Therapy and long-term outcomes of acute anal fissure: a high-volume referral centre experience with 623 patients.

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anal Fissures.

Until know surgical intervention considered to be the cornerstone for treatment of anal fissure condition. Regarding all the circumstances that hinder the possibility of accomplishment of surgical operation and the possible post-urgical complications; all that motivates the necessity for a non-surgical procedure for treatment of anal fissure. This study was designed to establish a pharmaceutically active and chemically and physically stable formula of 0.4% (w/w) glyceryl trinitrate ointment. High Performance Liquid Chromatography (HPLC) was used to assay the active ingredient and to determine the rate of release of glyceryl trinitrate from the prepared ointment base. After establishing the formula, the prepared ointment was clinically tested on selected patients under supervision of specialized surgeons. After 3 months monitoring of a small scale pilot batch of 0.4% glyceryl trinitrate ointment and depending on Accelerated stability method, a physically and chemically stable formula was achieved with an unaltered pH and with a release rate value range between 83.4-85.1%. Up to 6 months of clinical follow up shows a variation in responses from complete healing to moderate relief of symptoms. Glyceryl trinitrate shows a high rate of healing for both acute and chronic anal fissures with tolerable side effect. A significant rate of pain relief and a high rate of complete healing lead to a conclusion of effectiveness of glyceryl trinitrate as a non-surgical treatment of both chronic and acute anal fissure.

Objective: 1) To evaluate the effectiveness of topical 0.2% Glyceryl Trinitrate (GTN) ointment in symptomatic relief and healing of anal fissure 2) To establish the role of GTN as a first line treatment for both acute and chronic anal fissure. 3) To elaborate the safety profile of GTN with respect to its side effects. Design: Prospective, randomized case control study. Place of studs: Surgical unit II, Jinnah Hospital, Lahore. Duration of Study: I year from 1-2-2005 to 31-2-2006. Materials and Methods: Fifty patients of all ages and either sex with a clinical diagnosis of fissure in ano (both acute and chronic) were included in the study. Patients were randomly divided into two groups. The treatment group (Group-A) was advised 0.2% GTN ointment whereas the control group (Group-B) was prescribed a local anesthetic ointment (Lignocaine Compound® Knoll). Both groups applied the given drugs twice daily for a period of 8 weeks and follow-up at the end of first, second and eighth week was carried out. A long-term follow-up at the end of 6 months was undertaken to look for any recurrence of the disease. Results: 18 patients out of 50 patients presented with acute anal fissure while 32 presented with chronic anal fissure.77% of patients with acute fissure in Group A showed fissure healing while 44% of patients with acute fissure were benefited in Group B. When the failures of group B were subjected to GTN, 80% of the patients showed healing of their fissures. 81% of patients suffering from chronic anal fissure were cured in Group A while 25% of patients showed improvement in Group B. Non benefited patients in group B when subjected to GTN, 66% showed fissure healing. Recurrence vas seen in 8 patients in group A (24%) and 3 patients in group (38%) at long term follow-up. Conclusion: Anal fissure is a common general surgical problem associated with severe anal pain. Regarding conservative treatment, the advent of GTN is a healing hope for patients with anal fissure. It has revolutionized the non-surgical treatment, as it is effective, safe and economical in terms of cure of both acute and chronic anal fissures.

