GTN Ointment Research Articles

Role of local antibiotics in the treatment of acute anal fissure.

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.

What is the optimum treatment of chronic anal fissure?

Aim: To compare the efficacy of topical Glyceryl trinitrate 0.2% (GTN) with Lateral internal spincterotomy (LIS) for treating chronic anal fissure (CAF). Methodology: A randomized control trial was carried out in the general surgery department, Lady reading hospital, LRH MTI, Peshawar (January 2018 to July 2018). All consecutive patients 18 to 60 year old presenting to OPD with a clinical diagnosis of chronic anal fissure were enrolled after informed consent. A total of 60 patients were enrolled. The patients were assigned two groups, including treatment group A (lateral internal spinterotomy) or treatment group B (use of Topical GTN ointment 0.2%). Results: Out of the 60 patients, 30 were enrolled into each group. The female had majority of 57% (group A) and 60% (group B). Mean duration regarding symptoms in group A was 1 year with SD ± 3.51 vs 1 year ± 2.98 in group B. Majority of patients in both groups were in the 20 to 40 years age group (74% in group A vs 83% in group B). Complete fissure healing and resolution of symptoms was observed in 27(91%) in group A vs 20(66%) in group B. Conclusion: In conclusion, we derive that lateral internal spincterotomy is more effectual than Topical Glyceryl trinitrate 0.2% for treating chronic anal fissure. Keywords: Chronic anal fissure, lateral internal spincterotomy, Glyceryltrinitrate

Study of clinical profile of acute and chronic fissure in ANO and its management

Introduction: Fissure in ANO is one of the most common ANO rectal problems. Anal fissure is a linear or oval shaped tear in the anal canal starting just below the dentate line extending to the anal verge. Aims: The present study aims at determining the clinical presentation, site, symptomatic relief, healing rate and best treatment modality of fissure in ANO. Materials and Methods: This study is observational study in patients with ANO rectal problems who were randomly selected in this study. The diagnosis was made on the basis of ANO rectal examination which included inspection, digital rectal examination, and proctoscopic examination. Results: Our study found out that out of the 50 patients with ANO rectal problems.50 patients (100%) were having anal fissures. Out of them, 30 were males and 20 were females, majority were 18-30 years age group. Pain during defecation, bleeding and constipation were reported as the common clinical symptoms. In this study we compare clinical presentation, site, symptomatic relief, healing rate of 0.2% GTN treatment, Manual anal dilatation and lateral internal sphincterotomy in the treatment of fissure in ANO. 20 patients were underwent lateral internal sphincterotomy and 20 underwent manual anal dilatation with 10 patients treated with 0.2% GTN ointment. We studies outcome of these each modality and compared them with different studies. Lateral internal sphincterotomy remains the gold standard for definitive management of anal fissure. Conclusion: Lateral internal sphincterotomy is one of the standard and best treatment modality for fissure in ANO.

Comparative study of Glyceryl Trinitrate ointment versus lateral internal sphincterotomy in management of Chronic anal fissure.

Objectives: To compare efficacy of topical 0.2% glyceryl trinitrate ointment with lateral internal sphincterotomy in treatment of patients with chronic anal fissure. Study Design: Randomized Control Trial. Setting: Department of General Surgery, DHQ Teaching Hospital, Sahiwal. Period: From 20 September 2016 to 31 December 2017. Material & Methods: A total number of 60 patients included in this study and divided into two groups GTN and LIS group through computer generated randomization method. Three main outcome variables were assessed in this study; pain relief, healing of fissure and recurrence. SPSS version was used to analyze data. P value ≤ 0.05 was considered as significant. Results: A total number of 60 patients included in this study. Relief of pain GTN and LIS was (95%) and (86.7%) respectively. Fissure healing GTN and LIS was noted as (88.3%) and (83.3%) respectively. Recurrence was not found in any patient of the present study. Relief of pain was statistically significant. Conclusion: Topical application of GTN ointment for relief of pain is safe and effective method for relief of chronic anal fissure but pain relief is slow. On other hand lateral internal sphincterotomy is first line treatment and treatment of choice for chronic anal fissure when performed by an experienced surgeon.

