Abstract
Introduction
The initial management of chronic anal fissures nowadays is increasingly becoming medical since surgical procedures may be complicated by prolonged healing of wounds, higher incidence of incontinence of flatus/ mucous, anaesthesia requirement and higher cost. Medical treatment can be carried out on an outpatient basis and is cost-effective.
Aim and study design
We conducted a prospective randomised trial to comparatively evaluate the topical efficacy and complications of 0.2% GTN vs. 2% Diltiazem ointment in patients with chronic anal fissure.
Methods
A total of fifty patients were randomly assigned to two groups of 25 patients each, all of whom were treated with topical medication twice daily for a period of six weeks: group A was treated with 0.2% glyceryl trinitrate and group B with 2% diltiazem. None of the patients in either group received analgesics in any form during the course of treatment and follow-up. Cases of acute anal fissure, pregnancy, Crohn’s disease, HIV, tuberculosis, fistula in ano or anal cancer, known allergy to drugs, heart disease, hypertension and patients who refused consent were excluded.
Observation
The mean age of patients in both groups (34.6±12.8 vs. 30.6±9.5 years) was comparable. Group A (GTN) comprised 19 males and 6 females and Group B (Diltiazem) 17 males and 8 females (p>.05). The mean duration of symptoms for both groups was 16.64±12.3 vs. 16.08±11.9 weeks, and the mean pain score of patients before treatment was 8.64±0.95 vs. 8.44±1.19 weeks, which was comparable. Perceptible pain relief as compared to pretreatment levels was recorded for both groups after six weeks of therapy (p=.905). Complete healing was observed in 72% patients in group A vs. 80% in group B at the end of six weeks (p value 0.508). Headache was reported in 36% patients in group A and 8% in group B; this difference was statistically significant (p value 0.041). The incidence of recurrence in both groups was comparable at 3-month follow-up (p value 0.756).
Conclusion
Both 0.2% GTN and 2% Diltiazem ointment are equally effective in chronic anal fissure treatment in terms of symptomatic pain relief, healing and recurrence, but headache is a troublesome side effect in patients treated with glyceryl trinitrate ointment. When considering medical management of chronic anal fissure, 2% Diltiazem ointment may be preferable as first-line treatment.
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References
Utzig MJ, Krosean AJ, Buhr. Concepts in pathogenesis and treatment of chronic anal fissure–a review of literature. Am j Gastroenterol 2003; 8:968–74
Gibbons CP, Read NW. Anal hypertonia in fissures: Cause or Effect. Br J Surg 1988; 75:443–5
Corby H, Donnelly VS, O’Connell PR. Anal pressure are low in women with post partum anal fissures. Br J Surg 1997; 84:86–8
Klosterhalfen B, Vogel P, Rixen H, et al. Topography of the inferior rectal artery: a possible cause of chronic, primary anal fissure. Dis Colon Rectum 1989; 32:4352
Lund JN, Schofield JH. A randomised, prospective, doubleblind, placebo-controlled trial of glyceryl trinitrate ointment in treatment of anal fissure [see comments] published erratum appears in Lancet 1997; 349:656. Lancet 349:11-4
Carapeti EA, Kamm MA, Evans BK, et al. Topical diltiazem and bethanochol decreases anal sphincter pressure and heals anal pressures without side effects. Dis Colon Rectum 2000; 43:1359–62
Kocher HM, Steward M, Leather AJM, et al. Randomized clinical trial assessing the side effects of glyceryl trinitrate and diltiazem hydrochloride in the treatment of chronic anal fissure. Br J Surg 2002; 89:413–7
Lund JN, Parsons SL, Scholefield JH. Spasm of the internal anal sphincterin anal fissure-cause or effect? Gastroenterology 1996; 110:A711
Shrivastava UK, Jain BK, Kumar P, et al. Comparison of effects of diltiazem and glyceryl trinitrate ointment in treatment of chronic anal fissure -a randomised control trial. Surg Today 2007; 37:482–5
Knight JS, Birks M, Farouk R. Topical diltiazem ointment in treatment of chronic anal fissure. Br J Surg 2001; 88:553–6
Jawaid M, Masood J, Salim M. Topical diltiazem hydrochloride and glyceryl trinitrate in the treatment of chronic anal fissure. J Coll Phys Surg Pak 2009; 19:614–9
Rithin Suvarna, Hanumanthappa MB, Panchami, et al. Topical diltiazem versus topical glyceryl trinitrate (GTN) in the treatment of chronic anal fissure: prospective study. Int J Biol Med Res 2012; 3:1747–50
Carapeti EA, Kamm MA, McDonald PJ. Randomised controlled trials shows that glyceryl trinitrate heals anal fissures, higher doses are not more effective, and there is high recurrence rate. Gut 1999; 44:727–30
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Bansal, A.R., Kumar Yadav, P., Godara, R. et al. Comparative evaluation of 0.2% glyceryl trinitrate vs. 2% diltiazem ointment in treatment of chronic anal fissure treatment - a randomized trial. Hellenic J Surg 88, 25–30 (2016). https://doi.org/10.1007/s13126-016-0278-x
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DOI: https://doi.org/10.1007/s13126-016-0278-x