Anal fissure Anal fissures can cause a vicious cycle in which the patient, in anticipation of pain associated with bowel movement, resists the urge to defecate, causing stools to become larger and harder, resulting in more pain with defecation. Treatment should be focused on breaking this cycle to allow healing. If the patient is having a great deal of pain, a topical anesthetic may be applied. Diet modification to soften stools is also indicated in patients with anal fissures. Patients should increase fruits, vegetables, and soluble and insoluble fibers in their diets and increase fluid intake to treat the acute phase and to prevent recurrence. Bulking agents such as psyllium may be prescribed. Approximately half of all anal fissures heal with nonoperative therapy within 2-4 weeks. Use the WASH regimen in treatment of anal fissures, as follows: W arm water; shower or sitz bath after bowel movement A nalgesics S tool softener H igh-fiber diet Medications may also be prescribed for anal fissures, such as topical nitrates, calcium channel blockers, and onabotulinumtoxinA injections, and are considered first-line therapy.[13] These medications reduce anal sphincter tone, which, in turn, increases anodermal blood flow. When conservative treatment fails, surgical therapy may be an option to treat anal fissures. Historically, surgical therapy was common for the treatment of anal fissures and is considered superior to nonoperative therapies. However, due to the risk of complications, including incontinence, surgical therapy is often reserved when conservative treatment fails to heal anal fissures. Anal fistula Treatment of anal fistulas depends on (1) the location of the fistula, (2) evidence of sepsis or a large abscess, or (3) worrisome findings on physical examination. If an abscess is present, drainage is indicated. Intravenous antibiotics, antipyretics, and analgesics are provided as needed. However, simple rectal abscesses do not typically need antibiotics.[14] If the patient also has sepsis, intravenous fluids or a pressor may be necessary. Depending on the presence of systemic symptoms and the condition of the patient, surgery may be necessary. For anal fistulas, outpatient follow-up with a surgeon is indicated if consultation did not take place at the time of presentation. Surgical therapy is often indicated for healing of an anal fistula. The surgical approach is dependent on whether the fistula is simple or complex, as well as the risk of complications such as incontinence. A gastroenterologist should be consulted if inflammatory bowel disease is suspected. Asymptomatic anal fistulas from Crohn disease are not managed by surgery. However, if the patient is symptomatic, surgical management should be considered. Antibiotics should be reserved for those with overlying cellulitis or those with sepsis. Otherwise, symptomatic treatment with analgesics should be considered. In an open-label, single-arm clinical study by de la Portilla et al, local injections of expanded adipose-derived allogeneic mesenchymal stem cells proved beneficial for patients with perianal fistulas associated with Crohn disease. The study involved 24 patients, with investigators finding that in 69.2% of cases, the number of draining fistulas was reduced, while in 56.3% of patients, the treated fissures closed completely, and in 30% of cases, all existing fistula tracts completely closed.[15] Guidelines Consensus guidelines from a working group of the World Congress of Gastroenterology call for a multidisciplinary approach to the management of perianal fistulas associated with Crohn disease. The guidelines list surgical drainage of the abscesses as first-line treatment prior to starting immunosuppressive therapy. Definitive fistula repair with surgical treatment such as fistulotomy, ligation of the intersphincteric fistula tract (LIFT), or the use of mucosal advancement flaps, plugs, or fibrin glue should be considered only if there is no luminal inflammation. The guidelines also state that anti-tumor necrosis factor can provide first-line medical therapy, with an option being to combine this treatment with the use of antibiotics and/or thiopurines.[16] Calcium channel blockers Oral and topical calcium channel blockers (diltiazem and nifedipine) have been shown to be effective treatment options for anal fissures. Calcium channel blockers work by decreasing resting anal pressures. In a recent review, calcium channel blockers were shown to be as effective as topical nitrates. Adverse effects such as headaches are common, especially with the use of oral calcium channel blockers. [17] Oral calcium channel blockers have been shown to yield decreased healing rates compared with topical calcium channel blockers, as well as higher rates of adverse effects.[18] Topical nitrates Topical nitrates have been shown to be effective in the treatment of anal fissures. It is applied directly to the anus and decreases anal resting pressures. In a Cochrane review, topical nitrates were better than placebo in healing anal fissures (48.9% vs 35.5%). However, late recurrence was common (>50%) and headaches occurred frequently, causing cessation of therapy (up to 30%).[17] Different dosing has also been studied, from 0.05% to 0.4%, without a difference in healing rates.[19, 20, 21] Topical nitrates have also been compared with nitroglycerin patches applied to a remote area, with similar cure rates.[22] One small randomized controlled trial between topical diltiazem gel (2%) or glyceryl trinitrate ointment (0.2%) showed a healing rate of 92% with diltiazem compared with 60% with glyceryl trinitrate (P < .001).[23] Adverse effects were more common with glyceryl trinitrate. OnabotulinumtoxinA OnabotulinumtoxinA is used typically to treat muscle hypertonia and cosmetic disorders. Typically, onabotulinumtoxinA is injected into the internal sphincter, reducing hypertonia. Various dosing schemes have been used, and it is typically injected on both sides of the anal fissure. OnabotulinumtoxinA has been shown to be as effective as topical nitrates, but with fewer adverse effects, including headache, and can be an alternative to surgery.