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Topical Combination of Nifedipine with Lidocaine for Anal Fissure Treatment
Abstract
Background: A fissure consist of crack or tear in the vertical axis of the anal canal between the anal verge and the dentate line. Anal fissure is treated by two ways either medical or surgical treatment or both.
Objective: evaluate the healing response of topical application of nifedipine with lidocaine in acute and chronic anal fissure
Material and method: A prospective study of one hundred patients presented with anal fissure to outpatient surgical clinic in Al-Diwaniyah teaching hospital, the patients divided into two groups, 40 patients (15 males and 25 females) with acute anal fissure, and 60 patients (25 males and 35 females) with chronic anal fissure.
Results:
There was no statistically significant difference in the healing rate between acute and chronic lesion, however the rate of healed lesion in acute setting is higher than that of chronic setting (80% vs. 56%)
Conclusion:
Topical application nifedipine and lidocaine effective in treating acute anal fissures with the healing response of 85%, and prevent evolution of acute anal fissures to chronic anal fissure.
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A prospective comparative two arms study done in Al Kadhimiya teaching hospital for 1 year duration from June 2017 till June 2017, this study included 150 women with singleton pregnancies diagnosed with gestational DM. The primary endpoints were neonatal outcomes which include; neonatal hypo-glycemia (≥2 neonatal glucose values 46.8 m/dL), respiratory distress (ad-mission to neonatal care unite NUC), need for phototherapy (neonatal jaundice), 5-minute Apgar scores below 7, or premature birth (<37 weeks of gestation). The maternal outcome includes the rate of gestational hypertension, preeclampsia, mode of delivery and Polyhydramnios. Metformin offer less risk for the neonate to have an episode of blood glucose level <28.8 mg/dl compared to insulin RR (95%CI): 0.598 (0.457-0.999) and it was significant, metformin also offer less risk for the neonate to have recurrent blood glucose level <46.8 mg/dl RR (95%CI): 0.820 (0.586-1.289) but it was not statistically significant, metformin had slightly increased risk for preterm birth compared to insulin, the rest of the variables did not show a significant difference between both drugs. There was no significant difference in the maternal outcome between both drugs. There was no significant difference between met-formin and insulin in their FPG and HbA1c after commencing therapy. In conclusion , metformin is an effective and safe treatment option for women with GDM, and that metformin comparable with insulin in glycemic control, there is no a significant risk of maternal or perinatal adverse outcome with the use of metformin compared with insulin in GDM.
Multiple sclerosis (MS) is a chronic, inflammatory, immune-mediated disease of the central nervous system (CNS). More than 2 million people worldwide have MS. The goal of the present study was to compare Iraqi patients' treatment satisfaction with three different disease-modifying therapies (DMTs), administered orally, subcutaneously, and by slow infusion; namely, fingolimod, interferon beta-1b (IFNβ-1b), and natalizumab, respectively. As well as to assess the individual differences among these therapies about their effectiveness, convenience and global satisfaction also to assess the role of certain predictors on treatment satisfaction. Patient satisfaction with medication assessed by the Treatment Satisfaction Questionnaire for Medication (TSQM-9) which comprises three components medication effectiveness, convenience , and global satisfaction. For The treatment satisfaction outcomes, the IFNβ-1b using patients had the lowest score for all TSQM-9 subscales. The most consistent differences among the groups were related to the convenience of the medication, with oral fingolimod have the highest scores and na-talizumab the second. Regarding global satisfaction, natalizumab using group reported significantly higher satisfaction, as compared to both IFNβ-1b and fingolimod using groups. In conclusion, Iraqi relapsing-remitting MS patients are more satisfied with the natalizumab than with IFNβ-1b or fingolimod. Some predictors such as age, EDSS and duration of treatment, correlate with the level of satisfaction with different treatments.
Background
Parikartika is a common painful condition among anorectal diseases which resembles with fissure-in-ano. In the present era, due to changing lifestyle such as sedentary work pattern, increased stress, improper dietary and sleep habits, various lifestyle disorders are increasing continuously.
Aim and Objective
The aim is to assess the effect of Yashtimadhu Ghrita in comparison with lignocaine–nifedipine ointment in the management of Parikartika (Acute fissure-in-ano).
