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Anal Fissure

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Jonathan N Lund – 1st expert on this subject based on the ideXlab platform

  • A review of chronic Anal Fissure management
    Techniques in Coloproctology, 2007
    Co-Authors: E. E. Collins, Jonathan N Lund

    Abstract:

    Anal Fissure management has rapidly progressed in the last 15 years as our understanding of Fissure pathophysiology has developed. All methods of treatment aim to reduce the Anal sphincter spasm associated with chronic Anal Fissures. Surgical techniques have been used for over 100 years with success. Lateral internal sphincterotomy remains the surgical treatment of choice for many practitioners. Postoperative impairment of continence remains controversial. Recently, less invasive methods of treatment have been explored. Topical nitrates, calcium channel blockers and botulinum toxin are established treatments. These and other non-surgical treatments are described in this review. Various guidelines and treatment algorithms for Anal Fissure are also discussed.

  • nitric oxide deficiency in the internal Anal sphincter of patients with chronic Anal Fissure
    International Journal of Colorectal Disease, 2006
    Co-Authors: Jonathan N Lund

    Abstract:

    Anal Fissure is a common condition affecting young to middle-aged adults. It causes severe pain on defecation and rectal bleeding. The aetiology remains uncertain. Spasm of the internal Anal sphincter is a constant feature. Nitric oxide (NO) is the major inhibitory neurotransmitter of the internal Anal sphincter (IAS). In other spasmodic conditions of the GI tract a lack of normal nitric oxide synthase (NOS) activity has been reported. The aim of this preliminary study was to compare the presence of NOS in the internal sphincters of patients with and without chronic Anal Fissure. Internal Anal sphincter biopsies were taken under general anaesthesia from patients having lateral internal sphincterotomy for chronic Anal Fissure and from sphincter of patients having abdominoperineal resections as controls. Sections of IAS were stained to show the presence of NADPH diaphorase (and hence presence of NOS). Internal Anal sphincter was taken from 6 patients with chronic Anal Fissure and 6 controls. IAS taken from patients with chronic Anal Fissure showed little NOS presence compared with controls. It may be that there is an abnormal failure of relaxation of internal sphincter in those patients who develop chronic Anal Fissure caused by an intrinsic lack of neural NOS in the internal Anal sphincter.

  • an evidence based treatment algorithm for Anal Fissure
    Techniques in Coloproctology, 2006
    Co-Authors: Jonathan N Lund, Perolof Nystrom, Georges Coremans, A Herold, I Karaitianos, M Spyrou, W R Schouten, A A Sebastian, Mario Pescatori

    Abstract:

    Guidelines for the treatment of Anal Fissure have been published in the USA and UK but differ. Many centers follow guidelines based on local experience. In December 2005, we met with the aim of developing an evidence-based treatment algorithm for Anal Fissure, applicable to both primary and secondary care. This algorithm may rationalize the treatment of Anal Fissure in primary and secondary care settings.

John H. Scholefield – 2nd expert on this subject based on the ideXlab platform

  • glyceryl trinitrate is an effective treatment for Anal Fissure
    Diseases of The Colon & Rectum, 1997
    Co-Authors: Jonathan N Lund, John H. Scholefield

    Abstract:

    PURPOSE: 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. METHODS: 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. RESULTS: 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; pairedt-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. CONCLUSIONS: 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.

