COMPARATIVE STUDY ON THE EFFICACY OF TOPICAL METRONIDAZOLE, TOPICAL NITROGLYCERINE, AND TOPICAL DILTIAZEM IN THE MANAGEMENT OF CHRONIC ANAL FISSURE

PURSHOTAM DASS GUPTA; FAHAD TAUHEED; ANURAG SARASWAT; Karthik P

doi:10.22159/ajpcr.2023.v16i3.47443

Authors

PURSHOTAM DASS GUPTA Department of General Surgery, School of Medical Sciences and Research, Sharda University, Greater Noida, Uttar Pradesh, India. https://orcid.org/0000-0002-9356-0044
FAHAD TAUHEED Department of General Surgery, Hamdard Institute of Medical Sciences and Research, Jamia Hamdard, New Delhi, India. https://orcid.org/0000-0002-0235-5695
ANURAG SARASWAT Department of General Surgery, School of Medical Sciences and Research, Sharda University, Greater Noida, Uttar Pradesh, India.
Karthik P Department of General Surgery, School of Medical Sciences and Research, Sharda University, Greater Noida, Uttar Pradesh, India.

DOI:

https://doi.org/10.22159/ajpcr.2023.v16i3.47443

Keywords:

Chronic anal fissures, Topical treatment, Metronidazole, Healing rate, VAS scores

Abstract

Background and Aims: Chronic anal fissure (CAF) is usually managed with surgical modalities but it imposes huge cost with recurrence rates. Hence, topical therapies are preferred is such cases which has a good patient acceptability rate. The present study aims to compare the topical metronidazole (MTZ), diltiazem (DTZ), and glyceryl trinitrate (GTN) in terms of healing rate and pain reduction in CAF patients.

Methods: This was a randomized and prospective study conducted on 90 patients with CAF. The patients were grouped as follows (n=30), Group 1; 1% MTZ gel, Group 2; 0.2% Nitroglycerin ointment, and Group 3 (n=30): 2% DTZ ointment. The patients were evaluated at 2, 4, and 6 weeks for pain using visual analogue score (VAS) and healing rate. The results were compared and p<0.05 was considered as significant.

Results: The VAS scores between the groups was found to be non-significant (p>0.05), however the VAS scores where markedly reduced within the group at 6 weeks. The healing rate was higher in MTZ group (90%) as compared to GTN (83.3%) and DTZ group (83.3%) but it was not significant. Regarding side effect, burning sensation was observed in MTZ and GTN, DTZ groups were devoid of side effects.

Conclusion: The MTZ was more effective with good healing rate but with few side effects. Regarding the pain reduction, all the groups displayed equivocal effects. Thus topical MTZ is a suitable agent for the faster healing of CAF and thus avoids the requirement of surgical options.

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References

Stoker J. Anorectal and pelvic floor anatomy. Best Pract Res Clin Gastroenterol 2009;23:463-75. doi: 10.1016/j.bpg.2009.04.008, PMID 19647683

Bhardwaj R, Vaizey CJ, Boulos PB, Hoyle CH. Neuromyogenic properties of the internal anal sphincter: Therapeutic rationale for anal fissures. Gut 2000;46:861-8. doi: 10.1136/gut.46.6.861, PMID 10807901

Villalba H, Villalba S, Abbas MA. Anal fissure: A common cause of anal pain. Pers Med J 2007:62-5. doi: 10.7812/TPP/07-072

Tsunoda A, Kashiwagura Y, Hirose K, Sasaki T, Kano N. Quality of life in patients with chronic anal fissure after topical treatment with diltiazem. World J Gastrointest Surg 2012;4:251-5. doi: 10.4240/wjgs. v4.i11.251, PMID 23494072

Nelson RL, Manuel D, Gumienny C, Spencer B, Patel K, Schmitt K, et al. A systematic review and meta-analysis of the treatment of anal fissure. Tech Coloproctol 2017;21:605-25. doi: 10.1007/s10151-017- 1664-2, PMID 28795245

Pardhan A, Azami R, Mazahir S, Murtaza G. Diltiazem vs. glyceryl trinitrate for symptomatic relief in anal fissure: A randomised clinical study. J Pak Med Assoc 2014;64:510-13. PMID 25272534

Berry SM, Barish CF, Bhandari R, Clark G, Collins GV, Howell J, et al. Nitroglycerin 0.4% ointment vs placebo in the treatment of pain resulting from chronic anal fissure: A randomized, double-blind, placebo-controlled study. BMC Gastroenterol 2013;13:106. doi: 10.1186/1471-230X-13-106, PMID 23815124

Ho KS, Ho YH. Randomized clinical trial comparing oral nifedipine with lateral anal sphincterotomy and tailored sphincterotomy in the treatment of chronic anal fissure. Br J Surg 2005;92:403-8. doi: 10.1002/ bjs.4882, PMID 15739214

Samim M, Twigt B, Stoker L, Pronk A. Topical diltiazem cream versus botulinum toxin A for the treatment of chronic anal fissure. A double-blind randomized clinical trial. Ann Surg 2012;255:18-22. doi: 10.1097/ SLA.0b013e318225178a, PMID 21685792

Higuero T. Update on the management of anal fissure. J Visc Surg 2015;152:S37-43. doi: 10.1016/j.jviscsurg.2014.07.007, PMID 25305752

Vaithianathan R, Panneerselvam S. Randomised prospective controlled trial of topical 2% diltiazem versus lateral internal sphincterotomy for the treatment of chronic fissure in Ano. Indian J Surg 2015;77:1484-87. doi: 10.1007/s12262-014-1080-z, PMID 27011607

Jumaa MK, Kadhim AA, Al Badri AH. Prevalence rate and clinical features of fissure-in-Ano in a private surgical clinic in Ala-Diwaniyah province, Iraq. Med Legal Update 2021;21:1408-12.

Acar T, Acar N, Güngör F, Kamer E, Güngör H, Candan MS, et al. Treatment of chronic anal fissure: is open lateral internal sphincterotomy (LIS) a safe and adequate option? Asian J Surg 2019;42:628-33. doi: 10.1016/j.asjsur.2018.10.001, PMID 30366766

Motie MR, Hashemi P. Chronic anal fissure: A comparative study of medical treatment versus surgical sphincterotomy. Acta Med Iran 2016;54:437-40. PMID 27424014

Collins EE, Lund JN. A review of chronic anal fissure management. Tech Coloproctol 2007;11:209-23. doi: 10.1007/s10151-007-0355-9, PMID 17676270

Grekova NM, Maleva EA, