Anal fissure

Panthenol is frequently used in ointments and solutions for the treatment of burns, anal fissures, and inflammation of the conjunctiva. The vitamin has to be substituted in patients on total parenteral nutrition and in those who regularly undergo dialysis. Hypervitamin-osis has not been observed for doses up to 5 g/d (22). Furthermore, the administration of pantothenic acid leads to improved surgical wound healing due to its antiinflammatory properties. 

Ulcerative colitis Fever, tachycardia (with severe disease), dehydration, arthritis, hemorrhoids, anal fissures, perirectal abscesses... 

Irritable bowel syndrome, diverticulitis, upper and lower GI tract diseases, hemorrhoids, anal fissures, ulcerative proctitis, tumors, hernia, volvulus of the bowel, syphilis, tuberculosis, lymphogranuloma venereum, Hirschsprung s disease. 

Local complications (involving the colon) occur in the majority of ulcerative colitis patients. Relatively minor complications include hemorrhoids, anal fissures, or perirectal abscesses. 

Q52 Glyceryl trinitrate may be used topically every 12 hours for anal fissures. Glyceryl trinitrate is a nitrovasodilator that causes the anal sphincter to relax when applied topically. 

Glyceryl trinitrate can be used topically in the treatment of anal fissures. Being a nitrovasodilator when applied topically, glyceryl trinitrate tends to cause relaxation of the anal sphincter. It is applied to the anal canal until the pain stops. 

Constipation bulk-forming laxatives by increasing faecal mass tend to soften stools and relieve constipation, and have value in a range of symptomatic problems associated with anal fissure, haemorrhoids, and with ileostomy and colostomy dysfunction. Faecal softeners, lactulose and macrogols (polyethylene glycol) retain fluid in the bowel. Stimulant laxatives, such as the anthraquinone, senna, and bisacodyl, increase motility and can cause colic verdoses can cause diarrhea and electrolyte depletion. Chronic treatment for constipation is seldom needed, but may be in children with a tendency to faecal impaction, specialist advice should be sought. 

Local injections have also been shown to be beneficial in many other conditions including achalasia, chronic anal fissure, and hyperhidrosis. 

Rhubarb is indicated in constipation, bowel movement relief with anal fissures, hemorrhoids, after recto-anal surgery and in preparation for diagnostic interventions of the gastrointestinal tract. 

The therapeutic indications for BoNTs are numerous. They are used in the treatment of ophthahnological disorders (strabismus, Duane s syndrome, esotropia/exotropia), movement disorders (focal dystonias, blepharospasm), spasticity, neiuomuscular disorders, pain (headache, myo-facial pain), disorders of the pelvic floor (anal fissures), ear/ nose/throat disorders, cosmetic applications (wrinkles), and hyperhidrosis. The recent explosion in new indications for BoNTs in the treatment of a wide range of medical conditions also brings the possibihty for medical errors in BoNT dosing. Systemic botulism may result from injection of excessive doses of the potent neurotoxin. The most infamous case of systemic botulism involved the paralysis of four Florida patients, including the doctor, treated with BoNTs for wrinkles. The physician used non-FDA approved formulations of type A from Toxin Research International,... 

Involuntary muscle spasm blepharospasm, hemifacial spasm, spasmodic torticollis, and indeed the spasm of chronic anal fissure, are treated with botulinum toxin. This irreversibly blocks release of acetylcholine from cholinergic nerve endings and is injected locally. Its effect lasts about 3 months. Botulinum toxin is at least partially effective in up to 90% of patients with these conditions. Mild dysphagia occurs in 30% of patients receiving injections into their neck for torticoUis due to spread of the toxin in to the pharyngeal muscles. 

The softening properties of these agents are useful in the management of anal fissure (see below) and haemorrhoids. 

