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Could local antibiotics be included in the treatment of acute anal fissure?
Abstract
Objective:
Acute anal fissure is a very common disorder of the anorectal region. Its most widely used treatment method is the medications given in addition to conservative therapies. The objective of the present study was to investigate the effects of local metronidazole use in the treatment of acute anal fissure on the symptoms and remission processes of the patients.
Material and methods:
This was a prospective, randomized, controlled clinical study conducted on 100 consecutive patients who presented to our clinic between March 2016 and March 2017 and who were diagnosed with acute anal fissure. Patients were randomly divided into two groups of 50 persons. Patients in Group 1 were given only 5% lidocaine pomade as a local anesthesia, and those in Group 2 were given 5% lidocaine pomade and metronidazole cream. Patients applied the medications topically to the anal margin 3 times per day for 4 weeks. Patients' demographic characteristics, such as age and gender, were recorded. All patients were invited for check-up at the end of weeks 1, 2, and 4 of treatment. The Visual Analogue Scale scores for pain and the healing status of their fissure by visual inspection, as well as any adverse effects of the drugs, were recorded. The results were compared statistically. A p-value <0.05 was considered significant.
Results:
The mean ages of the patients were 34.2±4.1 years in Group 1 and 36.6±3.8 years in Group 2. As a result of the statistical comparison of the Visual Analogue Scale scores, there was a statistically significant difference between the two groups at the end of weeks 2 and 4 (p=0.004 and p<0.001, respectively). In Group 1, 28 (56%) patients recovered, but no recovery was observed in 22 (44%) patients. In Group 2, 43 (86%) patients recovered, whereas 7 (14%) patients had no recovery (p=0.004).
Conclusion:
The topical antimicrobial treatment with metronidazole as an addition to the classical medical treatments in acute anal fissure is an effective and safe practice resulting in further reduction in pain and increased healing rate.
... However, surgical risks and the incidence of late persistent incontinence are important postoperative complications. [7][8][9][10] Recent studies have suggested that presence of anaerobic bacteria in the anal fissure region may cause subclinical infection, and the use of topical or oral antibiotics in addition to conventional medical treatment increases wound healing and reduces pain. 7,11,12 In studies on this subject, the effect of local or systemic antibiotics was mostly performed on patients with anal fissure. ...
... [7][8][9][10] Recent studies have suggested that presence of anaerobic bacteria in the anal fissure region may cause subclinical infection, and the use of topical or oral antibiotics in addition to conventional medical treatment increases wound healing and reduces pain. 7,11,12 In studies on this subject, the effect of local or systemic antibiotics was mostly performed on patients with anal fissure. In this study, our aim was to investigate whether the use of topical metronidazole, which is effective against anaerobic bacteria, in addition to GTN, that has been used for years in the treatment of acute anal fissure, are superior to the use of GTN alone. ...
... The median VAS score levels were found to be 8 (6)(7)(8) in group 1 and 8 (6)(7)(8)(9) in group 2, respectively, on the day of enrolment. At the end of the first week of treatment, the median VAS score decreased from 8 to 5 (4-7) in group 1 and in group 2 while it decreased from 8 to 2 (1-3). ...
Background: An anal fissure is a longitudinal ulcer in the anoderm of the distal anal canal which extends from the anal verge proximally towards, but not beyond, the dentate line. Anal fissure is a disease characterized by severe pain in the anorectal region with constipation, per rectal bleeding and sometime itching. Recently, anaerobic bacteria are sorted out as a causative factor. Objective: This study investigates patient compliance in the treatment of anal fissure with adding topical metronidazole. Materials and method: A total number of 100 patients attended to the General Surgery Clinic of Delta Medical College Hospital, Department of Surgery, between December 2020 and May 2021 and diagnosed with acute anal fissure were included in this prospective study. Patients older than 18 years, including non-pregnant, pregnant and lactating women are recruited. Patients were randomly divided in two groups. One group (group: 1) was treated with topical glyceryl trinitrate [0.4% nitroglycerin ointment], and the other group (group: 2) was treated with topical glyceryl trinitrate [0.4% nitroglycerin ointment] and topical antibiotic [metronidazole 0.75%]. Results: There is no difference between the groups regarding age and symptoms. From week 1, fissure healing rates were high in group 2. Group 2 VAS score levels were lower than group 1 and achieved by group 1 only in week 4. Compliance of pregnant and lactating lady was more in group 2. Conclusion: Adding topical metronidazole to treatment of acute anal fissure reduces the duration and severity of pain, shortens healing time and increases the healing rate. Delta Med Col J. Jan 2021;9(2): 84-90
... It is widely used in clinical practice against protozoon infections as well as for the treatment of ailments where mixed pathogen microorganisms are active. In the study by Karapolat [14] Banu., it was seen that the topical antimicrobial treatment with metronidazole as an addition to the classical medical treatments in acute anal ssure was an effective and safe practice resulting in further reduction of pain and increased healing rate. ...
... These presenting symptoms were seen in all the three groups in similar proportions (p>0.05). Similarly other studies also showed pain and bleeding during defecation as the commonest symptoms with other minor symptoms 14 being constipation and itching. ...
... In our study, we found that VAS scores were signicantly lower with Metronidazole in comparison to Lignocaine at 4 weeks; whereas at 8 weeks, it was signicantly lower in Diltiazem group as compared to The effectiveness of Metronidazole in better healing of anal ssures 14 over lidocaine has been shown in the study by Karapolat B et al., where at week 4, the healing was 46% in Group 1 and 68% in Group 2 (p=0.004). This might be because Metronidazole helps decreasing the bacterial load with topical application and accelerates ssure healing. ...
Aim and objectives: To evaluate and compare the effects of topical application of metrogyl ointment, diltiazem ointment and lignocaine in the healing of chronic anal ssure (CAF). Materials and method: This Randomised controlled trial was conducted in the Department of General Surgery, Swaroop Rani Nehru Hospital, Prayagraj, after obtaining clearance from hospital Ethics Committee. The drugs were applied over thessure twice a day. Healing of the ssure in terms of complete epithelialization, and reduction of pain (measured by visual analogue score) were noted. VAS score was rated from 0-100 in terms of pain sensations as used in another similar study. Any side effects of the used drugs were recorded. The patients were followed up at 2, 4 and 8 weeks of initiation of treatment for assessing the outcomes. Results: It was noted that the VAS score were signicantly lower with Metronidazole in comparison to Lignocaine at 4 weeks; whereas at 8 weeks, it was signicantly lower in Diltiazem group as compared to Lignocaine group. There was a signicant difference in the healing between Diltiazem and Lignocaine (p=0.0006) and Metronidazole and Lignocaine (p=0.007) but no statistical difference between Diltiazem and Metronidazole (p=0.667). Headache was signicantly more in Diltiazem group (24%) and burning sensation was signicantly more with the use of Metronidazole. (p=0.022). Conclusion: Diltiazem and metronidazole are equivalent to treat anal ssures for relieving pain and healing, both of which are better in comparison to lignocaine.