A proper application of chemotherapeutic agent at the site of anal fissure: a major concern in healing anal fissure

Background: To show the efficacy of chemotherapeutic agent by special emphasis on its proper application at the site of anal fissure.Methods: All patients were seen in outpatient department and were initially started with 0.2% Glyceryl trinitrate ointment along with sitz bath and psyllium fiber as a primary treatment while 2% diltiazem cream reserved for refractory cases. The follow up visits were made weekly for perianal pain relief and ulcer healing rate.Results: Results in terms of healing of anal fissure and perianal pain relief in 2 or 4 weeks duration were recorded in SPSS version 17. 0.2% GTN ointment showed 75% results in 2 weeks. While complete response was achieved in 95% cases in 4weeks. 2% diltiazem responded in 98% cases in 2 weeks. Non-compliant (2%) abandoned the medical treatment early in the course and proceeded for surgery where 99.99% results were seen in 2weeks only.Conclusions: Conservative treatment is the gold standard for managing anal fissure. Effective counseling of proper application of ointment at the site of anal fissure is emphasized, which is usually failed by the patient due to intense, excruciating peri anal pain and spasmodic sphincter contraction which led them to proceed to surgery.

Effectiveness of 0.2% Glyceryl trinitrate and 0.5% Nifedipine in the Treatment of Chronic Anal Fissure

Anal fissure is an ischemic ulcer caused by combination of spasm of internal anal sphincter and poor blood supply to the posterior midline of anal canal. This study aimed to assess the efficacy of Glyceryl Trinitrate and Nifedipine in the treatment of chronic anal fissure. Ninety patients with symptomatic anal fissure in Kathmandu Medical College Teaching Hospital are allocated for study in two groups of 45 each from March 2013 to April 2014. The patients are assigned alternatively to GTN group and Nifedipine group. All patients were assessed every week till 8 weeks in regards to headache, compliance, healing and recurrence. The patients who had complete healing in 8 weeks were further followed up for 6 weeks to detect recurrence. Patients in the two groups were comparable in regard to demographic data (age and sex) as well as clinical factors. Headache was main complaint of patients using GTN in high percentage (16.6%) than complained by patients using topical Nifedipine (6.9%). This factor led to poor compliance with GTN compared with Nifedipine. Nifedipine showed better healing rate 82.5% compared with GTN 60%. Recurrence was comparable among the two groups. Nifedipine ointment showed better results than GTN ointment in chronic anal fissure regarding headache, compliance, healing and recurrence in 6 weeks of follow up period after complete healing of fissure in 8 weeks.

Comparison of Fissure Healing and The Incidence of Headache Among the Patients Treated with Endo- and Perianal Application of 0.2% Glyceryl Trinitrate for Chronic Anal Fissure

Chronic anal fissure is associated with significant morbidity and reduction in quality of life mostly in young healthy adults. Glyceryl Trinitrate, a most commonly used agent for treatment, is associated with incidence of headache causing discontinuation of treatment. There is belief that endoanal application instead of perianal is associated with lower incidence of headache. This study is to compare the incidence and severity of headache in between perianal and endoanal application of GTN ointment. Thirty patients were taken in each perianal and endoanal group. They were given orientation to apply 375gm of ointment either endoanally or perianally and to record severity of headache according to visual analogue scale. This record was noted by independent observer in telephonic conversation. Patients were followed up at 6 weeks for evaluation fissure. The mean age, male female ratio and features of chronicity was similar in both the group however the duration of symptoms between the group was different. Regarding outcome, Overall incidence of headache was seen in two-third of patient with severe headache in approx. 10%. Severity of headache was slightly lower in endoanal group but the difference was not significant. Healing rate was comparable. Two patient in perianal and 3 in endoanal group were lost for follow up. Endoanal application of GTN ointment is associated with slight decrease in intensity of headache and is comparable with perianal application for fissure healing.

