Abstract

OTERO R, William  and  GOMEZ Z, Martín. Idiopathic chronic anal fissure. Treatment with topical nitroglycerin. Rev Col Gastroenterol [online]. 2006, vol.21, n.3, pp.173-181. ISSN 0120-9957.

Introduction. Idiopathic chronic anal fissure (ICAF) is a tear of the distant part of the anal verge, whose pathogenesis involves hypertrophy of the internal anal sphincter and ischemia of the posterior face of the anus. Classically the treatment of choice has been an internal lateral sphincterotomy due to its high success rates (90 to 95%). Nonetheless this procedure weakens permanently the anal sphincter and may produce a deformity and anal incontinence. For this reason, no surgical therapeutic modalities have been studied aimed at decreasing the pressure of the external anal sphincter, to break this hypertony-ischemic cycle. Topically applied nitroglycerin in the anus is metabolized to nitric oxide decreasing the pressure of the EAS and improving the blood flow to this area. Objective. The objective of this study was to evaluate the efficacy of topical nitroglycerin (TN) in the treatment of FACI. Materials and methods. Open prospective intervention study in patients more than 18 years old, of both genders with the diagnosis of FACI, who had not responded to other empirical forms of treatment. The treatment consisted in the application of NT in the fissure, twice a day for eight weeks. Each patient was recommended to put NT with his/her index finger in the fissure and not around the anal area and to use local ice to relieve pain, as well as laxative bulk agents (corn or psyllum). The outcome variables were as follows: 1. Improvement or disappearance of the anal pain. 2. Complete healing of the fissure at the end of treatment. 3. Symptomatic improvement (disappearance of pain even though the fissure persisted). Results. 85 patients were recruited, age average 40,5 +/- 13,6 years, 53 women. In 7% of patients the fissure was anterior. Fissure healing: 2nd week: 23 (27%), 4th week: 50 (59%), 8th week: 68 (80%). Intended to treatment CI 95%, (68,9-87,8). Also by the 8th week in 15 patients whose fissure persisted, the pain had decreased in 3 and disappeared in 2, added these to the 68 patients in which the FACI disappeared, the overal improvement rate is 82,4% for AIT (CI 95%, 72,5-89,7). Severe headache occurred in 2 patients who withdrew from the study (2.4%), and 30% had transient slight headache. Conclusion. The results of this study proved excellent efficacy of topical NT, when administered for eighth weeks to patients affected with FACI. In our setting topical NT could well be considered first line therapy

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