... Most anal fissures are acute and resolve spontaneously or within 6 to 8 weeks of treatment [6]. Although its etiology is not known exactly, it is thought to be multifactorial and can be the result of spontaneous internal anal sphincter spasm, ischemia, infection, and local trauma [7]. In the treatment of acute anal fissure, conservative treatments such as a fiber-rich diet, regular toilet habits and warm sitz baths, muscle relaxants, and blood flow enhancing drugs such as diltiazem and anesthetic drugs are generally used [3,8,9]. ...
... In recent studies, it has been reported that there can be subclinical infection mostly due to the presence of anaerobic bacteria in the anal fissure region, and the use of topical or oral antibiotics in addition to conventional medical treatment increases wound healing and reduces pain [7,13,14]. In studies on this subject, the effect of local or systemic antibiotics was mostly performed on patients with chronic anal fissure. ...
... The median (IQR) VAS score levels were found to be 8 (6-8) in group 1 and 8 (7)(8)(9) in group 2, respectively, on the day of enrollment. At the end of the 1st week of treatment, the median (IQR) VAS score decreased from 8 to 5 (4-7) in group 2, while it decreased from 8 to 2 (1-2) in group 2. At the end of the 1st week, 25.0% of the patients in group 1 still had a VAS score above 7. ...
Purpose:
Acute anal fissure, a disease characterized by severe pain in the anorectal area, reduces quality of life and becomes chronic absent appropriate treatment. More recently, anaerobic infections have been noted as contributive to etiopathogenesis. This study investigates topical metronidazole's effect in the treatment of acute anal fissure.
Methods:
Our prospective randomized controlled double-blind study included 2 groups of 100 patients older than 18 years from our General Surgery Clinic with anal fissure complaints for less than 8 weeks. Topical diltiazem treatment was started in group 1, and topical diltiazem and metronidazole treatment in group 2. Pain levels were evaluated by the visual analogue scale (VAS) score, and recovery status was evaluated by physical examination findings ab initio and at the 1st, 4th, and 6th weeks. VAS score levels, demographic, clinical, and recovery status were then compared.
Results:
There was no difference between the groups as to age, sex, pain on defecation, bleeding, constipation, and duration of pain, bleeding and constipation (P>0.05). From week 1, fissure epithelialization and healing rates were higher in group 2 (P<0.001); group 2 VAS score levels were lower than in group 1 (P<0.001) and achieved by group 1 only in week 4 (P=0.073).
Conclusion:
Adding topical metronidazole to treatment reduces the duration and severity of pain, shortens healing time, and increases the healing rate.
... Based on the difference of proportion of healing rate over 6 weeks reported in previous study on acute anal fissure the effect size was estimated to be 16%. 8 Presuming 95% confidence interval with 80% power and 5% chance of type 1 error sample size was estimated to be 108 for two groups. Assuming 20% attrition rate the total sample size was 136. ...
... Karapolat B also reported similar finding after adding local antibiotic for the treatment of acute fissure. 8 Controlling the local infection leads to reduction in inflammation and lowering the sphincter spasm. This in turn will lead to lowering pain and has been demonstrated in our study by the comparison of NPRS. ...
Acute anal fissure is a common and painful condition of ano-rectal region characterized by tear in the anoderm causing pain during defecation. Mainstay of its treatment is pharmacotherapy with lifestyle modification.
Current study was undertaken to evaluate the role of add-on local antimicrobial in recovery and relief of symptoms of acute anal fissure in comparison to local anesthetic and vasodilator without any antimicrobial.
It was a randomized, assessor-blinded, active-controlled clinical study in which data of 68 eligible participants were analyzed. Participants of both group received local lignocaine and nifedipine and the test group (Group B) received metronidazole ointment in addition. Healing was assessed by clinical examination and pain by Numeric Pain Rating Scale. Sample size was calculated based upon result of older pilot study and the proportion of recovery were assessed by Chi-square test.
After 6 weeks of treatment, 61 out of 68 (i.e., 89.7%) patients receiving add-on antimicrobial recovered completely compared to 75% of the comparator group. Reduction of pain and cessation of bleeding were also significantly better in patients receiving additional antibacterial.
Healing and symptom relief in acute anal fissure is better with addition of local antibacterial along with local vasodilator and anesthetic.
... Local anesthetics reduce the pain but due to their propensity to sensitize the skin, they have to be used only for short time periods. Lignocaine is the commonest an aesthetic used and is mostly employed in combination with many other drugs like minoxidil nitrates, local antibiotics (metronidazole) [14] and steroids including hydrocortisone and betamethasone. ...
... Karapolat [14] conducted a clinical study on 100 patients with acute AF by randomly dividing into two equal groups. Patients in Group 1 were given only 5% lidocaine pomade as a local anesthesia, and those in Group 2 were given 5% lidocaine pomade and metronidazole cream. ...
Anal fissure is one of the most common clinical problems affecting the anorectal area in all age groups and both the genders. It results from a longitudinal tear or break in the anal mucosa distal to the dentate line. Fissures less than 6 weeks in duration are termed acute and the ones persistent after that deemed as chronic. Anal fissure may be primary when there is no underlying disease in the anorectum or secondary when the situation is otherwise. Painful defecation and bleeding per anum are the most common symptoms. Surgical management by lateral internal sphincterotomy is considered as the standard definitive management for primary anal fissures but this operation suffers from many drawbacks including fecal and flatus incontinence. Hence, in the recent years, a wide range of non-surgical options have been introduced for its management that are aimed at prompt alleviation of symptoms and the initiation of healing process. Most of these options tend to cause the relaxation of internal anal sphincter as hypertonia of this muscle is believed to impair blood flow to the fissure and retard the healing. To prevent the recurrence, there is need to identify any possible aggravating factors like constipation or anal intercourse, and thence to institute measures to control such factors. This article reviews the utility and efficacy of those non-surgical options of anal fissure management in the light of the recent literature.
... 24. IPD Sharing Statement: There is a plan to share IPD upon reasonable request during the trial period and for 3 years post-trial completion. ...
... Recent studies suggest that addressing the microbial colonization of the anorectal region in patients complaining of anal fissures could yield better treatment outcomes [22]. Moreover, trials of topical and oral antibiotics in addition to the usual indicated management of anal fissures showed significant improvement in terms of wound healing and pain score [23,24]. The review by Garg et al. stresses on the importance of absolute avoidance of constipation in order to achieve the best rate of fissure resolution [23]. ...
Background
Anal fissure is a common complication of the anorectal region and one of the most reported causes of anal pain. Acute anal fissure can be cured by surgery or medical treatment. There is an increase in the use of topical therapy for the treatment of anal fissures. A common topical drug used is Diltiazem (DTZ), a calcium-channel blocker, which relaxes the anal sphincter and thus promotes healing of the anal fissure. Moist exposed burn ointment (MEBO) is an ointment that is effective for the treatment of burns and wound healing and is becoming popular in the treatment of anal fissures.
Methods
This is a 1:1:1 randomized, controlled, parallel design, with endpoint measures of change in pain score, wound healing, defecation strain score and patient’s global impression of improvement. The study will be conducted at AUBMC over a 10-week period. Patients will be randomized to three treatment arms: MEBO, Diltiazem, and a combination of MEBO and Diltiazem ointments.
