Case Presentation

1. Case Presentation General Surgery Rounds February 20th, 2004

2. Case You�re working in the Ambulatory Care Clinic Patient referred to the clinic with bright red blood per rectum

3. Case 64 year old male Farmer from Eston, SK History & Physical

4. Case History Bleeding Definition Frequency Duration Quality Associated factors Bowel Habits Pain Abdominal Symptoms Constitutional Symptoms History Bowel Habits Change Bouts of constipation/ diarrhea Change in size Pain? Pain When? Quality Severity Temporality

5. Case History Perianal symptoms Itchiness Swelling Discharge Prolapse Family History Past Medical History Medications Differential Diagnosis?

6. Case 64 year old male Recurrent Bright red blood per rectum At the end of every bowel movement, drips into bowl Off and on for 4 months Will notice it on underwear at times On inquiry about BMs, severe pain at initiation, lasts for 1 to 2 hours Constipated over past 6 months, placed on Tylenol #3 for 2 weeks after fall Increasing pruritis ani Family History is negative for colon cancer and inflammatory bowel disease Medications: Atacand Allergies: none

7. Case Physical Examination General H&N/Chest/CVS Abdominal Exam Perianal Exam Uncomfortable, constantly shifting on the seat Benign abdominal exam Sentinel tag Tight anus Multiple linear tears in the lining of the anoderm, with base of granulation tissue

8. Differential Diagnosis Anal Fissure

9. Treatment Conservative Medical Surgical

10. Treatment Conservative Bowel care Pain control Sitz baths Medical Nitro Diltiazem/Nifedepine BoTox Surgical Anal dilation Lateral internal sphincterotomy

11. Case Patient trialled on nitro for 6 weeks Unable to tolerate Given option between BoTox and Lateral Internal Sphincterotomy Chose surgical treatment

12. Anal Fissures Traumatically induced longitudinal split in the squamous epithelium of the distal anal canal Extends from the anal verge to the dental line Most commonly occurs in the posterior midline

13. Symptoms Symptoms are characteristic Severe intense pain on the passage of stool Knifelike, tearing Relieved with sitz baths Lasts for hours Associated with pruritis (50%) Swelling Prolapse discharge History of constipation prior to anal symptoms Patients may complain of diarrhea or alternating constipation

14. Etiology Equal frequency in both genders Occurs mostly in otherwise healthy adults Approximately 10% occur in women postpartum Lateral tears should raise concern for: IBD Syphillis HIV

15. Pathogenesis Poorly understood Thought to be related to passage of hard stool Only 1 in 4 patients report constipation ? Dietary association Acute 90% will resolve within six weeks with good bowel care Chronic Failure to heal within 6 weeks, despite medical treatment

16. Pathogenesis Trauma during pregnancy 11% develop symptoms after childbirth Risk increases with traumatic deliveries Occur in the anterior midline ? Passage of fetal head ? Tethering of anal mucosa to the underlying muscle Do not have raised anal canal pressures

17. Pathogenesis Internal Anal Sphincter Hypotonia Anal canal resting pressure is a function of the internal sphincter Internal sphincter is always partially contracted Alpha-adrenergic pathways Relaxes in response to rectal distention Mediated by Ach & beta-adrenergic pathways Patients with chronic fissures Raised resting anal pressures Long high pressure zone in the anal canal Abnormal rectoanal inhibitory reflex Anal spasm not relieved by local anaesthetic

18. Pathogenesis Keck et al. (1995, DCR) Water perfused manometry on 12 patients, with age-matched and sex-matched controls Significantly higher anal resting pressure Longer high-pressure zone to sphincter length ratio Supported hypothesis of sphincter spasm

19. Pathogenesis Local ischemia Ulcers are described as ischemic ulcers Distal anal canal blood supply Inferior rectal art. via the int. pudendal vesels Most anal fissures occur at the posterior midline On cadaver studies, 85% of decreased arterioles Blood flow decreases with increasing anal pressure

20. Treatment Acute anal fissure 90% of acute anal fissures are of short duration High fiber diet Increased water intake Stool softener Topical anaesthetics? Topical steroids? Bring on occult viral disease

