Comparative Study of Lateral Sphincterotomy versus Local 2 % Diltiazem Ointment for the Treatment of Chronic Anal Fissure

Abstract

A chronic anal fissure is a non-healing linear tear in the distal anal mucosa below the dentate line and is a painful entity. A fissure is defined as chronic when it fails to heal within 6 weeks from an acute attack1. This study is an attempt to compare efficacy of lateral internal sphincterotomy versus topical 2 % Diltiazem ointment for the treatment of chronic anal fissure. This prospective comparative study was done in our hospital during one and half year from February'11 to August'12. 50 patients were treated with 2 % Diltiazem ointment and rest 50 underwent lateral internal sphincterotomy for chronic anal fissure. Patients were followed for 8 weeks and thereafter evaluated for symptoms relief in both the groups. Observations were recorded at 2nd, 4th, 6th and 8th week regarding relief of symptoms like pain, bleeding per rectum, healing of ulcer and side effects of fecal incontinence in surgical group. All data were collected and analyzed accordingly. It revealed that 56 % were male and 44 % were female and maximum numbers of patients were in the age group 30-39 years. The chief complaints of patients at presentation-29 % had pain during defecation with constipation, 22 % bleeding per rectum and 49 % had only pain during defecation. Most of them (90 %) had posterior anal fissure. Most of the patients (63 %) had ulcer only. But in 37 % of cases there were ulcer with sentinel piles. Lateral internal sphincterotomy is the treatment of choice while treating chronic anal fissure, because of its simplicity, better healing rates, better patient satisfaction, minimal morbidity and low complication rates. Taking this option also helps the patient to resume his/her normal works earlier than that of topical 2 % Diltiazem ointment. Keywords-Lateral internal sphincterotomy, 2 % Diltiazem ointment, chronic anal fissure. I. INTRODUCTION A chronic anal fissure is a crack in the distal anal mucosa which often does not heal after an acute attack. Apart from it being a painful condition it has different modes of presentation such as bleeding per rectum, pain during defecation and pain during defecation with constipation. There are several factors for the development of chronic anal fissure like internal sphincter hypertonia, trauma due to passage of hard stools or diarrhoea episodes, paucity of blood supply, especially the posterior commissure, by the compression of inferior rectal artery. The paucity of blood flow prevents healing of anal fissure until the cycle of internal sphincter hypertonia and decreased blood flow is broken by muscle relaxants or surgery. There are different non-surgical treatments for chronic anal fissure including 2 % Diltiazem ointment topical application and also there are different surgical interventions including lateral internal sphincterotomy. The study was designed to compare the effect of medical management with topical 2 % Diltiazem ointment and surgical treatment by lateral internal sphincterotomy in case of chronic anal fissure with regards to ulcer healing, pain reduction, cessation of bleeding per rectum and incontinence.