Discussion
The results of this study will allow physicians to assess the efficacy and safety of MEBO in the treatment of acute anal fissure, and also in comparison to Diltiazem. This trial will generate evidence-based conclusions regarding the use of a herbal/natural-based product (MEBO ointment) for the treatment of anal fissures.
Trial registration
ClinicalTrials.gov Identifier NCT04153032 . Clinical Trial Registration Date: 06-NOVEMBER-2019.
... 19 However, our findings are supported by studies that reported improved healing rates with the addition of metronidazole to topical treatments. 16,19,20,22 These studies suggest that combining metronidazole with topical treatments can enhance healing rates in patients with anal fissures. ...
Background: Anal fissure is a common anorectal condition characterized by severe pain and bleeding. Topical diltiazem is a widely used treatment, but its efficacy can be enhanced by combining it with metronidazole. To compare the efficacy of topical diltiazem with metronidazole versus topical diltiazem alone in treating acute anal fissure. Methods: This non-randomized clinical trial was conducted among 174 patients with acute anal fissure. Patients were allocated into two groups: combination group (topical diltiazem with metronidazole) and diltiazem alone group. Patients were followed up at 1, 2 and 4 weeks. Results: The combination group showed significant pain reduction (7.30±0.89 to 0.48±0.21, p<0.05) and higher healing rates compared to the diltiazem alone group. The requirement for surgery was significantly lower in the combination group (8% vs 20.7%, p<0.05). Conclusions: The combination of topical diltiazem with metronidazole is a safe and effective treatment for acute anal fissure, offering rapid and sustained pain relief, improved healing rates and reduced need for surgery.
... An increased healing rate was observed: 56% vs. 86% (p=0.004) (89). The most recent study of Mert randomized patients into a topical diltiazem 2% group and a diltiazem 2% and metronidazole 1% group. ...
Introduction: Acute and chronic anal fissures are common proctological problems that lead to relatively high morbidity and frequent contacts with health care professionals. Multiple treatment options, both topical and surgical, are available, therefore evidence-based guidance is preferred. Methods: A Delphi consensus process was used to review the literature and create relevant statements on the treatment of anal fissures. These statements were discussed and modulated until sufficient agreement was reached. These guidelines were based on the published literature up to January 2023. Results: Anal fissures occur equally in both sexes, mostly between the second and fourth decades of life. Diagnosis can be made based on cardinal symptoms and clinical examination. In case of insufficient relief with conservative treatment options, pharmacological sphincter relaxation is preferred. After 6-8 weeks of topical treatment, surgical options can be explored. Both lateral internal sphincterotomy as well as fissurectomy are well-established surgical techniques, both with specific benefits and risks. Conclusions: The current guidelines for the management of anal fissures include recommendations for the clinical evaluation of anal fissures, and their conservative, topical and surgical management.
... Theoretically, antibiotics like metronidazole can help to control local infection which might directly or indirectly help in healing of any ulcer and reduce pain. Studies by Banu Karapolat [25] and Shahid et al. [18] also seems to support this theory but needs further investigation. ...
Background and objectives. Fissure in ano is one of the most common colorectal diseases seen by surgeons in daily practice. Currently medical management is the first line therapy for treating acute fissure in ano. Apart from general measures, various drugs like nitrates and calcium channel blockers are also used for topical application. Recently topical application of sucralfate and metronidazole are being advocated for in the same way, although there isn't much evidence for their effectiveness. In this study we have compared the efficacy of sucralfate (7% and Metronidazole (1%) ointment to the most commonly used diltiazem (2%) ointment for healing in acute fissure in ano and control of pain. Materials and methods. The present study was a randomized clinical trial with total 96 patients, 47 in the Sucralfate + Metronidazole group and 49 in the Diltiazem group. Both drugs were prescribed for 4 weeks in addition to general measures like sitz bath, laxatives and oral fluids. Patients were followed up at 2 and 4 weeks. Control of symptoms like pain, bleeding and healing of ulcers in both groups were assessed. Frequency or graphs were used for qualitative variables and Mean+/-SD for quantitative variables. Chi-square and t-test was applied for comparison of the two groups, and p-value <0.05 was taken for statistical significance. Results. Most patients were male and belonged to age group 30-50 years. Most patients in both groups improved on conservative treatment. The difference observed in key outcome parameters like control of pain, bleeding and healing of fissure in both groups weren’t found to be statistically significant. Sucralfate and Metronidazole didn’t have any incidence of adverse effects and was cheaper in price compared to diltiazem ointment. Conclusions. Sucralfate and Metronidazole was as effective as diltiazem in treating of acute fissure in ano and can be recommended if allergy and adverse reactions to diltiazem are encountered.
... Three single-centre randomized controlled trials investigated the role of topical metronidazole in the treatment of acute anal fissure and concluded that the adjunct of topical metronidazole to local treatment with diltiazem, glyceryl trinitrate or lidocaine was associated with a significative increase of healing rate, shorter healing time and lower duration and severity of pain [45][46][47]. However, these studies had some methodological limitations and their results have still not been confirmed by welldone multi-center randomized controlled trials. ...
Introduction
The aim of these evidence-based guidelines is to present a consensus position from members of the Italian Unitary Society of Colon-Proctology (SIUCP: Società Italiana Unitaria di Colon-Proctologia) on the diagnosis and management of anal fissure, with the purpose to guide every physician in the choice of the best treatment option, according with the available literature.
Methods
A panel of experts was designed and charged by the Board of the SIUCP to develop key-questions on the main topics covering the management of anal fissure and to performe an accurate search on each topic in different databanks, in order to provide evidence-based answers to the questions and to summarize them in statements. All the clinical questions were discussed by the expert panel in different rounds through the Delphi approach and, for each statement, a consensus among the experts was reached. The questions were created according to the PICO criteria, and the statements developed adopting the GRADE methodology.
Conclusions
In patients with acute anal fissure the medical therapy with dietary and behavioral norms is indicated. In the chronic phase of disease, the conservative treatment with topical 0.3% nifedipine plus 1.5% lidocaine or nitrates may represent the first-line therapy, eventually associated with ointments with film-forming, anti-inflammatory and healing properties such as Propionibacterium extract gel. In case of first-line treatment failure, the surgical strategy (internal sphincterotomy or fissurectomy with flap), may be guided by the clinical findings, eventually supported by endoanal ultrasound and anal manometry.
... In contrast in a study done by Shahid et al. [20] at the end of 6 weeks, the VAS scores was significantly decreased in MTZ group as compared to GTN. Likewise, in a study done by Karapolat et al. [21] at the end of 4 th week, the mean VAS scores was significantly reduced in MTZ group as compared to lidocaine groups (1.36 vs 2.47; p<0.001). ...
Background and Aims: Chronic anal fissure (CAF) is usually managed with surgical modalities but it imposes huge cost with recurrence rates. Hence, topical therapies are preferred is such cases which has a good patient acceptability rate. The present study aims to compare the topical metronidazole (MTZ), diltiazem (DTZ), and glyceryl trinitrate (GTN) in terms of healing rate and pain reduction in CAF patients. Methods: This was a randomized and prospective study conducted on 90 patients with CAF. The patients were grouped as follows (n=30), Group 1; 1% MTZ gel, Group 2; 0.2% Nitroglycerin ointment, and Group 3 (n=30): 2% DTZ ointment. The patients were evaluated at 2, 4, and 6 weeks for pain using visual analogue score (VAS) and healing rate. The results were compared and p<0.05 was considered as significant. Results: The VAS scores between the groups was found to be non-significant (p>0.05), however the VAS scores where markedly reduced within the group at 6 weeks. The healing rate was higher in MTZ group (90%) as compared to GTN (83.3%) and DTZ group (83.3%) but it was not significant. Regarding side effect, burning sensation was observed in MTZ and GTN, DTZ groups were devoid of side effects. Conclusion: The MTZ was more effective with good healing rate but with few side effects. Regarding the pain reduction, all the groups displayed equivocal effects. Thus topical MTZ is a suitable agent for the faster healing of CAF and thus avoids the requirement of surgical options.
... A study done by Karapolat concluded that in conjunction with traditional medical therapies, topical antimicrobial therapy with metronidazole is an efficient, simple-to-use, safe, quick, and painless technique that reduces anal fissure symptoms and accelerates healing. With this promising treatment, cases with acute anal fissures can be prevented from becoming chronic, and patients can be saved from being subject to future surgical interventions that involve high complication rates [12]. ...
Background and objective
An anal fissure is a longitudinal, oval lesion in the anal canal. In over 90% of instances, the anal fissures are located posterior to the midline and produce discomfort upon defecation and/or bleeding owing to spasms of the internal anal sphincter that leads to ischemia. This research aimed to determine if topical metronidazole treatment when combined with glyceryl trinitrate 0.2% (GTN), is more successful than GTN alone in reducing the time for an acute anal fissure to heal.
Material and methods
This study was a single-blinded, randomized controlled trial conducted at the DHQ Hospital Okara from January 2022 to August 2022. Patients of both genders, aged 18 to 70 years, with acute anal fissures, were included. One hundred forty patients who satisfied the inclusion criteria were randomized through the lottery technique and were divided into two groups (70 in each group). Group A contained patients who got metronidazole combination with GTN, while in Group B, patients treated with GTN alone without metronidazole. The primary endpoint was fissure healing, confirmed as finding a scar where the fissure was. While the secondary endpoint was maximum pain on defecation assessed by the Visual Analogue Scale (VAS). Statistical analysis was performed using Statistical Package for Social Sciences (SPSS) v24. Chi-Square and Fisher’s Exact tests were done for statistical analysis, and p < 0.05 was considered significant.
Results
Three patients lost the follow-up. Out of the remaining 137, 70 (51.1%) patients were male. The patient’s ages ranged from 22 to 68 years, with a mean age of 39.18 ± 11.52. One hundred twenty six (92%) complained of pain on defecation with a mean VAS of 6.01 ± 2.35. 80 (58.4%) patients complained of perianal itching, while 25 (18.2%) patients complained of bleeding on defecation.
On week 1 follow-up, in group A out of 69 patients, 27 (39.1%) had complete healing, 38 (55.1%) had partial healing, while in group B out of 68 patients, one (1.4%) had complete healing, 43 (63.2%) had partial healing (p = < 0.001, significant).
On week 3 follow-up, in group A out of 69 patients, 47 (68.1%) had complete healing, and 22 (31.8%) had partial healing, while in group B out of 68 patients, 16 (23.5%) had complete healing, 49 (72%) had partial healing (p = < 0.001, significant). Mean VAS score of group A was 0.61 ± 1.38 while that of group B was 2.57 ± 2.50 (p = < 0.001, significant).
Conclusion
Using topical metronidazole as an addition to standard therapy may reduce the chronicity of acute anal fissures and prevent surgical treatments with high rates of complications.
... Anal fissure is a frequent disease in the society with a lifetime incidence of 11% (1). For treatment of acute anal fissure, healing is possible by exercising high-fibre diet, taking warm-sitz bath, and applying cremes that reduce internal sphincter pressure (2). Today's gold standard for treating chronic anal fissure is the Lateral Internal Sphincterotomy (LIS) (3). ...
Objective
Today's gold standard for treating chronic anal fissure is the Lateral Internal Sphincterotomy (LIS). Botulinum Toxin (BoNT) injection is, on the other hand, an alternative treatment for patients who do not want to have surgical treatment, patients undergoing chemotherapy, patients of high risk for surgery, and those who have the risk of anal incontinence (e.g., elderly, past anorectal surgery, vaginal multiple births, etc.). The aim of this study is to compare the effectiveness of BoNT and redo-LIS for treatment of post-LIS recurrent chronic anal fissure, and reveal differences if any.This study aims to compare redo-LIS and BoNT injection for treating post-LIS recurrent anal fissure.
Material and method
Nineteen patients who received LIS treatment and then redo-LIS or BoNT injection due to recurrence in the follow-up were included in this study. Group I (redo-LIS group) include 11 patients and group 2 (BoNT group) includes 8 patients. Their data on age, sex, anal incontinence scores and pain (VAS score) score as well.
Results
During the 3-month post-surgery follow-up period, there was statistically significant difference ( p < 0.01) between groups by pain. No deterioration in the incontinence scores of patients in the group during the 6-month post-surgery period.
Conclusion
This study demonstrates that redo lateral internal sphincterotomy (LIS) is a reliable method for patients who received LIS but developed recurrent chronic anal fissure, and achieves successful results in terms of recurrence and relief of pain.
... These data is compatible with those in the literature. 7 In the present study, we observed that combination of local metronidazole and 0.2 % nitroglycerine ointment for acute anal fissure resulted in a significant relief of symptoms especially pain score after 2 weeks of treatment. The tear occurring at the anal mucosa causes spasm of the internal sphincter and increases resting pressures of the anal canal, leading to increased pain and decrease blood flow leading to relative ischemia. ...
Objective: To assess the role of topical antibiotic (mertronidazole) in the treatment of acute anal fissure. Study Design: Randomized Control Trial. Setting: General Surgery Outpatient Department of Aziz Fatima Hospital. Period: January 2020 and March 2021. Material & Method: In this study, patients were divided into two groups randomly. Patients in Group 1 were given only 0.2% GTN ointment and those in Group 2 were given 0.2% GTN ointment and metronidazole cream. All patients’ VAS scores for pain and healing of fissure by examining the peri anal area, as well as any adverse effects of the drugs, were recorded and statistically compared. Patients demographic characteristics, such as age and gender, were recorded. All patients were physically examined at the end of weeks 2, 4, and 6 of treatment. All statistical data analyses were performed using the Statistical Package for the Social Sciences (SPSS) version 23.0. Descriptive statistics were used for comparisons. t test, and chi-square test were used to assess independent samples. A p-value <0.05 was accepted as statistically significant. Results: There were 46 (92%) female and 4 (08%) male patients in Group 1 and 48 (96%) female and 2 (24%) male patients in Group 2. The mean ages of the patients were 35.4±3.7 years in Group 1 and 37.8±4.2 years in Group 2. The mean VAS scores of the patients at the time of presentation to the hospital (pretreatment) were 7.2±1.2 in Group 1 and 7.4±0.9 in Group 2 (p=0.058). The mean VAS scores of the patients at the end of week 2 were 4.6±0.8 in Group 1 and 4.2±0.9 in Group 2 (p=0.058). The mean VAS scores of the patients at the end of week 4 were 3.2±O.7 in Group 1 and 2.4±0.8 in Group 2 (p=0.00004). The mean VAS scores of the patients at the end of week 6 were 2.36+0.65 in Group 1 and 1.86±0.48 in Group 2 (p<0.00054). In Group 1, 6(12%) patients had recovery at week 4 and 26 (32%) patients at week 6 with no recovery seen in 18(36%) patients. In Group 2, 9 (18%) patients had recovery at week 2 and 33(66%) patients at week 4 with no recovery seen in 8(16%) patients. There was a statistically significant difference between these data (p=0.022). Conclusion: We have observed that topical metronidazole along with other traditional management is an fruitful, easy-to-use, safe, rapid and secure option that helps in further reducing pain associated with anal fissure and increasing the healing rate. It is also effective in preventing the anal fissure to become chronic.
... Anal ssure is a frequent disease in the society with a lifetime incidence of 11% [1]. For treatment of acute anal ssure, healing is possible by exercising high-bre diet, taking hot-hip bath, and applying cremes that reduce internal sphincter pressure [2]. Today's gold standard for treating chronic anal ssure is the Lateral Internal Sphincterotomy (LIS) [3]. ...
Today’s gold standard for treating chronic anal fissure is the Lateral Internal Sphincterotomy (LIS). Botulinum Toxin (BoNT) injection is, on the other hand, an alternative treatment for patients who do not want to have surgical treatment, patients undergoing chemotherapy, patients of high risk for surgery, and those who have the risk of anal incontinence (e.g. elderly, past anorectal surgery, vaginal multiple births, etc.). The objective of this work is to compare the effectiveness of BoNT and redo-LIS for treatment of post-LIS recurrent chronic anal fissure, and reveal differences if any.
Purpose: This study aims to compare redo-LIS and BoNT injection for treating post-LIS recurrent anal fissure.
Material and method: Nineteen patients who received LIS treatment and then redo-LIS or BoNT injection due to recurrence in the follow-up were included in this study as they met the criteria for doing so. Their data on age, sex, anal incontinence scores and pain (VAS score) score as well.
Results: During the 6-month post-surgery follow-up period, there was statistically significant difference (p<0.01) between groups by pain. No deterioration in the incontinence scores of patients in the group during the 6-month post-surgery period.
Conclusion: This study demonstrates that redo lateral internal sphincterotomy (LIS) is a reliable method for patients who received LIS but developed recurrent chronic anal fissure, and achieves successful results in terms of recurrence and relief of pain.
... Anal ssure is a frequent disease in the society with a lifetime incidence of 11% [1]. For treatment of acute anal ssure, healing is possible by exercising high-bre diet, taking hot-hip bath, and applying cremes that reduce internal sphincter pressure [2]. Today's gold standard for treating chronic anal ssure is the Lateral Internal Sphincterotomy (LIS) [3]. ...
Today’s gold standard for treating chronic anal fissure is the Lateral Internal Sphincterotomy (LIS). Botulinum Toxin (BoNT) injection is, on the other hand, an alternative treatment for patients who do not want to have surgical treatment, patients undergoing chemotherapy, patients of high risk for surgery, and those who have the risk of anal incontinence (e.g. elderly, past anorectal surgery, vaginal multiple births, etc.). The objective of this work is to compare the effectiveness of BoNT and redo-LIS for treatment of post-LIS recurrent chronic anal fissure, and reveal differences if any.
PURPOSE :
This study aims to compare the success rates of redo-LIS and BoNT injection for treating post-LIS recurrent anal fissure.
METHODS :
Prospectively prepared standard forms were evaluated retrospectively. Nineteen patients who received LIS treatment and then redo-LIS or BoNT injection due to recurrence in the follow-up were included in this study as they met the criteria for doing so. And their data were reviewed retrospectively. Their data on age, sex, healing duration, and anal incontinence scores and pain (VAS score) score as well.
RESULTS : During the 6-month post-surgery follow-up period, there was statistically significant difference (p<0.01) between groups by pain. No deterioration in the incontinence scores of patients in the group during the 6-month post-surgery period.
CONCLUSION :
This study demonstrates that redo lateral internal sphincterotomy (LIS) is a reliable method for patients who received LIS but developed recurrent chronic anal fissure, and achieves successful results in terms of recurrence and relief of pain.
... The anus is an area where bacteria are concentrated. If the patient has anal fissure and does not pay enough attention to personal hygiene, this area can easily get infected after treatment [27], which forms a vicious circle [28]. The results of this study demonstrated that the incidence and recurrence rate of postoperative infection in the RG were dramatically lower than those in the CG. ...
Background:
To explore the efficacy of posterior median anal incision plus incision and drainage of anal sinus on chronic anal fissure (CAF), and its influence on incidence and recurrence of postoperative infection.
Methods:
Altogether 130 patients with CAF treated during January 2017 and January 2021 were included and divided into a research group (RG) and control group (CG). Among them, 80 patients in the RG were treated with posterior median anal incision and expansion plus anal sinus incision and drainage, while 50 in the CG were treated with lateral internal sphincterotomy. Clinical indexes (wound healing time, recovery time of bowel sounds, intraoperative blood loss, length of stay), levels of inflammatory factors (IL-6, IL-8, CRP) before and one week after treatment, changes of psychological and emotional scores (SAS, SDS scores) before and 6 months after treatment, sleep and scores of daily activities after admission and 6 months after treatment, VAS scores at 1 day, 1 week and 2 weeks after operation, compliance, total effective rate, and incidence and recurrence rate of postoperative incision infection were compared between the groups.
Results:
Compared with the CG, the wound healing time, recovery time of bowel sounds and length of stay were shorter, and intraoperative blood loss was lower in the RG; the levels of IL-6, IL-8 and CRP were lower in RG one week after treatment. Six months after treatment, the SAS, SDS and PSQI scores were lower, the ADL scores were higher, the compliance and total effective rate were higher, and the incidence and recurrence rate of postoperative incision infection were lower in the RG.
Conclusion:
Posterior median anal incision plus incision drainage of the anal sinus has better efficacy on CAF, and can effectively reduce the incidence of postoperative infection and recurrence.
... However, the mechanism of action of TM in reducing postoperative pain in unknown [15]. Karapolat used TM for cases of acute fissure-in-ano and showed that it is safe and effective for healing [16]. ...
Background:
Topical metronidazole (TM) is commonly used in many infective conditions and postoperative wounds including after anorectal surgery. TM was prescribed in patients operated for benign anorectal conditions (anal fistula and hemorrhoids) to hasten wound healing. After the initiation of this protocol, the incidence of postoperative wound bleeding seemed to increase. There are no data in the literature suggesting that topical metronidazole increases the risk of bleeding.