Morbidity associated with treatment of chronic anal fissure

To assess the effectiveness of different modes of treatment of chronic anal fissure as regards improvement of symptoms and complications. This prospective study included 129 consecutive patients with chronic anal fissures presented to the Surgical Outpatients' Department of Islam Teaching Hospital Sialkot, Pakistan; from September 2010 to November 2012. Patients were distributed in three groups. In "OBG group", patients had attended Gynae/Obs OPD and got treated and were then referred to surgical OPD for failure of treatment or recurrence. Patients who presented with history of treatment by GPs were included in "GP Group" "SGR Group" included those who directly reported to surgical OPD for treatment. Patients were managed both pharmacologically as OPD patients and surgically as admitted patients. Patients were instructed to apply small amounts of 0.2% GTN paste in soft white paraffin, to the anoderm with finger tips three times a day. Patients were evaluated at two-week intervals and at each visit the symptoms control, adverse effects and fissure status were recorded. If there was symptomatic relief or the fissure healing was in progress, the treatment was continued for a total duration of eight weeks. Operated patients were nursed in wards after surgery i.e Internal Anal Sphicterotomy. They were advised to report to OPD weekly for one month or earlier if they experienced any symptoms suggestive of complications. Patients were declared cured in case of complete symptomatic relief with fissure healing. Success, failure and associated problems were recorded and analysed to get results. This study included 129 patients who could be followed up for a minimum of three months. These patients were referred by gynaecologist i.e. 22 (17%) for treatment failure while 5 patients with wrong diagnosis were not included in statistical analysis; similarly 41 (32%) patients were referred by general practitioners and 9 patients with wrong diagnosis were excluded. Sixty six patients i.e. 51% were those who directly reported to surgical OPD and had no previous treatment. With surgical treatment, pain, bleeding per rectum and constipation showed significant improvement as compared to GTN ointment application. Fissure healing was 100% in surgical group as compared to 74% in medical group. Complications were recorded and were found to be headache with medical treatment; while the most feared complication with surgical treatment i.e. permanent incontinence was not encountered in our study. Topical glyceryl trinitrate is economical, has a good healing rate, and faecal incontinence has not been reported. Its effectiveness, however, depends on patients' compliance which may be poor in view of associated headaches and a local burning sensation. It is first line of treatment for anal fissure but lateral internal sphincterotomy is superior, more effective and curative than the chemical sphincterotomy. Surgery is reserved for people with anal fissure who have tried medical therapy for at least one to three months but failed.

A case of PSS applied with GTN ointment therapy

A case of PSS applied with GTN ointment therapy

ACUTE ANAL FISSURE

Objective: To evaluate the role of topical glyceryl trinitrate (0.2% GTN) on the clinical features of acute anal fissure. S t u dydesign a n d setting: A prospective, open label therapeutic trial was carried out at Combined Military Hospital, Kharian Cantonment during onecalendar year. Patients a n d M e t h o d s : All adult males and females presenting with acute anal fissure were included. Patients with chronic analfissure, associated pathology (hemorrhoids, fistula in ano), age < 15 years, previous surgery of anal canal were excluded. The diagnosis wasbased upon history and physical examination. A detailed history was taken regarding their symptoms like painful defecation, bleeding perrectum, constipation and itching. Then the patients were examined to look for anal fissure, associated mucus discharge and sphincter toneand recorded in the proforma. 0.2% topical GTN ointment was prescribed twice daily for local application in the anal canal with the help of cottonpledget on a stick (soaked completely in ointment). The duration of treatment was four weeks and their symptomatology and healing of analfissure was assessed weekly. Results: A total of 40 patients were treated in this study. Age varied between 22 - 51 years. 36 patients (90%)were male while only 4 patients (10%) were females. Painful defecation (100%), bleeding PR (87.5%), constipation (50%), and itching (40%)were the main complaints. Posterior fissure was seen in 85%, anterior fissure in 12.5%, while both anterior and posterior fissures were seenin 2.5% of patients. Out of 40 patients 21 had complete healing of anal fissure while 03 patients recovered partially. Thus the healing rate was60%.Conclusion: Topical glyceryl trinitrate is an effective treatment modality for acute anal fissure.

Topical 0.2% glyceryl trinitrate ointment for anal fissures: long-term efficacy in routine clinical practice.

OBJECTIVE: Randomized controlled trials have reported fissure healing rates of 60-70% using topical 0.2% GTN ointment, but the effectiveness of this therapy in routine clinical practice, particularly in the long term, is uncertain. This study aimed to evaluate the efficacy of topical GTN for anal fissures in an outpatient setting. PATIENTS AND METHODS: A case note review and postal questionnaire survey were undertaken for patients with a diagnosis of anal fissure dispensed 0.2% GTN ointment from one hospital pharmacy over a two year period (June 1996-May 1998). RESULTS: Ninety-three patients (53 male) applied 0.2% GTN ointment twice daily to the anoderm for anal fissure. They were reviewed on average 8 (2-16), weeks later, by which time 57 (61%) fissures had healed, 33 persisted and 3 patients were lost to follow up. Seventy-two patients (41male), median age 42 (22-83) years, returned completed questionnaires (77% response rate). Forty-nine (68%) had healed with GTN, but 25 had recurrent symptoms after a median of 6 (1-18) months. Sixteen of those patients reporting symptomatic recurrence were prescribed further GTN for a recurrent fissure: 14 (88%) healed, but 2 persisted, and had surgery. In the other nine patients symptoms resolved spontaneously. Thirty-five (49%) experienced headaches, 3 (4%) discontinuing treatment as a result. The median follow up was 25 (13-36) months. CONCLUSION: 0.2% GTN heals 60% of fissures in the outpatient setting but half the patients develop headaches. Up to one third of healed fissures may recur within 18 months but the majority respond to further GTN. Only 4% of patients initially healed with GTN later require sphincterotomy for recurrences.

