environment. The chapter will be focusing on a few plants which have medicinal properties and potential pharmaceutical/industry applications. Generally, medicinal plants used for traditional medicine play a significant role in the healthcare of the majority of people in many developing countries. At the same time, those plants can play a bigger role in solving many environmental issues like the gradual conversion of habitable land used for agriculture into a desert and reduce the carbon footprint. In this chapter, we will be discussing and reviewing the major role of multiple usage of shrubs growing or potentially can be grown in arid and semi-arid areas such as jojoba, Aloe vera, Moringa and Acacia.
... Clinical studies for which ef cacy has been established for external use of Aloe vera gel preparations include reduction in the incidence of alveolar osteitis (postoperative complication of tooth extraction) (Poor et al., 2002), anal ssures (small tears in the lining of the anus) (Rahmani et al., 2014), mild to moderate burns (Thamlikitkul et al., 1991;Visuthikosol et al., 1995;Akhtar and Hatwar 1996;Shahzad & Ahmed 2013), cesarean wound healing (Molazem et al. 2014), diaper dermatitis (rash) in children (Panahi et al., 2012), erythema (skin in ammation) (Reuter et al., 2008), genital herpes (Syed et al., 1996b;Syed et al., 1997), nipple soreness in breastfeeding women (Alamolhoda et al., 2019), oral lichen planus (in ammation in the mouth) (Choonhakarn et al., 2008;Salazar-Sanchez et al., 2010;Mansourian et al., 2011), peristomal skin conditions such as colostomy (Rippon et al., 2017), seborrheic (scalp) dermatitis (Vardy et al., 1999), traumatic mouth ulcers (Leiva-Cala et al., 2019), chronic ulcers (Avijgan et al., 2016), vulvar lichen planus (in ammation of the female external genitals) (Rajar et al., 2008), and wound healing of skin graft donor sites (Burusapat et al., 2018). ...
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Synonyms: Aloe barbadensis Mill., Aloe vulgaris Lam., Aloe perfoliata var. vera L. (Adams, 1972)
Article
Ethnopharmacological relevance Skin diseases are among the most common human health affections. A healthy skin promotes a healthy body that can be achieved through modern, allopathic and natural medicines. Therefore, medicinal plants can be a reliable therapy in treating skin diseases in humans through a diverse range of bioactive molecules they contain. Aim of the study This review aims to provide for the first-time scientific evidence related to the dermatological properties of Morocco's medicinal plants and it aims to provide a baseline for the discovery of new drugs having activities against skin issues. Methods This review involved an investigation with different search engines for Moroccan ethnobotanical surveys published between 1991 and 2021. The plants used to treat skin diseases have been determined. Information regarding pharmacological effects, phytochemical, and clinical trials related to the plants listed in this review was collected from different scientific databases like PubMed, Science Direct, Google Scholar, Web of Science and Scopus. The data were analyzed and summarized in the review. Results A total of 401 plants belonging to 86 families mainly represented by Asteraceae, Lamiaceae, Fabaceae, and Apiaceae which have been documented to be in common use by Moroccans for managing skin diseases. Among those plants recorded, the most commonly used are Allium cepa L, Chamaeleon gummifer (L.) Cass and Salvia rosmarinus Schleid. Mill. Leaves were the most commonly used plant part, while powder and decoction were the most common method of traditional drug preparation. 107 of the 401 plants (27%) have undergone pharmacological validation. A total of 44 compounds isolated from 27 plants were investigated to treat different types of skin diseases, and 25 plants have been clinically studied for their activities against skin diseases. Conclusion The beneficial effects of using Moroccan medicinal plants to treat skin diseases, according to traditional practices, have been proven in numerous scientific studies. Therefore, other studies should focus on isolating and identifying specific bioactive compounds from plant extracts, revealing more valuable therapeutic properties. Furthermore, additional reliable clinical trials are needed to confirm their beneficial effect on patients with skin diseases.