Objective:
Analysis of the association of TM with an increased risk of bleeding in postoperative anorectal wounds.
Design:
This was an observational and a retrospective study. Propensity score matching was performed.
Setting:
This study was conducted at a specialized center for anorectal disorders in postoperative patients suffering from anal fistula and hemorrhoids.
Materials:
The incidence of postoperative bleeding in the patients in whom TM was used (study group) was retrospectively compared with the patients operated one year before this period in whom TM was not used (control group).
Sample size:
There were 35 patients in the study group and 181 patients in the control group.
Main outcome measures:
The incidence of bleeding and the number of bleeding episodes were evaluated.
Results:
The incidence of bleeding was significantly higher in the study group as compared to the control group (8/35 (22.8%) vs. 8/181 (4.4%), respectively, p = 0.0011). In most cases, bleeding was controlled with conservative measures. The number of bleeding episodes was also significantly higher in the study group (14 vs. 11, respectively, p = 0.0001). The number of patients requiring operative intervention was also higher in the study group (2/35-5.7%) as compared to the control group (1/181-0.56%), but this was not statistically significant (p = 0.069).
Conclusions:
The study highlighted that application of topical metronidazole in postoperative anorectal wounds increased the risk of bleeding. Most of the bleeding episodes were controlled with conservative measures but they caused considerable patient anxiety and apprehension.
... According to Garg, the use of antibiotics should be reserved for chronic or acute-on-chronic AF in which there can be a low-grade infection [320]. In a recent prospective controlled randomized study [321], 100 patients with acute AF were randomly divided into two groups (group 1: 5% lidocaine; group 2: 5% lidocaine plus metronidazole cream). All patients applied the therapy 3 times per day for 4 weeks. ...
Anorectal emergencies comprise a wide variety of diseases that share common symptoms, i.e., anorectal pain or bleeding and might require immediate management. While most of the underlying conditions do not need inpatient management, some of them could be life-threatening and need prompt recognition and treatment. It is well known that an incorrect diagnosis is frequent for anorectal diseases and that a delayed diagnosis is related to an impaired outcome. This paper aims to improve the knowledge and the awareness on this specific topic and to provide a useful tool for every physician dealing with anorectal emergencies.
The present guidelines have been developed according to the GRADE methodology. To create these guidelines, a panel of experts was designed and charged by the boards of the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) to perform a systematic review of the available literature and to provide evidence-based statements with immediate practical application. All the statements were presented and discussed during the WSES-AAST-WJES Consensus Conference on Anorectal Emergencies, and for each statement, a consensus among the WSES-AAST panel of experts was reached. We structured our work into seven main topics to cover the entire management of patients with anorectal emergencies and to provide an up-to-date, easy-to-use tool that can help physicians and surgeons during the decision-making process.
Introducción: La fisura anal es una patología proctológica frecuente, cronificante, caracterizada por la presencia de lesiones dolorosas ocasionadas por la hipertonía del musculo liso del esfínter anal interno. A pesar de su impacto, los tratamientos convencionales disponibles pueden ser limitados en términos de reproducibilidad, eficacia y tolerabilidad a largo plazo. Debido a ello, la exploración de nuevas terapias farmacológicas, en sincronía con nanovehículos que permitan su direccionamiento específico al lugar de acción, ofrecen una alternativa potencial para mejorar su tratamiento. Método: Se plantea como un estudio de tipo retrospectivo y longitudinal. Resultados: Se aplican diferentes abordajes terapéuticos, desde medidas higiénico-sanitarias, tratamientos farmacológicos no invasivos, hasta la cirugía, la mayoría de ellos dirigidos a disminuir la hipertonía. Los fármacos habituales a nivel hospitalario son lidocaína, diltiazem, nifedipino, nimodipino, nitrato de isosorbide y la toxina botulínica. Aprovechando las ventajas de la nanotecnología farmacéutica en la mejora de la eficacia terapéutica, disminuyendo los efectos adversos generados en la administración sistémica y aumentando la tasa de curación, se han encontrado estudios sobre la aplicación de nanopartículas poliméricas, vesiculares y micro-nano emulsiones para vehiculizar fármacos para el tratamiento sintomático de la fisura anal. Algunas formulaciones cuentan con autorización sanitaria y otras se encuentran en fase de investigación. Conclusiones: Se ha evidenciado que las nuevas formulaciones, especialmente aquellas basadas en nanotecnología, muestran un potencial significativo para mejorar la cicatrización de las fisuras en comparación con los tratamientos convencionales. No obstante, son necesarios estudios sobre el uso seguro de estos sistemas antes de su implementación clínica generalizada.
Introduction
Anal fissure is one of the most common diseases of the anorectal region that is frequently encountered in surgical practice, equally affects both women and men. Acute anal fissures last shorter than 6 weeks. The American Society of Colon and Rectal Surgeons favors conservative management of anal fissure as the first line of treatment. A rectal ointment containing 0.2% glyceryl triturate (GTN) can be recommended to promote the healing of anal fissures and decreasing sphincter spasm. Metronidazole is a 5-nitroimidazole derivative antibiotic with a cytotoxic bactericidal effect particularly on anaerobic bacteria.
The purpose of the present study was to investigate whether local metronidazole antibiotic cream is effective and safe to use in reducing the symptoms and improving the healing process of acute anal fissure.
Patients and methods
This study was performed in Mansoura University Hospital, surgery outpatient clinic from the period of July 2022 till July 2023. This study was a single-blinded, randomized controlled trial.
Total 100 patients were included in this study and randomly divided into two groups, 50 patients in each group. First group (group 1) treated by combination of local metronidazole 10% with 0.2% GTN while the second group treated only with GTN.
Results
Anal pain were present in both group in all patients with acute anal fissure while constipation were 88% in group 1 and 76% group 2. To lesser extent itching, bleeding, and diarrhea were presented in both group.
Visual analog scale for pain intensity were equal in both groups at the time of first clinical examination. After 1 week and 1 month of treatment there were statistically significant difference between both groups thus the visual analog scale were lower in group 1 than group 2 (0.001 and <0.001, respectively).
Healing of acute anal fissure was assessed clinically at variable interval for all patients there is statistically significant difference between both group (0.004) as regard healing, first group showed earlier and faster healing and fewer number of nonhealing of the fissure at the end of follow up.
Conclusion
Adding local metronidazole 10% to the classic GTN treatment will improve the symptoms of acute anal fissure specially pain and discomfort and markedly accelerate healing process.
To determine whether the medical Treatment of anal fissure can be an effective alternative for surgery Methods: Retrospectively, we randomly selected 190 Patients being treated for anal fissure between the years 2005-2010 in 3 equal groups: group A: Patients who received medical treatment with topical nitroglycerin, group B: Patient treated with topical diltiazem, and group C: Patients underwent surgery. The results were then correlated with the statistical program SPSS using chi-square test. Main complaints of the patients were first anal pain and then bleeding. The response to treatments for relieving pain was: 77% in A, 83% in B, and 98% in group C. Response of treatments for fissure healing, in order of groups A, B and C was: 74%, 83%, and 94%. Despite good response to medical treatment, surgical treatment was more effective and medical treatment of choice in patients who are willing to have surgery.