Materials and Methods
A total of 36 patients of acute fissure-in-ano were selected and randomly allocated into two groups (18 in each group). In Group A (n = 18), local application of Yashtimadhu Ghrita in fissure bed (Parikartika) twice a day after sitz bath for 4 weeks was given. In Group B (n = 18), local application of lignocaine–nifedipine ointment in fissure bed (Parikartika) twice a day after sitz bath for 4 weeks was given.
Results
Patients of Group A (Yashtimadhu Ghrita) taken more time than the patients of Group B (lignocaine–nifedipine ointment) to get relief from pain in ano. Ulcer in ano healed earlier in patients of Group A (Yashtimadhu Ghrita) in comparison with patients treated with lignocaine–nifedipine ointment application. Patients of both groups have taken similar time to get relieved from bleeding PR. Complete remission of symptoms of Parikartika was more in patients treated with Yashtimadhu Ghrita than lignocaine–nifedipine ointment.
Conclusion
Both the interventions Yashtimadhu Ghrita and lignocaine–nifedipine ointment are equally effective in symptomatic relief in Parikartika (acute fissure-in-ano).
Chronic anal fissure is the most common cause of anal pain associated with internal anal sphincter hypertonia. Reduction of hypertonocity is a special treatment for fissure healing. For this purpose chronic anal fissures were conventionally treated by anal dilatation or by lateral sphincterotomy. However, both of these methods may cause a degree of incontinence in some patients. The uptake of medical therapies that create a reversible chemical sphincterotomy has recently become widespread. The aim of this prospective clinical trial study was to assess the effectiveness of nifedipine in healing anal fissure, a calcium channel blocker that reduces sphincter pressure. A single-blind randomized comparative trial was setup to compare traditional treatment with stool softeners and 2% lidocaine cream against 0.5% nifedipine cream for 4 weeks. 110 patients were included in this study, 60 patients in the nifedipine group and 50 patients in the control group and the therapeutic outcome and side effects were recorded. Healing had occurred in 70% of patients in the nifedipine group and in 12% of patients in the control group after 4 weeks treatment (P < 0.005). Recurrence of symptoms occurred in four of healed patients in the nifedipine group and three patients in the control group in two months. The final result of nifedipine application after 12 months follow up was recurrence in 11 patients (26.19%). Mild headache occurred in four patients (6.6%) of the nifedipine group. Patients in the nifedipine group showed significant healing and relief from pain compared with patients in the control group. Recurrence rate with nifedipine use in spite of control of predisposing factors such as constipation was significant. Another finding was low complication rate with this treatment.
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.
There are many different sexually transmitted infections that can cause proctitis. Recognition of the common symptoms with anoscopic examination is crucial in accurate diagnosis of the pathogen. Clinicians should have a high index of suspicion of more than one inciting pathogen. Treatment should be prompt and extended to sexual partners who have been exposed to the disease. Effective treatment can alleviate the discomfort and potentially serious complications associated with sexually transmitted proctitides. This article illustrates and discusses the clinical presentations, diagnostic pearls, and treatments of sexually transmitted proctitides.
It has been suggested that chronic anal fissure is ischemic in origin because of poor blood supply and spasm of the internal anal sphincter. Nitric oxide donors such as glyceryl trinitrate (GTN) cause a chemical sphincterotomy leading to healing of the fissure. This study addresses the hypothesis that topical GTN ointment may be an effective nonsurgical treatment for chronic anal fissure.
Thirty-nine consecutive patients (23 women; median age, 34 (range, 16-54) years) with chronic anal fissure presenting to the surgical outpatient department were treated for four to six weeks with 0.2 percent GTN ointment applied twice daily to the anoderm. Maximum anal resting pressure was measured at steady state before and after application of the ointment at the first visit. Patients were assessed at two weekly intervals.
Previous surgery for fissure had been performed in seven patients. There were 30 posterior and 9 anterior fissures. Resting maximum anal resting pressure fell from 122.1 +/- 44 to 72.5 +/- 33.3 cm of water (mean +/- standard deviation) by 20 minutes after application of ointment (P < 0.0001; paired t-test). Healing was complete in 14 patients at four weeks and in 33 patients at six weeks. Fissures recurred in five patients after treatment had been stopped. Four recurrences were successfully treated by further GTN ointment and one by sphincterotomy.