Article
The Aloe species is known for its medicinal and cosmetic properties. Aloin is an active ingredient found in the leaves of medicinal plants of the genus Aloe. Aloin has attracted considerable interest for its antiinflammatory, anticancer, antibacterial, and antioxidant activities. However, since its clinical application is restricted by its unclear mechanism of action, a deeper understanding of its pharmacological activity is required. This review provides an overview of current pharmacological and toxicological studies published in English from February 2000 to August 2021. Herein, we summarized the sources and potential health benefits of aloin from a clinical application perspective to guide for further studies on the sources of aloin, aimed at efficiently increasing aloin production. Importantly, the function and mechanism of action of aloin remain unclarified. In future research, it is necessary to develop new approaches for studying the pharmacological molecular mechanisms underlying the activity of this compound against various diseases.
Article
Background Fissure in ano is a common benign anorectal disorder occurs exclusively in midline, predominantly posterior midline. They generally arise with local trauma caused by hard stool and hypertonic anal sphincter. It affects more than 10% of patients attending proctology clinics. Its incidence is growing high day by day. Objective To evaluate the effect of Aelwa (Aloe barbadensis mill.) in fissure in ano. Material & Methods A prospective study carried out at National Institute of Unani Medicine, Bengaluru. The Patients of anal fissure in the age group of 18 to 60 years, were included in the study. The test drug was given to patient in the form of fine powder packed in small sterilized container and asked to sprinkle the powder over the fissure two times a day. Assessment was carried on weekly basis for 3 weeks (7th, 14th and 21st day) on the basis of subjective and objective parameters. Post treatment follow- up carried out at 1 week after completion of trial (on 28th day). Results The mean age at presentation was 32.03 years. The male to female ratio was 16:14. The typical presentation was painful defecation and bleeding per rectum. Fissure in Ano frequently lies in the posterior midline position and associated with a sentinel pile. Pain scores significantly reduced on 7th, 14th and 28th days with this treatment (p<0.001). Healing of fissure, control of bleeding and reduction in anal spasm were seen in all patients with p-value <0.001. Hepatic and renal functions were unaltered in all patients. One patient in our study was HbsAg positive. Conclusion Topical application of Aelwa (Aloe barbadensis Mill.) is effective, safe and less expensive in the management of anal fissures. There was no adverse effect of drug and also the drug was not associated with any complications.
Chapter
Aloe is a succulent plant grown in tropical climates that is cultivated for medicinal use. Its history dates back 6000 years to ancient Egypt. The gel from the pulp of aloe leaves can be used topically to treat wounds and burns, among other skin conditions. Aloe is also available in capsule and liquid forms. Researchers have investigated clinical use of aloe for diseases of the mouth and oral cavity, diabetes, irritable bowel syndrome, Alzheimer’s disease, gastroesophageal reflux, HIV, cancer, and more. This chapter examines some of the scientific research conducted on aloe, both alone and in combination formulas, for treating numerous health conditions. It summarizes results from several in vitro and human studies of aloe’s use in treating several cardiometabolic, neurologic, oncologic, and gastrointestinal conditions. Finally, the chapter presents a list of aloe’s Active Constituents, different Commonly Used Preparations and Dosage, and a Section on “Safety and Precaution” that examines side effects, toxicity, and disease and drug interactions.
Article
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PURPOSE: This study was performed according to a prospective, randomized, double-blind, multicenter design. The aim was to test the efficacy of local application of nifedipine gel a in healing acute anal fissure by relaxing the internal anal sphincter. METHODS: Two hundred eighty-three patients who gave informed consent were recruited; they received a clinical examination. A questionnaire to evaluate the symptoms and the pain was administered, and a proctoscopy and anorectal manometry were performed. Patients treated with nifedipine (n=141) used topical 0.2 percent nifedipine gel every 12 hours for three weeks. The control group, consisting of 142 patients, received topical 1 percent lidocaine and 1 percent hydrocortisone acetate gel during therapy. Manometry was performed before and on Days 14 and 21. Anal pressures were measured by recording resting and squeeze pressures. RESULTS: Results obtained were as follows: total remission from acute anal fissure was achieved after 21 days of therapy in 95 percent of the nifedipine-treated patients (P<0.01), as opposed to 50 percent of the controls (P<0.01), and previously elevated maximum resting anal pressures decreased from a mean value standard deviation of 72.510.07 mmHg to 50.510.03 mmHg in the nifedipine group. This represents a mean reduction of 30 percent (P<0.01). We also observed a significant decrease in squeeze pressures in nifedipine-treated patients (from a mean standard deviation of 130.519.25 mmHg to 108.518.55 mmHg, a mean reduction of 16.8 percent;P<0.01). No changes in anal pressures were observed in the control group. We did not observe any systemic side effect or significant anorectal bleeding in patients treated with nifedipine. CONCLUSIONS: Our study clearly demonstrates that the therapeutic use of nifedipine, which at present is used only in cardiovascular pathologies, should be extended with local use to the conservative treatment of anal fissures.
