Comparison of topical 2% diltiazem and lateral internal sphincterotomy in the treatment of chronic anal fissure

Dr Subhash Chandra Sharma; Dr Madhu Lata Rana

Volume : VIII, Issue : I, January - 2019

Comparison of topical 2% diltiazem and lateral internal sphincterotomy in the treatment of chronic anal fissure

Dr Subhash Chandra Sharma, Dr Madhu Lata Rana

Abstract :

Introduction- Fissure in ano is one of the most common causes of severe anal pain which presents with pain while defecation and may persist for few hours with occasional passage of ight red blood per anum. It is a longitudinal tear in the anoderm of anal canal either posteriorly or anteriorly which extends from the anal verge proximaly and may reach upto the dentate line (1). Primary fissures may be idiopathic, benign, and may be due to local trauma i.e., hard stools, repetitive injury, prolonged diarrhoea and vaginal delivery(3). Chronic ,non healing , multiple or lateral and frequently recurrent anal fissure may be due to some other pathologies, such as chron,s disease, tuberculosis , some other inflammatory bowel disease or malignancies(2). They require further investigations and multidisciplinary management.Acute anal fissure presents within 3 – 6 weeks of symptoms onset and usually heals spontaneously or with conservative therapy. If fissure does not heal for more than 6 weeks then the fissure becomes chronic (4). It is usually deeper and may has exposed internal sphincter fibers in its base. It is often associated with sentinel pile at its distal aspect(5). These types of fissures usually respond better with surgical treatment(6)(7)(8). Probably acute injury to anal canal causes pain and spasm of internal sphincter which in turns results in high resting anal pressure (8) further leading to reduced blood flow and ischemia(9), poor healing and thus again aggrevating anodermal ulcer and so the vicious cycle continues(10) . There is not much clear guideline to manage fissure in ano but the goal of treatment is to each this vicious cycle of anal sphincteric spasm, allowing improved blood flow and thus healing (11). Certain pharmaceutical agents such as nitrates and calcium channel blockers like 2% diltiazem(12) lowers the resting anal pressure and promote healing of fissure (13). Surgial management involves division of internal anal sphincter and thus reducing anal sphincter tone leading to healing of anal fissure (14). In this study we will compare the conservative management i.e chemical spincteritomy with topical 2% diltiazem with the surgical management i.e lateral internal sphincterotomy (LIS) in the treatment of chronic anal fissure. Material and Methods -This is a prospective study conducted in SGRRIM and HS ,Dehradun, from may 2018 to nov2018. Study was conducted randomly in 180 patients who presented in surgery outpatient department with chronic anal fissure. Clearance from local ethical committee was obtained. Inclusion criteria- fissure in ano for more than 6 weeks was labeled as chronic anal fissure. Patient of both sexes between age 15 years to 55 years who presented with the symptoms of chronic anal fissure were included in the study. Exclusion criteria. Fissure in ano less than 6 weeks, fissures associated with hemorrhoids , fistula in ano,malignancies, tuberculosis, inflammatory bowel disease, chron,s disease and pregnant women were exluded from the study. Two groups were made for the purpose of study. Group I consisted of patients who were treated conservatively with 1 cm of 2% topical diltiazem into anoderm for 6 consecutive weeks twice a day .Group II consisted of patients who underwent lateral internal sphincterotomy under spinal anesthesia. Patients of both the groups were advised sitz bath , stool softner, analgesics and high fie diet. Review of all the patients was done in surgery outpatient department weekly for six consecutive weeks and monthly for subsequent 3 months. At each visit preset questions were asked regarding pain, bleeding while defecation , constipation , complication like leakage of flatus and faeces. Per rectum examination as done to look for sphincter spasm if patient allowed. Pain was assessed using Likert scale ranging from 0 – 4 where 0 implies no pain and 4 means maximum pain. Healing was assessed visually and complete healing was considered as complete disappearance of fissure in ano. The data was collected and analysed .Chi square test was used to calculate P values. P value < 0.05 is considered statistically significant. Patients with persisted symptoms which were not healed for 6 weeks were evaluated for other cause of symptoms. Conclusion – Though use of pharmaceutical drugs in the management of chronic anal fissure has minimal complications but lateral internal sphincterotomy is superior in terms of early pain relief , better healing rate and is more effective than the chemical sphincterotomy It should be considered for patients suffering from chronic anal fissure refractory to medical therapy