This study shows that most anal fissures can be treated nonsurgically with topically applied 0.2 percent GTN ointment. Prospective, randomized controlled trials are now needed, because nonsurgical treatment of anal fissure avoids permanent division of part of the sphincter and the consequent disturbance of continence mechanisms.
Constipation is a frequent, distressing, and underestimated complication in patients with advanced cancer. It may develop from general disturbances that may or may not be cancer related, but the use of opioids is one of the main causes in this population. Opioids affect the intestine by reducing motility and secretions and by increasing fluid absorption and blood flow. Untreated constipation may lead to several complications. Effective management of constipation starts with a careful assessment of the patient, including the history of the frequency and difficulty of defaecation, symptoms caused by constipation, and physical and rectal examinations. When the diagnosis of constipation is unclear, an abdominal X-ray may be required. The treatment of constipation includes general interventions, such as the availability of comfort and privacy or the elimination of medical factors that may contribute to constipation, and therapeutic interventions including oral or rectal laxatives and the use of prokinetic drugs and naloxone. The purpose of this paper is to review the pathophysiology and causes of constipation and the effects of opioids on the gastrointestinal tract, and to propose an approach for its assessment and management. Randomized clinical trials between different laxatives and/or prokinetic agents in cancer patients are needed, and future studies should focus on the validation of different clinical assessment tools for constipation.
Pharmacological manipulation of the anal sphincter is hampered by a lack of specificity. This study aimed to determine differences in the role of intracellular and extracellular calcium in the development of tone and agonist-induced contractions between internal anal sphincter (IAS) and rectal circular muscle which might allow targeted manipulation.
Smooth muscle strips from the IAS and rectal circular muscle of 24 Large White pigs were mounted for isometric tension recording in a superfusion organ bath in the presence of different perfusates.
IAS developed tone and spontaneous activity that were abolished by nifedipine, which also reduced contractions to noradrenaline to 72 per cent of control values. Rectal smooth muscle developed spontaneous activity but no tone. Nifedipine abolished the activity and reduced contractions to carbachol to 17 per cent of control. Contractile activity was abolished in both tissues in calcium-free solution. Transient exposure to a high calcium concentration reloaded the stores, and the ability of agonists to release stored calcium was tested after 3 min in calcium-free solution. In IAS, noradrenaline contraction was 76 per cent of control and in rectal circular muscle carbachol contraction was 57 per cent of control. Store loading was prevented by nifedipine in rectal smooth muscle but not IAS. Cyclopiazonic acid reduced store filling in both tissues.
Agonist-induced contraction of IAS is largely due to release of stored calcium and L-type calcium channels are not needed for store filling. Rectal circular smooth muscle depends more on extracellular calcium and uses L-type calcium channels for agonist-induced contraction and store filling. These differences suggest that targeted manipulation may be possible in patients with anorectal disorders.
Chronic anal fissure has traditionally been treated surgically. Initial enthusiasm for chemical sphincterotomy has waned because of poor outcomes with glyceryl trinitrate ointment. In this study the use of topical 2 per cent diltiazem ointment has been investigated as an alternative method of chemical sphincterotomy.
A prospective assessment of 71 consecutive patients with a chronic anal fissure treated with 2 per cent topical diltiazem ointment for a median duration of 9 (range 2--16) weeks was performed.
Fifty-one patients (75 per cent) experienced healing of the fissure after 2--3 months of treatment with topical diltiazem. Seventeen patients who did not heal were treated for a further 8 weeks with topical diltiazem. Eight of these patients subsequently healed with diltiazem. Fifty-nine of 67 patients who completed follow-up therefore healed on diltiazem ointment. Four patients experienced perianal dermatitis and one patient experienced headaches. No other side-effects were recorded. After a median of 32 (range 14--67) weeks' follow-up following completion of treatment, 27 of 41 patients available remain symptom free. Six of seven patients with recurrent fissure were treated successfully by repeat chemical sphincterotomy.
Topical 2 per cent diltiazem ointment used as an agent for chemical sphincterotomy for chronic anal fissure offers significant healing rates but does not have a significant side-effect profile, which may aid compliance to treatment. Early recurrences are common but usually amenable to further chemical sphincterotomy.