Article
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PURPOSE: Nitric oxide is an important neurotransmitter mediating internal anal sphincter relaxation. Patients suffering from fissure-in-ano were treated with topical nitroglycerine. The clinical evidence for therapeutic adequacy was examined in a prospective, randomized study. METHODS: The study included 35 patients with acute and chronic anal fissures. In Group A, including 20 patients with the clinical diagnosis of acute (12 patients) and chronic (8 patients) anal fissures, treatment consisted of topical nitroglycerine. Group B, consisting of 15 patients (10 acute and 5 chronic fissures), received topical anesthetic gel during therapy. Manometry was performed before and on days 14 and 28 in the course of topical application of either 0.2 percent glyceryl trinitrate ointment or anesthetic gel (lignocaine). Anal pressures were documented by recording the maximum resting and squeeze pressures. RESULTS: In 60 percent of cases treated with topical nitroglycerine (Group A, 11 acute (91.6 percent) and 1 chronic (12.5 percent)), anal fissure healed within 14 days, in contrast to Group B in which no healing was observed. The healing rate after one month was 80 percent (11 acute (91.6 percent); 5 chronic (62.5 percent)) in Group A and was significantly superior to Group B (healing rate, 40 percent: 5 acute (50 percent); 1 chronic (20 percent)). DISCUSSION: Previously increased maximum resting pressures decreased from a mean value of 110 to 87 cm H 2 O. This represents a mean reduction of 20 percent (P =0.0022). We also noted a significant decrease in squeeze pressures (from 177.8 to 157.9 cm H 2 O (11 percent)). However, anal pressures did not decrease significantly in the four chronic fissure patients from Group A, whose fissures only healed after 28 days. Similarly to these Group A chronic fissure patients, no significant anal pressure reduction was observed in any Group B patients. Except for mild headache (20 percent), no side effects of treatment were reported. CONCLUSIONS: Topical application of nitroglycerine represents a new, easily handled, and effective alternative in the treatment of anal fissures. All of our patients reported a dramatic reduction in acute anal pain. However, it should be noted that a lack of sphincter tone reduction is a likely reason for the great tendency of chronic anal fissures to recur.
Article
Symptomatic hemorrhoidal disease is frequently encountered by clinicians in a wide range of specialities. For the majority of patients, simple dietary changes and alterations in bowel habits will provide symptomatic relief. For those patients not responding to conservative measures, there are a number of office-based procedures available to the endoscopist that successfully provide relief of symptoms. This article reviews the anatomy and pathophysiology of hemorrhoidal disease, outlines the evaluation and diagnosis, and describes the nonoperative treatment options, including diet modification, rubber band ligation, infrared photocoagulation, and sclerotherapy.
Article
Acute wound healing occurs in four stages, namely, haemostasis, inflammation, proliferation and remodelling. Underlying metabolic disturbances and/or disease may disrupt the regenerative process, causing delayed healing. This has imposed a huge financial burden in both the developed and undeveloped world. As a result, the possibility of deriving alternative, cost effective therapies from traditional plant-based medicines has been explored. The majority of such investigations take the form of in vitro assays based on cell culture models of the various phases of healing. Although insightful in terms of possible modes of drug action, it is conceded that in vitro assessments are insufficient to demonstrate efficacy and both animal testing and human trials are required for global scientific acceptance. Aloe vera is the only herbal medicine to be subjected to all three forms of assessment and is an appropriate example of the scientific methodologies to which herbal medicines are currently subjected. A discussion of the virtues and drawbacks of the in vivo and in vitro approach is given, together with an indication of the information which may be derived from each. It is concluded that in vitro models based on cells derived from diseased tissues are superior to other in vitro models and, in some respects, to animal studies. The investigation of wound healing herbal therapies should be directed toward clinical trials. For the purpose of the joint demonstration of efficacy and elucidation of drug mechanisms, such trials should, where possible, be performed with attendant tissue culture of cells derived from participants.
