anal fissure Flashcards
what is it
Tear or ulcer in lining of anal canal, immediately within the anal margin
clinical features of anal fissure
○ Bleeding on defecation
○ Persistent pain on defecation
○ Linear split in anal mucosa
treatment for acute anal fissure (<6 weeks)
- initial management is to ensure stools are soft and easily passed
1st line = bulk forming laxatives e.g. isphagula husk
alternative = osmotic e.g. lactulose - topical preparation of LA e.g. lidocaine
- analgesic e.g. ibup/parac for prolonged burning after shitting
treatment for chronic anal fissure (>6 weeks) and associated pain
GTN rectal ointment 0.4% or 0.2% (unlicensed, special)
Alternatives: topical diltiazem HCl 2% ointment (unlicensed, special) and nifedipine 0.2-0.5% (unlicensed, special)
Oral nifedipine or diltiazem (unlicensed indication) may be as effective as topical treatment but with higher incidence of adverse effects - hence topical preferred!
Patients who do not respond to 1st line treatments may be referred to a specialist for local injection of botulinum toxin type a (unlicensed indication)
Treatment for CHRONIC anal fissure (>6 weeks) and associated pain - an option is GTN rectal ointment 0.4% or 0.2% (unlicensed, special). Discuss the use of higher strength
- Limited evidence suggests strength used does not influence effectiveness
- Higher strength may increase risk of SE
what is a very common side effect of GTN rectal ointment use
headaches
When should you discard GTN rectal ointment after opening
8 weeks
(same as GTN tabs)
true or false - recurrence of fissure after GTN rectal ointment treatment is common
true
true or false - topical diltiazem HCl 2% ointment (unlicensed, special) and nifedipine 0.2-0.5% (unlicensed, special) have higher incidence of SE than topical GTN
false they have lower incidence of SE then with topical GTN
when can surgery be considered
- Effective option for management of chronic cases in adults
- Generally reserved for those who do not respond to drug treatment