Successful treatment of chronic anal fissure with diltiazem gel.

OBJECTIVE: Diltiazem is a calcium channel blocker that has shown potential to heal chronic anal fissures. We have prospectively evaluated the treatment of patients with anal fissure with diltiazem gel (SLA Pharma, UK). PATIENTS AND METHODS: All patients with chronic anal fissure from September 1999 to May 2000 were treated topically with 8 mg 2% diltiazem hydrochloride gel (equivalent to 2 cm of gel supplied by SLA Pharma) three times daily. The 23 patients (12 female), median age 45 (range 22-80) years had a 2-36 month (median 6 months) history of fissure. These were associated with a sentinel tag in 9 (39%) patients. RESULTS: The fissure healed in 11 (48%) of 23 patients, including 6 (75%) of 8 patients who previously failed to heal with GTN ointment. There were no recurrences at 3 months and no adverse effects. Of the 12 patients who did not respond to diltiazem, 4 have undergone sphincterotomy. CONCLUSION: Diltiazem gel has a healing rate similar to that observed with GTN ointment but there were no adverse effects, the recurrence rate was lower, and diltiazem was effective in 75% of patients previously treated unsuccessfully with GTN ointment.

ANAL FISSURE

Anal fissure is a common condition, and although most are short-lived and heal spontaneously, those that persist and require intervention cause considerable morbidity in an otherwise healthy young population. Traditionally, lateral internal sphincterotomy was the gold standard treatment for chronic fissures, but this procedure is associated with a risk of incontinence to some degree in 30% of patients. The discovery of pharmacologic agents that effectively cause a chemical sphincterotomy and heal most fissures has led to approximately two thirds of patients avoiding surgery. Topical 0.2% GTN ointment probably is the most widely used first-line treatment. Other drugs currently under investigation may offer effective treatment with fewer side effects. Another advantage of these novel treatments is that by acting through different pathways, they may be effective in the 30% of cases in which GTN fails, the risks associated with surgery may be avoided. Studies of botulinum toxin injection into the anal sphincter have reported excellent healing rates, although the procedure is more invasive, and patients may find it uncomfortable and less tolerable. Chemical sphincterotomy is particularly suitable in patients with associated inflammatory bowel disease, in whom sphincterotomy for anal fissure generally is contraindicated. When pharmacologic therapy fails or fissures recur frequently and patients have raised resting anal pressure, lateral internal sphincterotomy is the surgical treatment of choice. The results are satisfactory when patients are selected carefully and the incision is limited to the length of the fissure. When chemical sphincterotomy fails and resting anal pressures are not elevated, as is commonly the case with patients developing fissures postpartum, an advancement flap should be considered.

COMPARISON OF LATERAL INTERNAL PARTIAL SPHINCTEROTOMY AND TOPICAL USE OF GLYCERYLTRINITRATE OINTMENT (0.2%) IN THE MANAGEMENT OF CHRONIC ANAL FISSURE

OBJECTIVE: The objective of this study was to compare the results of surgical internalsphincterotomy with that of local 0.2% Glyceryltrinitrate ointment (chemical, sphincterotomy) in thetreatment of chronic anal fissure.STUDY DESIGN: This is a descriptive, comparative, prospective study.PLACE AND DURATION OF STUDY: The study was conducted in the Department Of SurgerySaidu Group of Teaching Hospital Saidu Sharif Swat from January 2011 to January 2014.PATIENTS AND METHODS: Total of one hundred and fortypatients between the age of 15 and 60years with chronic anal fissure were randomized in a prospective trial to receive either surgicalsphincterotomy or 0.2% Glyceryl trinitrate ointment locally. Patients were followed up at 2 weeks’interval for 14 weeks. Symptomatic relief, fissure healing and anal continence were the parameter forthe outcomes. Data was analyzed using SPSS version 16 employing chi-square test(X test). A p-valuebelow 0.05 was considered statistically significant.RESULTS: Surgical sphincterotomy was significantly more effective in providing pain relief and wasassociated with significantly better fissure healing at 6 weeks and 10 weeks, in all 66(100%)patients(both p<0.01). There were persistent problems with compliance in ointment group related to slowhealing ( 42(67.74%) patients} and longer time needed for symptomatic relief ( 50(80.64%) patients}.Minor incontinence was (4.54%) in sphincterotomy group and none inointment group (p>0.05).CONCLUSION: lateral partial internal sphincterotomy is an effective first line management for chronicanal fissure. This has excellent symptoms relief, a better healing response and low recurrence rates.KEYWORDS: Anal fissure, sphincterotomy, 0.2% GTN ointment