Article
PURPOSE: Pain after hemorrhoidectomy is universal. Several attempts have been made to reduce or alleviate the pain after excisional hemorrhoidectomy. The origin of pain is undetermined. Current theories propose that the pain is mediated through the internal sphincter. This prospective, randomized study was performed to assess the degree of discomfort in patients with and without a sphincterotomy when performing a closed hemorrhoidectomy. METHODS: Between December 1999 and September 2001, 42 patients (22 males), median age 52 (range, 30–80) years, who underwent excisional hemorrhoidectomy were randomly chosen to have an internal sphincterotomy in the base of the left lateral wound. RESULTS: Thirty-nine patients were available for the study. Parameters elicited in the study were pain, postoperative bleeding, urinary retention, impairment of continence by day and by night, and day the patient returned to work. There was no statistical difference in the postoperative pain in each of the two categories at four hours after surgery, after the first bowel movement, or four days after surgery. CONCLUSIONS: Results showed no difference in the perception of pain after hemorrhoidectomy in patients who had an internal sphincterotomy compared with those who did not. Both groups were equally likely to have difficulty with control of gas and soiling.
Article
Purpose: Fissure-in-ano and acutely thrombosed external hemorrhoids are common, benign anal conditions, usually characterized by severe anal pain. Internal anal sphincter hypertonia appears to play a role in the etiology of this pain. Nitric oxide has recently been identified as the "novel biologic messenger" that mediates the anorectal inhibitory reflex in humans. This report documents a therapeutic role for nitroglycerin, a nitric oxide donor, in the treatment of acutely thrombosed external hemorrhoids and anal fissure. Methods: Five patients with thrombosed external hemorrhoids and fifteen patients with anal fissure or ulcer were identified. A treatment regimen that included 0.5 percent nitroglycerin ointment applied topically to the anus was instituted. After one week of therapy, all patients were re-examined and questioned regarding pain relief and side effects of treatment. Fissure patients were followed for eight weeks or until healing occurred. Results: All patients reported dramatic relief of anal pain following application of nitroglycerin. Pain relief lasted from two to six hours. Complete healing of fissures occurred within two weeks in ten patients and within one month in two patients. One patient, whose fissure had not healed completely within two weeks requested surgical sphincterotomy. Two patients remained with persistent anal ulcers despite two months of therapy. Both, however, were pain-free. Side effects were limited to transient headache in 7 of 20 patients. Conclusion: Topically applied nitroglycerin ointment appears to have a therapeutic role in the treatment of thrombosed external hemorrhoids and anal fissure.
Article
PURPOSE: This study was undertaken to compare local application of a glyceryl trinitrate ointment with lateral internal sphincterotomy for the treatment of chronic fissure-in-ano. PATIENTS AND METHODS: A sample of 24 consecutive patients with chronic anal fissure was randomly allocated to treatment with sphincterotomy or local glyceryl trinitrate. Patients were followed-up for a median of 22 months. RESULTS: All 12 patients healed following sphincterotomy; 10 of 12 healed with local glyceryl trinitrate ( P =0.239). There were no recurrences or side-effects in either group. CONCLUSIONS: Local application of glyceryl trinitrate can avoid surgery in more than 80 percent of patients with chronic anal fissure.
Article
PURPOSE: Internal anal sphincterotomy for treating chronic anal fissure can irreversibly damage anal continence. Reversible chemical sphincterotomy may be achieved by anal application of glyceryl trinitrate ointment (nitric oxide donor), which has been reported to heal the majority of patients with anal fissure by inducing sphincter relaxation and improving anodermal blood flow. This trial aimed to further clarify the role of glyceryl trinitrate in the treatment of chronic anal fissure. METHODS: A total of 132 consecutive patients from nine centers were randomly assigned to receive 0.2 percent glyceryl trinitrate ointment or placebo twice daily for at least four weeks. The severity of pain and maximum anal resting pressure were measured before and after one week of treatment. Anodermal blood flow was measured before and after application of glyceryl trinitrate or placebo in ten patients. RESULTS: The study was completed by 119 patients (59 glyceryl trinitrate and 60 placebo), matched for gender, age, duration of symptoms, duration of treatment, site of fissure, previous attempts to treat, pain score, and maximum anal resting pressure. Twenty-nine patients (49.2 percent) healed after glyceryl trinitrate and 31 patients (51.7 percent) healed after placebo (P= not significant). Pain score fell significantly in both groups, in addition to maximum anal resting pressure. Anodermal blood flow improved significantly in seven patients receiving glyceryl trinitrate, but not in the three receiving placebo. Twenty-three patients (33.8 percent) experienced headache and 4 (5.9 percent), orthostatic hypotension after glyceryl trinitrate. CONCLUSION: This trial fails to demonstrate any superiority of topical 0.2 percent glyceryl trinitrate treatmentvs. a placebo, although the effects of glyceryl trinitrate on anodermal blood flow and sphincter pressure are confirmed. This finding, together with the high incidence of side-effects, should discourage the use of this treatment as a substitute for surgery in chronic anal fissure.
