S1677 Topical Cannabidiol (CBD) for the Treatment of Anal Fissures: A Case Series

Abstract

INTRODUCTION: An anal fissure is defined as a longitudinal tear in the anal canal distal to the dentate line. It is a common benign condition that may be primary, resulting from local trauma, or secondary, stemming from an underlying disorder such as a malignancy, sexually transmitted infection, or inflammatory bowel disease. The primary symptom is anal pain particularly during defecation but may last for several hours. While the pathophysiology remains unclear, a mechanism of internal anal sphincter spasm, reduced perfusion and local ischemia has been proposed. Current first-line therapy involves a combination of a topical vasodilator therapy (nitroglycerin or calcium channel blockers) along with supportive measures such as a high fiber diet, sitz baths, local anesthesia, and stool softeners. Topical vasodilators are effective in 50% of cases but are often limited by side effects. The vasoactive properties of Cannabidiol (CBD) has been described in both human and animal models. CBD induced vasodilation has been shown in renal, mesenteric, opthalmic and cerebral arteries. The vasorelaxant properties of CBD have yet to be exploited in the management of anal fissures. We report five patients with anal fissures that were successfully treated with topical CBD. CASE DESCRIPTION/METHODS: Five consecutive patients who presented or were referred to a single Gastroenterology practice for an anal fissure were prescribed topical cannabidiol (1.4–2 mg/g) twice daily and supplemental fiber. One patient was female. Mean age was 49 (Range 31–63). Duration of symptoms was greater than 6 weeks in all patients. Each patient was asked to complete a modified HEMO-FISS QoL questionnaire to measure symptom improvement after two weeks of therapy. All patients reported a significant improvement in symptoms at follow-up. No side effects were reported. One patient later had a recurrence of symptoms that required treatment with Botulinum toxin injection. DISCUSSION: Cannabidiol has been shown to induce endothelium dependent vasorelaxation in human mesenteric arteries through activation of CB1 receptors. It is likely that the vasoactive properties of CBD reduce local ischemia and promote healing of chronic anal fissures. As far as we are aware, this is the first report showing a potential role for CBD in the management of acute and chronic anal fissures. Given the limited options for topical therapy and significant side effects, CBD provides an attractive alternative to conventional first line treatment. Further studies are warranted.