  • Glyceryl trinitrate is an effective treatment for Anal Fissure
    Diseases of The Colon & Rectum, 1997
    Co-Authors: Jonathan N Lund, John H. Scholefield

    Abstract:

    PURPOSE: 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. METHODS: 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. RESULTS: 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

  • use of glyceryl trinitrate ointment in the treatment of Anal Fissure
    British Journal of Surgery, 1996
    Co-Authors: Jonathan N Lund, N. C. Armitage, John H. Scholefield

    Abstract:

    Anal Fissure is often treated surgically by sphincterotomy. There is growing concern over the effects of this procedure on continence. Nitric oxide donors such as glyceryl trinitrate are thought to cause a reversible ‘chemical sphincterotomy’, capable of healing the Fissure. Twenty-one consecutive patients with chronic Anal Fissure (13 women, mean age 36 years) were treated for 4–6 weeks with 0·2 per cent glyceryl trinitrate ointment applied to the Fissure twice daily. Maximum Anal resting pressure (MARP) was measured before and after application of the ointment at the first visit. There were 16 posterior and five anterior Fissures. Mean(s.d.) MARP fell from 118·7(45·0) to 70·3(34·1) cmH2O over 20 min after application of the ointment (P<0·001). Healing was complete in 11 patients at 4 weeks and in 18 at 6 weeks. The Fissure recurred in four patients after cessation of treatment; three were successfully treated by further glyceryl trinitrate. Mild headache occurred in four patients. Anal Fissure can be successfully treated with 0·2 per cent glyceryl trinitrate ointment applied topically.

Richard L. Nelson – 3rd expert on this subject based on the ideXlab platform

  • non surgical therapy for Anal Fissure
    Cochrane Database of Systematic Reviews, 2012
    Co-Authors: Richard L. Nelson, Kathryn Thomas, Jenna Morgan, Abigail Jones

    Abstract:

    Background
    Because of the disability associated with surgery for Anal Fissure and the risk of incontinence, medical alternatives for surgery have been sought. Most recently, pharmacologic methods that relax the Anal smooth muscle, to accomplish reversibly what occurs in surgery, have been used to obtain Fissure healing.

    Objectives
    To assess the efficacy and morbidity of various medical therapies for Anal Fissure.

    Search methods
    Search terms include “Anal Fissure randomized”. Timing from 1966 to August 2010. Further details of the search below.

    Selection criteria
    Studies in which participants were randomized to a non-surgical therapy for Anal Fissure. Comparison groups may include an operative procedure, an alternate medical therapy or placebo. Chronic Fissure, acute Fissure and Fissure in children are included in the review. Atypical Fissures associated with inflammatory bowel disease or cancer or Anal infection are excluded.

    Data collection and Analysis
    Data were abstracted from published reports and meeting abstracts, assessing method of randomization, blinding, “intention to treat” and drop-outs, therapies, supportive measures (applied to both groups), dosing and frequency and cross-overs. Dichotomous outcome measures included Non-healing of the Fissure (a combination of persistence and recurrence), and Adverse events (including incontinence, headache, infection, anaphylaxis). Continuous outcome measures included measures of pain relief and anorectal manometry.

    Main results
    In this update 23 studies including 1236 participants is added to the 54 studies and 3904 participants in the 2008 publication, however 2 studies were from the last version reclassified as un included, so the final number of participants is 5031.

    49 different comparisons of the ability of medical therapies to heal Anal Fissure have been reported in 75 RCTs. Seventeen agents were used (nitroglycerin ointment (GTN), isosorbide mono & dinitrate, Botulinum toxin (Botox), diltiazem, nifedipine (Calcium channel blockers or CCBs), hydrocortisone, lignocaine, bran, minoxidil, indoramin, clove oil, L-arginine, sitz baths, sildenafil, “healer cream” and placebo) as well as Sitz baths, Anal dilators and surgical sphincterotomy.
    GTN was found to be marginally but significantly better than placebo in healing Anal Fissure (48.9% vs. 35.5%, p < 0.0009), but late recurrence of Fissure was common, in the range of 50% of those initially cured. Botox and CCBs were equivalent to GTN in efficacy with fewer adverse events. No medical therapy came close to the efficacy of surgical sphincterotomy, though none of the medical therapies in these RCTs were associated with the risk of incontinence.