[17, 24] Botulism toxin has not been shown to be an effective treatment when other medical therapies have failed.[25] Topical analgesics Topical lidocaine can be used as an anesthetic to help relieve pain associated with anal fissures. Clove oil has also been studied and shows some promise in providing analgesia.[26] Surgical Treatment of Chronic Anal Fissures Chronic anal fissures frequently require surgical treatment.[12] Surgical procedures involve anal dilation, flap and fissurectomy, or cutting the lateral internal sphincter. Open lateral internal sphincterotomy (LIS) is considered the treatment of choice for chronic anal fissure and can be performed either opened or closed.[13, 27, 28] It reduces the hypertonia of the internal anal sphincter, increases anodermal blood flow, decreases pain, and allows the fissure to heal. However, traditional LIS has been associated with relatively high rates of incontinence. Other surgical techniques have been described, including a more tailored approach, which showed lower rates of complications but higher rates of treatment failure.[29, 30, 31] LIS has been shown to have a higher rate of cure than anal dilation. Data for subcutaneous fissurectomy with anal advancement flap are limited.[13] Medication Summary Medications may also be prescribed for anal fissures, such as topical nitrates, calcium channel blockers, and onabotulinumtoxinA injections, and are considered first-line therapy.[13] These medications reduce anal sphincter tone, which, in turn, increases anodermal blood flow. Antibiotics may be necessary for the treatment of anal fistulas, especially if the patient presents with systemic symptoms.Class Summary Psyllium facilitates easier passage of stools. Psyllium (Fiberall, Metamucil, Konsyl, Reguloid, Natural Fiber Therapy)Constipation 2.5-7.5 g in 8 oz of water PO, up to 30 g/d divided PO or 1 teaspoonful or 1 tbs in 8 oz of water PO qD-TID, depending on product Other Indications & Uses Off-label: IBS, hypercholesterolemia Psyllium promotes bowel evacuation by forming a viscous liquid and promoting peristalsis.Vasodilators that cause smooth muscle relaxation are used for relief of anal spasm. Nitroglycerin rectal (Rectiv) Organic nitrate is indicated for moderate to severe pain associated with chronic anal fissures. It elicits internal anal sphincter relaxation and reduces sphincter tone and resting intra-anal pressure. These agents may potentiate the effects of gamma-aminobutyric acid (GABA) and facilitate inhibitory GABA neurotransmission. Diazepam (Valium, Diastat) Diazepam is indicated for the relief of severe anal sphincter spasms. Antibiotic therapy must cover both aerobic and anaerobic gram-negative organisms. View full drug information Vancomycin Vancomycin is a potent antibiotic that is directed against gram-positive organisms and is active against Enterococcus species. It is useful in the treatment of septicemia, enterocolitis, and skin-structure infections. Vancomycin is indicated for patients who are unable to receive or have not responded to penicillins and cephalosporins or for patients with resistant staphylococcus infections. Creatinine clearance measurements are used to adjust the dose in patients with renal impairment. Metronidazole (Flagyl) Metronidazole is active against various anaerobic bacteria and protozoa. It appears to be absorbed into cells. Intermediate metabolized compounds are formed and bind DNA and inhibit protein synthesis, causing cell death. The antimicrobial effect may be due to production of free radicals. Ampicillin and sulbactam (Unasyn) This drug combination of a beta-lactamase inhibitor with ampicillin interferes with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms. Ticarcillin and clavulanate potassium (Timentin) This drug combination of antipseudomonal penicillin plus a beta-lactamase inhibitor inhibits biosynthesis of cell wall mucopeptide and is effective during the stage of active growth. It provides coverage against most gram-positive, gram-negative, and anaerobic organisms. Clindamycin (Cleocin) Clindamycin is effective in the treatment of anaerobic bacteria. It has been shown to have superior effectiveness against streptococci and staphylococci. It continues to be effective against methicillin-resistant Staphylococcus aureus (MRSA).Dosing Forms & Strengths Serious Infections Caused by Anaerobic Bacteria 150-450 mg PO q6-8hr; not to exceed 1.8 g/day, OR 1.2-2.7 g/day IV/IM divided q6-12hr; not to exceed 4.8 g/day Amnionitis 450-900 mg IV q8hr Inhalational & Gastrointestinal Anthrax (Off-label) 900 mg IV q8hr with ciprofloxacin 400 mg PO q12hr or doxycycline 150-300 mg PO q12hr Bacterial Vaginosis 300 mg PO q12hr for 7 days Class Summary Calcium channel blockers work by decreasing resting anal pressures. In a recent review, calcium channel blockers were shown to be as effective as topical nitrates. Oral and topical calcium channel blockers (diltiazem and nifedipine) have been shown to be effective treatment options for anal fissures. Nifedipine (Nifediac CC, Adalat CC, Procardia, Procardia XL) Nifedipine is the prototypical dihydropyridine. The topical form is preferred but must be compounded in the pharmacy. Diltiazem (Cardizem, Cardizem CD, Cartia XT, Dilacor XR, Tiazac) Diltiazem is a nondihydropyridine that has been reported to be effective. The topical form is preferred but must be compounded in the pharmacy. OnabotulinumtoxinA is used typically to treat muscle hypertonia and cosmetic disorders. Typically, onabotulinumtoxinA is injected into the internal sphincter, reducing hypertonia. Various dosing schemes have been used, and it is typically injected on both sides of the anal fissure. OnabotulinumtoxinA has been shown to be as effective as topical nitrates, but with fewer adverse effects, including headache, and can be an alternative to surgery. OnabotulinumtoxinA (BOTOX) OnabotulinumtoxinA is used typically to treat muscle hypertonia and cosmetic disorders. Typically, onabotulinumtoxinA is injected into the internal sphincter, reducing hypertonia.
Posted on: Tue, 06 Jan 2015 18:43:28 +0000
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