Anal fissures are often intensely painful due to sphincter spasm. Anaesthetic ointments and stool softening agents have been widely used, with surgery (lateral internal sphinterotomy) for severely affected cases, but this procedure can cause incontinence from loss of sphincter control. An alternative is topical application of nitrate which heals two-thirds of fissures. Preparations should be diluted to 0.2% as such use may be complicated by headache tolerance can develop. Intrasphincteric injection of botulinum toxin has also been shown to be effective. 

Janne P A, Mayer R J 2000 Chemoprevention of colorectal cancer. New England Journal of Medicine 342 1960-1968 Madoff R D 1998 Pharmacologic therapy for anal fissure. New England Journal of Medicine 338 257 Midgley R, Kerr D1999 Colorectal cancer. Lancet 353 391-399... 

Local anesthetic ointments are widely used to relieve the symptoms of hemorrhoids and anal fissures. Absorption through the mucosa can be considerable a case of convulsions as a suspected consequence of such treatment has been cited (SED-12, 253) (347). 

A 51-year-old man with systemic sarcoidosis took methotrexate for 36 months and developed a large anal fissure with a diffuse polymorphic infiltrate containing large Epstein-Barr virus-positive lymphoid cells, similar to the classical B cell lymphoproliferative disorders that occur in immunosuppressed transplant recipients of solid organs (121). 

In a multicenter, randomized, placebo-controlled, doubleblind study of 0.2% glyceryl trinitrate ointment in 132 patients with anal fissures over at least 4 weeks, healing rates were similar with glyceryl trinitrate and placebo, but adverse events were more frequent in those who used glyceryl trinitrate 34% complained of headache and 5.9% had orthostatic hypotension (16). 

Brisinda G, Maria G, Bentivoglio AR, Cassetta E, Gui D, Albanese A. A comparison of injections of botulinum toxin and topical nitroglycerin ointment for the treatment of chronic anal fissure. N Engl J Med 1999 341(2) 65-9. 

Dorfman G, Levitt M, Platell C. Treatment of chronic anal fissure with topical glyceryl trinitrate. Dis Colon Rectum 1999 42(8) 1007-10. 

Hyman NH, Cataldo PA. Nitroglycerin ointment for anal fissures effective treatment or just a headache Dis Colon Rectum 1999 42(3) 383-5. 

Altomare DF, Rinaldi M, Milito G, Arcana F, Spinelli F, Nardelli N, Scardigno D, Pulvirenti-D Urso A, Bottini C, Pescatori M, Lovreglio R. Glyceryl trinitrate for chronic anal fissure—healing or headache Results of a multicenter, randomized, placebo-controled, double-blind trial. Dis Colon Rectum 2000 43(2) 174-81. 

Kocher HM, Steward M, Leather AJ, Cullen PT. 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(4) 413-17. 

Part A of the Patient Group Direction will list the conditions that can be treated by use of this Patient Group Direction (for example, anal fissures, inflammatory bowel disease, management of colostomy/ileostomy patients, etc.). 

Ulcerative colitis can be accompanied by complications that may be local (involving the colon or rectum) or systemic (not directly associated with the colon). With either type the complications may be rmld, serious, or even life threatening. Local complications occur in the majority of ulcerative colitis patients. Relatively minor complications include hemorrhoids, anal fissures, or perirectal abscesses, and are more likely to be present during active colitis. Enteroenteric fistulas are rare. 

Hemorrhoids, anal fissures, or perirectal abscesses may be present... 

Amino-5-(5-nitro-2-luryl)-l,3,4-thiadiazole has been used in gastroenteritis (25 mg/kg per day) with 85 per cent efficacy , and also as a topical agent for the symptomatic relief of chronic inflammatory disorders of the anorectal area (haemorrhoidal, anal fissures and proctitis) > . 

Caicium Carbonate (1 Constipation, hypercalcemia, metabolic alMosis, hemorrhoids, bleeding anal fissures. Rarely, milk-alkali syndrome (if taken chronically with milk or bicarbonate). 

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