Background: Acute anal fissure is a painful conditioncommonly results due to an increase in internal anal sphincterpressure. It is a painful condition which leads to significantmorbidity mostly in young adults. It is a split in the mucosaof the distal anal canal that can progress to form a chroniclinear ulcer. The common symptoms are severe pain on orafter defecation and bleeding per anus.Aim of Study: The main aim of this study is to evaluatethe efficacy and adverse effects of topical 2% Diltiazem (Calcium channel blocker) and topical 0.2% Glyceryl trinitrate (GTN), when administered as single agents in the treatmentof acute anal fissure.Patients and Methods: 40 Patients with acute anal fissurewere enrolled in the study. They were randomized using aclosed envelop technique into two group (20 patients each):Group A (2% Diltiazem users), and Group B (0.2% Glyceryltrinitrate users). Pain was evaluated using a pain Visual AnalogScale (VAS), we also evaluated the anal bleeding, constipation,perianal itching (anal pruritus) before, during and after thetopical medications are used, and the results of each topicalmedications as healing, recurrence rates, onset of relief ofsymptoms, onset required to achieve complete healing, numberand severity of side effects as (headache, postural hypotension,flushing, allergy, GIT upset) or ineffectiveness.Results: Both 0.2% glyceryl trinitrate ointment and 2%diltiazem ointment are equally effective concerning pain relief,and recurrence rates, while higher healing rates with topicalDiltiazem (DTZ) than topical Glyceryl Trinitrate (GTN) wererecorded (85% compared to 75% respectively). However,headache is a troublesome side effect with topical glyceryltrinitrate. Accordingly, topical 2% diltiazem is preferable asthe treatment of choice for acute anal fissure.Conclusion: Although surgical management like analdilatation and open or closed sphincterotomy are a one-timesolution with good symptomatic relief, it may be complicated by complications of wound healing, and permanent incontinence of flatus or faeces. The preferable treatment of acute anal fissure is becoming more medical since it is cost-effective. Both 0.2% glyceryl trinitrate ointment and 2% diltiazem ointment are equally effective in concerning pain relief, healing and recurrence rates. However, headache is a troublesome side effect in patients treated with topical glyceryl trinitrate.Therefore, when considering medical management for treatingacute anal fissure, topical 2% diltiazem is the treatment ofchoice.

Background: The aim of the study was to choose best method for the management of acute fissure-in-ano, by comparing among zinc oxide cream and lidocaine ointment and conversion of acute fissure into chronic fissure-in-ano. Aims and Objectives: The aim of the study was to compare the effect of zinc oxide cream and lidocaine ointment in acute fissure and conversion of acute fissure into chronic fissure-in-ano requiring surgery. Materials and Methods: Two hundred patients who were diagnosed with acute anal fissure between November 2021 and November 2022 at MGM Medical College and M. Y. Hospital were undertaken for this prospective randomized trial. All cases randomized into two groups. Group 1 where the patients of acute anal fissure who applied 15% of zinc oxide cream twice a day. Group 2 where the patients would apply 5% of lidocaine ointment twice a day. Healing rates, pain relief, recurrences, changes in symptoms after the treatment, and complications were recorded. Results: There was no statistical difference among groups in terms of age and gender. The healing and symptomatic relief with the conservative method for acute anal fissure was significantly much more. Recurrence rate was very less in symptomatic group. There was a significant reduction in conversion of acute anal fissure into chronic anal fissure with the use of conservative management. Conclusion: Conservative management is better treatment option for acute fissure-in-ano with reduced conversion into chronic fissure-in-ano.

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

IntroductionAnal 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 methodsThis 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.ResultsAnal 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.ConclusionAdding 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.

Objective – to evaluate the clinical efficacy of a personalized treatment algorithm for acute anal fissures based on a fissure chronicity risk scale compared with standard symptomatic therapy. Materials and methods. This prospective non-randomized comparative study included 175 patients with acute anal fissure treated at the proctology department of Kyiv City Clinical Hospital № 18 between 2021 and 2024. The mean patient age was 39.29±12.98 years. The study group received individualized treatment based on chronicity risk assessment, while the control group received standard symptomatic treatment. Efficacy was assessed by the rate of complete healing at week 4, pain dynamics on the VAS scale, and the incidence of chronicity. Results. The personalized treatment protocol resulted in a higher rate of complete healing compared to standard therapy (81.63% versus 41.56%, p < 0.001). The incidence of chronicity of anal fissures was lower in the study group (4.08%) than in the control group (23.38%). Patients in the study group achieved pain reduction of more than 50% faster than those in the control group (6.1±2.3 versus 12.8±3.5 days). Side effects were observed in both groups, including local redness (11% and 14%), temporary incontinence (7% and 0%), and headache (0% and 3%). Conclusions. The personalized protocol for managing acute anal fissures shows higher efficacy and significantly improved clinical outcomes compared to standard conservative therapy. Implementation of this approach in clinical practice accelerates healing, reduces chronicity rates, and lowers early recurrence. Therefore, adoption of the proposed protocol is recommended.