21. Treatment Chronic Fissures Choice of treatment continues to be controversial < 10% will heal without intervention Most of these patients will have increased resting anal pressures

22. Treatment Treatment of choice is sphincterotomy to relieve resting tone of anal sphincters Choice of chemical vs. surgical sphincterotoy

23. Treatment Medical sphincterotomy Nitro paste Kennedy et al. (1999, DCR) Double blind RCT Nitro vs. placebo 43 patients, with short and long term followup Decreased pain and increased healing in patients with nitro paste 46% vs 16% short term 59% healed with nitro in the longer term 35% of patients underwent lateral internal sphincterotomy

24. Treatment Medical sphincterotomy Nitro paste Carapeti et al. (Gut, 1999) RCT 80 patients Fissures healed in nitro group 67% vs. 32% in placebo group 43% with placebo recurred, 37% with nitro paste

25. Treatment Medical sphincterotomy Calcium channel blockers Perotti et al. (DCR, 2002) Double Blind RCT Topical nifedipine vs. placebo in 55 patients 97% of fissures with nifedepine resolved as opposed to 18% with placebo

26. Treatment Medical sphincterotomy Calcium channel blockers Diltiazem vs. Nitro paste Kocher et al. (BJS, 2002) 52 patients, RCT Equivalent rates of fissure healing @ 67% Decreased side effects with diltiazem

27. Treatment Medical sphincterotomy Calcium channel blockers Topical vs. oral diltiazem Jonas et al. (DCR, 2001) 50 patients randomized, blinded Topical diltiazem was more effective in healing (65% vs. 38%)

28. Treatment Medical sphincterotomy BoTox First report, Josh (DCR, 1997) 100 patients, treated with BoTox 79% of patients had healing at 6 months Transient incontinence in 8% of patients

29. Treatment Medical sphincterotomy BoTox Brisinda et al. (1999, NEJM) 50 patients, RCT 96% healing with BoTox, 60% with Nitropaste Decreased side effect profile No data on recurrence

30. Treatment Medical sphincterotomy BoTox Lysy et al. (Gut, 2001) RCT BoTox with Nitro works better than Nitro alone (76% vs. 63%)

31. Treatment Surgical sphincterotomy �Reserved for patients who have failed medical therapy� Multiple large series reported 1% to 6% healing within 6 months. 1.5% to 15% patients have flatus incontinence 0% to 11% of patients have fecal soilage Complications include hemorrhoids, hemorrhage, absess, fistula

32. Treatment Surgical sphincterotomy Closed technique Anal retractor Sphincters palpated 11 blade advanced in intersphincteric groove to dentate line, and then rotated Open technique incision from dentate line to the anal verge, and division of anal sphincter

33. Treatment Surgical sphincterotomy open/limited technique Anal retractor Divide the internal sphincter to the uppermost aspect of the fissure Non-randomized series (Littlejohn & Newstead, 1997) < 2% recurrence 1 to 2 % rates of non-healing

34. Treatment So which one? Medical or Surgical or both? BoTox vs. LIS (DCR, 2003) RCT, 61 patients in BoTox, 50 patients in LIS BoTox group 74% patients had complete healing at 6 months, with 10 patients requiring repeat injections 40% recurrence at one year Surgical group 82% healed at one month 96% healed at two months 2 recurrences, but responded to conservative measures

35. Treatment Nelson (Cochran Review, 2003) Meta-analysis and systematic review of all non-surgical treatments of anal fissure Healing at six months was only outcome examined Nitro paste vs. placebo Equivalent Nitro paste vs. CCB Equivalent BoTox vs. placebo Equivalent High recurrence rates for all medicinal management

36. Treatment Summary Nitro paste, CCB and BoTox are all good treatments for analgesia BoTox and diltiazem paste have decreased side effect profile, when compared to Nitro paste For optimal healing, and non-recurrence, Lateral Internal Sphincterotomy remains the treatment of choice However, if patients are kept well informed, treatment should remain minimal for management of a benign disease

37. Treatment Summary Nitro paste � 0.2% to 0.6% tid Diltiazem paste � 2% bid BoTox � 0.3 U/kg