Utility of Ultrasound in the Evaluation of Chronic Anal Fissure

Introduction: Anal fissure is a linear tear in the anal mucosa seen distal to the dentate line. The diagnosis of chronic anal fissure depends on clinical history, physical exam, anoscopy and other imaging modalities are uncommonly recommended unless an associated condition was suspected. Management is either by chemical sphincterotomy or surgery through lateral internal sphincterotomy when chronic anal fissure was resistant to treatment. Purpose of the Study: The current study aimed to evaluate the sonographic findings that can be observed in cases with chronic anal fissure and their significance. Methodology: 15 asymptomatic patients and 30 patients with chronic anal fissure were examined with 3 dimensional transperineal ultrasound and if females an additional transvaginal ultrasound was performed. Results: 26 patients (86.5%) showed diffusely thickened internal anal sphincter of mean thickness >3.5mm, ranging from 3.7 mm to 6.4mm and the mean value was 5mm. 3 patients (10%) with posterior fissure showed a lucent narrow defect in the internal anal sphincter at the midline of the distal aspect of the anal canal wall. One of them showed associated localized intersphincteric plane sepsis. Conclusion: Use of ultrasound in cases with chronic anal fissure may show gapping of the internal anal sphincter and an associated intersphincteric plane sepsis corresponding to the high morphological grade of anal fissure which predict poor healing response to chemical sphincterotomy and further studies that correlate between the thickness and texture of IAS and the healing response to chemical sphincterotomy recommended.

Evaluation of clinical effectiveness of topical 0.2% glyceryl trinitrate, topical 2% diltiazem and their combination in the treatment of chronic anal fissure

Background: The longitudinal tear or defect in the epithelial lining of the anal canal distal to the dentate line is called anal fissure. It is of two types: acute and chronic. The break in the cycle of pain, spasm and ischemia is essential for successful treatment of anal fissure. Among multiple non-surgical treatment approaches, the appropriate approach with good patient compliance might be the use of topical agents as chemical sphincterotomy. However, the effectiveness of these agents has not been evaluated widely. Objectives: To evaluate clinical effectiveness of topical 0.2% glyceryl trinitrate, topical 2% diltiazem and their combination in the treatment of chronic anal fissure. Methodology: The study was prospective comparative type including total 158 patients. Initially, they were given first line therapy followed by chemical sphincterotomy agents. The study drugs were given to 84 patients (three groups - 0.2% glyceryl trinitrate, 2% diltiazem and their combination) who were not healed after initial therapy. Patients were assessed for pain using visual analogue scale and other symptoms prior to and after two and six weeks of therapy. Results: Complete healing rate was higher with combination (92.86%) than individual agents. The reduction of visual analog scale score within each group and between the groups in the period between before and after treatment was found to be statistically significant. Headache and hypotension were the common side effects seen during study. Conclusion: Anal fissures can be successfully managed by chemical sphincterotomy. The topical nitrates and calcium channel blockers in combination are found to be effective choice rather than individual agents.

Topical diltiazem versus topical glyceryl trinitrate in the treatment of chronic anal fissure: a prospective comparative study

Background: Acute anal fissure (AAF) heals spontaneously with conservative line of treatment. Chronic anal fissure (CAF) needs either traditional surgical lateral sphicterotomy or chemical sphincterotomy with topical agents. The present study aims at the effectiveness of topical diltiazem (DTZ) cream over topical glyceryl trinitrate (GTN) ointment in the treatment of chronic anal fissure.Methods: A total of 100 patients with CAF were included in this comparative prospective study conducted in Rajarajeswari Medical College and Hospital Bengaluru from July 2017 to December 2018. Eligible patients were randomly assigned to one of the two treatment groups of 50 patients each and were advised to apply 2% DTZ cream or 0.2% GTN ointment by fingertip to the anal verge twice daily for 8 weeks. The results were analysed and compared on two weekly intervals to know the effectiveness of treatment. P value of <0.05 is considered to be significant.Results: Complete healing of the fissure occurred in 80% of the patients in DTZ group against 76% in the GTN group by the end of 6 weeks (p>0.05, statistically not significant). Mild headache was experienced by 14% of the patients in the DTZ group, while 46% of the cases in the GTN group reported about the same (p<0.05 statistically significant).Conclusions: Topical 2% DTZ appeared to be well tolerated and effective preferred first-line method of chemical sphincterotomy with less side effects for chronic anal fissure.

Efficacy of chemical sphincterotomy with 2% diltiazem cream vs. surgical sphincterotomy in the management of chronic fissure in ano: a clinical study

Background: Surgical intervention like lateral internal sphincterotomy is very effective and in a time of few weeks, healing can occur but there is danger of the anal incontinence. Hence alternative methods were sought like 2% diltiazem and other agents and they have been shown to lead to proper healing without anal incontinence. The objective was to study efficacy of chemical sphincterotomy with 2% diltiazem cream vs. surgical sphincterotomy in the management of chronic fissure in ano.Methods: A hospital based follow up study was carried out among 60 patients with chronic fissure in ano. They were randomly assigned in two groups. Group I consisted 30 patients who were treated with 2% diltiazem cream on outpatient basis. Group II patients i.e. 30 patients were operated for sphincterotomy. Both the group patients were followed for six weeks at two weeks interval. Outcome like complete healing, fecal incontinence, flatus incontinence was seen at follow up. Chi square test and t test were used to determine the significant difference between the groups.Results: Both the groups were comparable to each other in terms of age, sex, presenting symptoms, mean duration of symptoms and internal findings. Diltiazem group patients had significantly much better healing rate i.e. 96.7% compared to only 80% from patients with surgery group. Incidence of complications like fecal/flatus incontinence was zero in diltiazem group compared to 13.3%/20% in surgery group.Conclusions: Authors conclude that diltiazem 2% topical application is better than surgical sphincterotomy and should be used instead of surgery.