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.

Background and objective An anal fissureis 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.

Background : In our institution, the first line treatment in acute anal fissures (AAF) or chronic anal fissures (CAF) is the injection of a sclerosing agent consisting of phenol, menthol and peanut oil (Phenomen®, Sterop laboratory, Belgium) under the fissure after a local anaesthesia. This retrospective study presents the technique of injection, evaluates its efficacy and demonstrates the minimal occurrence of complications, continence problems and recurrences. Methods : 129 patients with an anal fissure were treated between January 2010 and June 2011. 124 patients were reviewed retrospectively. 109 patients benefited from a sclerosis in our outpatient clinic. Results : Of the 109 patients treated by a sclerosis, 58 had an AAF and 51 had a CAF. 53/58 AAF (91.4%) healed and 40/51 CAF (78.4%). Duration of pain after injection was 2 days or less in 55 cases (50.4%), 1 week or less in 35 cases (32.2%) and more than 1 week in 19 cases (17.4%). The complication rate was low (2.7%): 2 necrosis of the skin and 1 abscess at the site of injection. The rate of troubles of continence was 2.7%: 2 cases of soiling and 1 case of incontinence for gas all resolving within a month. At the end of the study, a fissure had recurred in 17 patients (15.6%). Conclusions : The injection of a sclerosing agent under the fissure is performed in the practitioner’s office. Healing rates are high, complications and recurrences are low. This therapeutic option may be a good alternative to classical treatments in case of anal fissures.

Long-term Angiographic and Clinical Outcomes in Completely Versus Incompletely Coiled Ruptured Intracranial Aneurysms

Objective: To evaluate the efficacy of 0.2% glyceryl trinitrate (GTN) paste as first line treatment in acute anal fissure with no severe side effects. Study Design: Randomized control trial.Place and Duration of Study: Combined Military Hospital Kharian and Combined Military Hospital MalirPakistan from January 2008 to August 2010.Patients and Methods: Patients presenting with acute anal fissure were randomized in 2 groups by using computer generated table. Group A received 0.2% GTN paste and group B received lignocaine gel twice daily in addition to high fiber diet, sitz bath and stool softeners. Pain scores on 100 mm Visual Analogue Scale, healing of fissure and side effects (headache and flatus incontinence) were noted at 0,2,4,6 and 8 weeks. Evolution to chronic anal fissure and recurrence rates (3 and 6 months) was also noted. Data was entered on SPSS 16.0 and p value was calculated. Results: Out of 161 patients, 109 patients (56 in group A and 53 in group B) completed the study. Demographical data was comparable in both the groups. Results were statistically significant (p &lt;0.05 or less) in terms of complete healing of fissure and pain relief at each visit. Patient in group A had less recurrence Conclusion: Use of 0.2% GTN as first line treatment in acute anal fissure showed better pain relief fastened healing, less rec

Aim of the study: To assess the clinical efficacy of 0.2% glyceryl trinitrate ointment in the management of acute and chronic anal fissures. Patients and Methods: A prospective clinical study conducted on consecutive patients presented to the surgical clinic of Erbil teaching Hospital, Erbil city with acute and chronic anal fissures, from June 2009 till August 2012.These patients were treated with topical 0.2% glyceryl trinitrate (GTN) paste in soft white paraffin three times a day. Patients were examined at regu- lar intervals to evaluate the fissure status, adverse reactions, symptomatic control and recurrence. One hundred and fifty nine patients with acute and chronic anal fissures were evaluated in the study. Fifty one of them were lost to follow-up and 108 were remaining (94.7%)Results: At the end of complete course (6-8 weeks), pain was completely relieved in 80.9 % and partially better in 7.4%, bleeding was absent in 83.7%, anal tone became normal in 80%, and in 80.3 % had heal-ing. The course was completed or taken for longer duration in patients 62.9%. GTN was stopped before end of the course in 40 patients (37%) due to differ-ent causes, side effects mainly headache 60 %, non compliance 95%, or no response at all 50%.

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. 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. 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). 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.