Article
PURPOSE: Although glyceryl trinitrate ointment has become the first-line treatment for chronic anal fissure, healing rates are lower than after lateral internal sphincterotomy. The purpose of this study was to identify which factors are associated with treatment failure of glyceryl trinitrate ointment. METHODS: All patients who presented with chronic anal fissure from March 1997 to November 1998 were treated with 0.2 percent glyceryl trinitrate ointment. They were prospectively evaluated until healing or lateral internal sphincterotomy occurred, and long-term follow-up was obtained by standardized telephone questionnaire. A Cox model multivariate analysis was used with seven variables to determine significant factors related to healing. RESULTS: Sixty-four patients (42 men and 22 women; mean age, 37.5 years) with chronic fissure-in-ano were treated with 0.2 percent glyceryl trinitrate ointment. Sentinel piles were observed in 19 patients (29.7 percent). Twenty-six patients (40.6 percent) were healed initially, but 12 (46.2 percent) experienced recurrence. Mean follow-up time was 15.6 (5.5) months. Twenty-nine patients (45.3 percent) had known risk factors for anal fissure, including constipation (n=21; 32.8 percent), recent childbirth (n=6; 9.3 percent), colonoscopy (n=1; 1.6 percent), and anoreceptive intercourse (n=1; 1.6 percent). Fissures were significantly less likely to heal initially (P<0.05), more likely to recur (P<0.05), and more likely to remain unhealed in the long term (P<0.05) in the presence of a sentinel pile. Fissures with a history of more than six months were less likely to heal initially (P<0.05). CONCLUSION: The presence of a sentinel pile adversely affects the outcome of treatment of chronic anal fissures with glyceryl trinitrate ointment, and a long history of the fissure reduces the rate of initial healing. Reasons for these findings are discussed.
Article
Purpose: Lateral internal sphincterotomy is the procedure of choice for chronic anal fissure because it relieves symptoms and heals the fissure in nearly all patients. However, there is evidence that fecal incontinence complicates lateral internal sphincterotomy. The aim of this study was to examine the outcome of lateral internal sphincterotomy in terms of fissure healing and incidence of fecal incontinence. Methods: Between 1984 and 1996, 585 patients underwent lateral internal sphincterotomy and were surveyed by questionnaire. Eighty-three percent (487/585) responded. The mean follow-up was 72 (range, 6-145) months. Results: Fissures had healed by a median of three weeks after surgery in 96 percent of patients. Recurrent fissures occurred in 8 percent. Two thirds of the recurrent fissures healed on conservative management alone. Ninety-eight percent of patients were satisfied with the outcome of surgery, but some degree of fecal incontinence occurred in fully 45 percent of patients at some time in the postoperative period. Incontinence occurred in 53.4 percent of women and 33.3 percent of men (P < 0.05). Incontinence to flatus, mild soiling, and gross incontinence occurred in 31, 39, and 23 percent of patients, respectively. However, by the time of survey (a mean of >5 years after lateral internal sphincterotomy) 6 percent reported incontinence to flatus, 8 percent had minor fecal soiling, and 1 percent experienced loss of solid stool. Importantly, only 3 percent of patients stated that incontinence had ever affected their quality of life. Conclusion: Although lateral internal sphincterotomy heals and relieves symptoms of chronic anal fissure in nearly all patients (96 percent), incontinence occurs frequently. Most episodes of incontinence are indeed minor and transient, but in a small subgroup, incontinence seems to be permanent.