Summing it up - fissure treatments

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Summing it up - fissure treatments

Postby Fissulyna » 28 May 2008, 00:44

Evaluation
The diagnosis of anal fissure is often made on the basis of the
patient's medical history. Several anorectal disorders can present
with severe anal pain; anal fissure is the most common cause of pain
with or after defecation (Table 1). Anal examination can confirm the
diagnosis at the initial visit but is often limited by the patient's
discomfort. The patient is usually examined in the prone position. A
gentle spreading of the buttocks can reveal the fissure in some
patients. If the patient is too apprehensive and in much discomfort,
the examination should be aborted. The patient is treated for the
presumed diagnosis of anal fissure and a complete examination is
deferred to the next visit, usually three or four weeks later. If
the fissure is not visualized, lidocaine 2% jelly is used to locally
anesthetize the anal opening so that a gentle digital examination
can be attempted. Anal spasm is often present. Posterior or anterior
midline tenderness can be elicited with gentle palpation. If the
patient tolerates the digital examination, then anoscopy can be
performed. In addition to direct visualization of the fissure, the
clinician may note a sentinel pile or tag just distal to the fissure
and a hypertrophied anal papilla just proximal to it (Figure 1). The
exposed white fibers of the internal sphincter muscle can be seen in
the center of chronic fissures. The clinician should be ready to
abort the examination at any time if the patient has severe pain.
Under such circumstance, carrying out the examination causes
needless suffering and often cannot be completed despite the
perseverance of the examiner. If there are findings suspicious for
other disorders, such as draining pus from anal opening, swelling
and erythema of the perianal area, or a mass, then the patient
should undergo an examination under anesthesia.
It is important to note that benign fissures are located in the
posterior or anterior midline. Fissures located in the lateral
quadrants are referred to as atypical fissures or ulcers and are
often secondary to other conditions (Table 2). Atypical fissures can
be multiple, deep, wide; have irregular margins; and may present
with purulent drainage from the anus. Atypical fissures warrant a
complete medical workup and often require an examination under
anesthesia, with biopsies and cultures.
Treatment Options
More than 90% of fissures heal spontaneously. Symptomatic fissures
warrant treatment. Conservative management is the first line of
therapy. Increasing dietary fiber and water intake should be coupled
with fiber supplementation. Psyllium-based products are our
preferred fiber supplement. For patients who cannot tolerate
psyllium because of excess gas or bloating, other fiber products are
available (Table 3). Ideally the adult diet should contain 25 to 35
g of fiber daily (Table 4). In addition to increasing dietary fiber,
patients should begin fiber supplementation once a day (ie, 6 g
psyllium), and if that is tolerated, their dosage should be
increased to twice a day within a week. Patients should drink at
least two glasses of water or fluids each time they take a fiber
supplement dose. A laxative, such as two tablespoons milk of
magnesia once or twice a day, is added for patients with persistent
constipation despite increased fiber intake. Stool softeners such as
docusate can also be added to the fiber regimen. A sitz bath in warm
water once or twice a day for ten minutes may offer some relief.
Lidocaine 2% jelly is prescribed to reduce pain as needed before and
after bowel movements. Steroid-based creams and hemorrhoidal
ointments are usually not effective. Ointments such as nitroglycerin
0.2% to 0.3%, diltiazem 2%, and nifedipine 0.03% can heal
symptomatic fissures; their reported success rate is between 30% and
70%.2-4,7-11 Most of these medications must be compounded as an
ointment preparation by a pharmacy. Gel or liquid preparations are
not as effective because of a shorter duration of action.
Furthermore, they are cumbersome to use and do not adhere to the
anal area as well as ointments do. Diltiazem 2%, applied three times
daily and five minutes prior to a bowel movement, is our ointment of
choice and has a higher rate of fissure healing than nitroglycerin
does and can heal fissures that have been unsuccessfully treated
with nitroglycerin.10 Headache is a common side effect with
nitroglycerin, experienced by up to 50% of patients.8 About 10% of
patients using diltiazem ointment will experience itching.10
Patients should wear a glove or a finger cot to apply the
medication. The relaxation of sphincter tone induced by diltiazem,
nitroglycerin, and nifedipine can relieve the pain within a few
days, but complete healing may take up to two months. Patients
should be reassessed at one month; if there is persistent fissure
but decreased symptoms, the ointment should be continued for another
month.
Patients in whom medical therapy fails may be candidates for
surgical intervention. The timing of intervention depends on the
initial response to conservative therapy and on symptom severity.
Patients with severe anal pain can be offered surgical intervention
if no improvement is seen within a week. Injection of botulinum
toxin type A into the internal sphincter can lead to symptomatic
relief and healing of some fissures. Overall, it is safe and rarely
causes any degree of incontinence. The paralysis that it causes
occurs within hours of injection, reaches its peak within a week,
and can last between one and three months.8 However, in many
patients the relief is temporary and long-term fissure recurrence is
common, often making additional injections necessary.8 Furthermore,
botulinum is expensive; the cost of 100 units is $558 at our
institution. Because of these reasons, we do not offer injection as
a sole treatment. However, for a subgroup of patients with fissures
refractory to medical therapy who are at risk of incontinence or are
reluctant to undergo the gold standard surgical treatment of lateral
internal sphincterotomy (LIS), we have combined injection of
botulinum with fissurectomy. Debridement of the fibrotic edges of a
chronic fissure can stimulate healing when combined with
fissurectomy.11 Typically we inject 60 to 80 units of botulinum
toxin type A into the internal sphincter muscle; we have seen
complete fissure resolution in many patients.
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Re: Summing it up - fissure treatments

Postby Guest » 28 May 2008, 03:33

Many thanks for posting this Fiss
x
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Re: Summing it up - fissure treatments

Postby cherylk » 28 May 2008, 06:12

Great article, Fiss! We might not get healed from our fissures, but we are becoming quite knowledgeable about them!! I took two Citrucel tabs last night and think it might have been helpful. I am not sure what a psyllium supplement would be.
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Re: Summing it up - fissure treatments

Postby Guest » 28 May 2008, 06:29

Great article! Thanks for posting.
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Re: Summing it up - fissure treatments

Postby Fissulyna » 28 May 2008, 14:21

Lecia - you look soo cute today !!! xoxo
Cheryl - Psyllium is Metamucil : )
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Re: Summing it up - fissure treatments

Postby cherylk » 28 May 2008, 14:26

Right! I bought Walgreen's brand of Metamucil this morning and realize that is psyllium.
Thanks,
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Re: Summing it up - fissure treatments

Postby Guest » 29 May 2008, 06:40

Psyllium worked wonders for me for fissure no1.
Just be sure to gradually increase the dose, opposed to starting off on the required dose !
Good luck ! please let me know how you get on
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