    Authors’ conclusions
    Medical therapy for chronic Anal Fissure, currently consisting of topical glyceryl trinitrate, botulinum toxin injection or the topical calcium channel blockers nifedipine or diltiazem in acute and chronic Fissure and Fissure in children may be applied with a chance of cure that is marginally better than placebo. For chronic Fissure in adults all medical therapies are far less effective than surgery. A few of the newer agents investigated show promise based only upon single studies (clove oil, sildenifil and a “healer cream”) but lack comparison to more established medications.

  • Medical Therapy for Anal Fissure: Past, Present, and Future
    Seminars in Colon and Rectal Surgery, 2006
    Co-Authors: Richard L. Nelson

    Abstract:

    Medical therapy for Anal Fissure is designed to relax the internal Anal sphincter, much as is done by sphincterotomy, but reversibly, and thus avoiding long standing minor incontinence. The effectiveness and future of this approach is assessed. Publications were sought in Medline using the search terms: Anal Fissure randomized, and all articles screened for inclusion. Randomized controlled trials that had at least one arm involving medical therapy for Anal Fissure were chosen, as were systematic Cochrane reviews of these articles and the quantitative assessment of therapeutic effectiveness reported. In addition, the newer therapies being developed are listed, most of which have not yet been subjected to randomized trials, so their effectiveness is unknown. Lastly, the major problems still facing medical therapy for Anal Fissure are listed in hope that trials will be conducted that will specifically address these questions. Currently medical therapy for Anal Fissure is effective in achieving long term cure, whether glyceryl trinitrate ointment, botulinum toxin injection, or calcium channel blockers given orally or topically, but only marginally so. They are far less effective than surgery.

  • a systematic review of medical therapy for Anal Fissure
    Diseases of The Colon & Rectum, 2004
    Co-Authors: Richard L. Nelson

    Abstract:

    Purpose: This is a meta-Analysis of randomized, controlled trials to assess the efficacy and morbidity of medical therapies for Anal Fissure. Methods: Medline and the Cochrane Controlled Trials Register and the Cochrane Colorectal Cancer Review Groups Controlled Trials Register were searched using the terms “Anal Fissure randomized” from 1966 to 2002. Studies in which participants were randomized to a nonsurgical therapy for Anal Fissure were the focus of this review. Comparison groups included an operative procedure, an alternate medical therapy, or placebo. Chronic Fissure, acute Fissure, and Fissure in children were included in the review, however, atypical Fissure associated with inflammatory bowel disease, cancer, or Anal infection were excluded. Data were abstracted from published reports and meeting abstracts, assessing method of randomization, blinding, “intention to treat” and dropouts, therapies, supportive measures, dosing and frequency, and crossovers. Outcome measures included nonhealing of the Fissure and adverse events. Results: Twenty one different comparisons of medical therapies to heal Anal Fissure have been reported in 31 trials, including 9 agents—glyceryl trinitrate, isosorbide dinitrate, botulinum toxin, diltiazem, nifedipine, hydrocortisone, lidocaine, bran, placebo—as well as Anal dilators and surgical sphincterotomy. Glyceryl trinitrate was favored in the Analysis over placebo (odds ratio =0.55, 95 percent confidence interval, 0.41–0.74). After excluding two studies from Analysis because of placebo response rates < 2 standard deviations below the mean for all studies, the advantage of glyceryl trinitrate over placebo was no longer statistically significant (odds ratio = 0.78; 95 percent confidence interval, 0.56–1.08). Nifedipine and diltiazem did not differ from glyceryl trinitrate in their ability to cure Fissure (0.66; 0.22–2.01). Botulinum toxin compared with placebo showed no significant efficacy (0.75; 0.32–1.77), and was also no better than glyceryl trinitrate (0.48; 0.21–1.10). Surgery was more effective than medical therapy in curing Fissure (0.12; 0.07–0.22). Conclusions: Medical therapy for chronic Anal Fissure, acute Fissure, and Fissure in children may be applied with a chance of cure that is only marginally better than placebo, and for chronic Fissure, far less effective than surgery.