Fissure in ano is a very common disorder of the
anorectal region. Internal sphincter hypertonia with decreased
relaxation coupled with mucosal ischemia of posterior anal
canal are the major pathologies in chronic anal fissure (CAF).
Though lateral internal sphincterotomy (LIS) remains the gold
standard of treatment for the disease, it is accompanied by the
potential complication of incontinence to both flatus and
faecal matter. The aim of our study was to explore the role
of topical diltiazem as an effective and a safe alternative to
sphincterotomy for chronic anal fissure. Ninety patients with
CAF were randomly assigned to group A and group B, with
45 patients each. Group A patients received 2 % diltiazem
topical application, twice daily, and group B patients
underwent LIS. All the patients were reviewed at first, fourth
and sixth week after initiation of treatment. Visual analogue
scores for pain and healing of fissure by visual inspection were
recorded and compared. In group A, 71 % had complete
healing of fissure at 6 weeks, with fair amount of pain relief
(mean VAS—3.38), and in group B, 96 % showed healing
of fissure, with excellent pain relief (mean VAS—1.87).
Headache and flushing were noted in two patients in
group A while no patients in group B developed incontinence. We conclude that LIS is more effective than topical
diltiazem in the treatment of CAF. Topical diltiazem may
be employed as an initial conservative treatment option
before considering the surgical alternative.
Objectives:
To determine the efficacy and safety of 'healer' cream as monotherapy in the treatment of acute and chronic anal fissure.
Study design:
A prospective, randomized, single blinded, comparative trial.
Methods:
Sixty patients suffering from anal fissure were included in the study. Patients were randomly divided into three groups: group A: treated with 'healer' local cream application 3 times daily; group B: treated with nitroglycerine 0.25% local cream 3 times daily; group C: treated with a lidocaine 2% cream applied locally 3 times daily. All the followings were followed up and compared between groups. (1) Visual pain analogue score after defecation; (2) severity of straining and discomfort during defecation; (3) frequency of ulcer healed at 30 days; (4) any side effects or complications.
Results:
The pain scoring after defecation was significantly reduced in the three treatment groups. The group treated with 'healer' isosorbide-di-nitrate showed the greatest reduction of the visual pain analogue score median from 9 before treatment to 3 & 1 after 10 and 20 days respectively, while the median visual pain analogue score in group B treated with nitroglycerine cream was 9 reduced to 4 & 2 after 10 and 20 days respectively, and the median visual pain analogue score in lidocaine group only dropped from 9 to 6 and 4, respectively. The reduction of both pain scoring and defecation scoring with 'healer' was statistically significantly greater than the other two treatments by Kruskal-Wallis test, P<0.001. The number of patients experiencing complete relief and passing stools easily after 10 days was significantly higher in 'healer' group, by Pearson Chi square = 22.94, P<0.001. After 30 days, the fissures were healed in 18 (90%) of 20 patients in the 'healer' group and in 12 (60%) of 20 in the nitroglycerin group, while only 6 (30%) of patients treated with lidocaine cream had their fissures healed by the 30 days treatment. Chi square = 15 (P = 0.001).
Conclusion:
'Healer' is a promising effective and safe line of treatment in acute and chronic anal fissure. The characteristic pharmacokinetics of isosorbide-di-nitrate leads to a better effect than nitroglycerin in healing (more prolonged action). Also the less fast absorption than nitroglycerin leading to a smoother dose concentration curve, may be the cause that headache is less frequent and less severe in 'healer' treatment versus nitroglycerin.
As lateral sphincterotomy and anal dilatation causes complications, a reversible chemical sphincterotomy method has been recently proposed as an alternative treatment in patients with anal fissure. In this study, the effect of botulinum toxin causing temporary paralysis in internal anal sphincter was compared with that of lidocaine in patients with chronic anal fissure.
A total of 62 outpatients were randomly assigned to receive botulinum toxin or lidocaine pomade. The patients were evaluated before and after two months of treatment with physical examination and anal manometry. Pain and nocturnal pain were scored.
In an evaluation period of two months, in 24 of 34 patients of botulinum group (70.58%), and in six of 28 patients of lidocaine group (21.42%) showed complete epithelization (p = 0.006). All patients who had previously reported nocturnal pain became symptom free in botulinum group and in four patients of lidocaine group. Pain following defecation disappeared in 24 patients of botulinum group and in 20 patients of control group (p = 0.959). There was no adverse effect in both groups. While resting anal pressure and maximum voluntary pressure were significantly low in botulinum toxin group, both parameters did not change in lidocaine group.
Botulinum toxin is a reliable and effective method for patients with chronic anal fissure. It can be applied easily without any anesthesia and instrumentation. It is cheaper in comparison with surgical methods and it can be a good alternative treatment in patients with risk of incontinence.
Chronic anal fissure is one of the most frequent proctological disorders in Western populations. Open lateral internal sphincterotomy is one of the therapeutic options accepted as the treatment of choice for chronic anal fissure, since it reduces the hypertonia of the internal anal sphincter (the main etiopathogenic mechanism of fissures), decreases anal pain, and allows the fissure to heal.
We carried out a prospective study of 120 patients operated on for chronic anal fissure with open sphincterotomy under local anesthesia at our Proctology Outpatient Unit from 1998 to 2001. No preoperative studies, bowel preparation, or antibiotic prophylaxis were carried out. All patients were followed up after 1 week, 2 months, 6 months, and 1 year, and underwent an anal manometry before and after surgery.
Early complications: 3 hematoma-ecchymosis of the wound (2.5%), 3 self-limited hemorrhage events (2.5%). No hemorrhoidal thrombosis, fistulas, or perianal abscesses occurred. Fissures recurred in nine patients (7.5%) within one year. The initial rate of incontinence of 7.5% at two months dropped down to 5% at six months. The mean resting pressure (MRP) in incontinent patients was lower than in continent patients (55 +/- 7 mmHg versus 80.7 +/- 21 mmHg). The difference in mean squeeze pressure (MSP) between incontinent patients and continent patients was not statistically significant.
Open sphincterotomy under local anesthesia has a long-term rate of healing and a morbidity rate similar to other techniques. It may therefore be considered an effective treatment for chronic anal fissure.
This study was planned compare local application of nitric oxide donor ointment and anesthetic gel for the reduction of anal resting, squeeze pressures and also healing rates of acut and chronic anal fissures. Patients with anal fissures were divided into two (A and B) groups. There were 17 patients (acute 10, chronic 7) in each groups. They were received respectively topical 2% nitric oxide donor ointment and 5% anesthetic lignocaine gel three times a day during the four weeks period. Anal resting pressure, squeeze pressure and clinical examination were done a weekly intervals before and during the therapy periods. After one week treatment period, mean anal resting pressure was significantly reduced with topical nitric oxide donor ointment application in group A, but similar results were not observed in group B. Anal squeeze pressures were not significantly reduced by local applications in two groups. The healing rates were obtained 80 percent in acute (n=8) (p=0.001), 29 percent in chronic (n=2) (p=0.172) in group A and 60 percent in acute (n=6) (p=0.005), 0 percent in chronic (n=0) in group B after four weeks therapy period. In this study, topical nitric oxide donor application causes to anal canal resting pressure reduction and improve vascular perfusion of anal fissure tissue. Patients were undergone operation for chronic anal fissure that resistant to medical management can be reduced with topical nitric oxide donor application.
Although the recommended treatments of chronic anal fissure are anal dilatation and lateral internal sphincterotomy, which are successful in 85-90% of patients, these procedures permanently weaken the sphincter, which may be associated with incontinence, infection, and anal deformity. The aim of that study is to investigate the efficacy of alternative treatment methods such as nifedipine, glyceryl Seventy-five consecutive patients who applied to Department of Surgery with the diagnosis of chronic anal fissure between 1998 and 2000 were included in the study. Patients were divided into nifedipine (n=25), glyceryl trinitrate (n=25), and botulinum toxin (n=25) groups in a prospective randomised manner. Oral nifedipine 20mg daily for five days in nifedipine group, topical 0.2% glyceryl trinitrate ointment twice daily for 30 days in glyceryl trinitrate group, and a single injection of 25 unit botulinum toxin to internal anal sphincter in botulinum group were applied. The patient in each group were evaluated for their anal resting and squeeze pressures just before and 30 days after treatment, and for their physical signs and symptoms just before and 15 and 30 days after treatment. The resting anal pressures in all treatment groups were decreased significantly according to pre-treatment results (p<0.05). Patients' signs and symptoms were also diminished or disappeared significantly in all treatment groups. No major complication due to applications was detected. It is concluded that oral nifedipine, topical glyceryl trinitrate, and botilunum toxin injection may be alternative to surgical treatment and may diminish permanent complications due to surgical management.
Background:
Chronic anal fissure is a common disease that is accompanied with pain and bleeding during defecation. Various surgical and non-surgical methods have been offered for the treatment of this condition. The aim of this randomised clinical study was to compare the effectiveness and safety of nifedipine and isosorbide dinitrate (ISDN) in the treatment of chronic anal fissure.
Methods:
This double-blind clinical trial study was performed on patients aged 20 to 60 years old in 2012 to 2013. The samples with a primary diagnosis of chronic anal fissure were enrolled from the patients admitted to public treatment at the educational Imam Ali Clinic, Shahrekord, Iran by researchers and general surgery specialists. The patients were randomised into two groups: nifedipine 0.3% (n = 35) or ISDN 0.2% (n = 35) applied three times a day for three weeks. The patients were examined on the 7th, 14th, and 21st days of treatment, and the symptoms including bleeding, pain, and healing status, as well as the side effects of the drugs, were assessed. Pain was evaluated using a visual analogue scale (VAS).
Results:
After 21 days of follow-up, complete healing was achieved in 77.1% (n = 27) of patients in the nifedipine group and 51.4% (n = 18) in the ISDN group (P = 0.05). The mean VAS of the pain on day 21 was 0.91 (SD 0.01) in the ISDN group and 0.45±0.78 in the nifedipine group, with a statistically significant difference (P = 0.038). The bleeding was similar in the two groups (P = 0.498).
Conclusion:
In view of the findings on healing status and pain in the patients, nifedipine may be significantly more effective in the treatment of chronic anal fissure than ISDN.
Chronic anal fissures (CAFs) rarely heal with conservative management. Because they are associated with strong anal sphincter tone, most treatment aim to reduce anal pressure. Although infections can cause fissures, as can traumatic injury to the anal canal, antimicrobial treatment is not recommended. In a previous study, we reported identifying a wide spectrum of pathogenic microorganisms in the bases of CAFs, anaerobic bacteria being present in half the cases. We postulated that microbial colonization delays healing of CAF and aimed to determine whether decreasing the bacterial load with topical antibacterial treatment accelerates fissure healing.
We cultured fecal samples and swabs from the bases of CAFs in 103 patients. Patients in whose samples anaerobic bacteria were identified (47 patients) were then invited to participate in a prospective randomized clinical trial comparing topical metronidazole with conventional treatment. The primary endpoint was fissure healing confirmed on anoscopy. Secondary endpoints of maximum pain on defecation assessed by visual analog scale, maximum anal resting pressure, and rectal pH were recorded on entry and at 10, 21, and 28 days.
The CAFs were colonized by mixtures of gram-positive/gram-negative anaerobic bacteria or gram-negative aerobic monocultures. Patients with anaerobic bacteria in their swabs who received topical metronidazole treatment experienced rapid relief of pain and anal sphincter spasm along with enhanced fissure healing (95.6 % healing rate compared with 70.8 % in the control group, p = 0.048).
Topical antimicrobial treatment can be effective in patients with CAF provided the relevant microorganisms are correctly identified.
Anal fissure is an ulceration of the anoderm in the anal canal. Its pathogenesis is due to multiple factors: mechanical trauma, sphincter spasm, and ischemia. Treatment must address these causative factors. While American and British scientific societies have published recommendations, there is no formal treatment consensus in France. Medical treatment is non-specific, aimed at softening the stool and facilitating regular bowel movements; this results in healing of almost 50% of acute anal fissures. The risk of recurrent fissure remains high if the causative factors persist. If non-specific medical treatment fails, specific medical treatment can be offered to reversibly decrease hypertonic sphincter spasm. Surgery remains the most effective long-term treatment and should be offered for cases of chronic or complicated anal fissure but also for acute anal fissure with severe pain or for recurrent fissure despite optimal medical treatment. Surgical treatment is based on two principles that may be combined: decreasing sphincter tone and excision of the anal fissure. Lateral internal sphincterotomy (LIS) is the best-evaluated technique and remains the gold standard in English-speaking countries. Since LIS is associated with some risk of irreversible anal incontinence, its use is controversial in France where fissurectomy combined with anoplasty is preferred. Other techniques have been described to reduce the risk of incontinence (calibrated sphincterotomy, sphincteroplasty). The technique of forcible uncalibrated anal dilatation is no longer recommended.
Chronic anal fissure: is it an infection in a physically deformed lesion?-a new insight into an old plight
- P Garg
- P Lakhtaria
- S Nalamati
- V Gupta
- J Thakur
Garg P, Lakhtaria P, Nalamati S, Gupta V, Thakur J. Chronic anal
fissure: is it an infection in a physically deformed lesion?-a
new insight into an old plight. In Annual conference of American Society of Colon Rectum Surgeons (ASCRS). San Antonio
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Non-surgical management of chronic fissurein-ano with high success rate: a simple novel concept in the treatment of chronic fissure-in-ano
- P Garg
- P Lakhtaria
Garg P, Lakhtaria P. Non-surgical management of chronic fissurein-ano with high success rate: a simple novel concept in the treatment of chronic fissure-in-ano. In Annual conference of American Society of Colon Rectum Surgeons (ASCRS). Fort Laurderdale
2014.
Acute anal fissure and antibiotics
- B Karapolat
Karapolat B.
Acute anal fissure and antibiotics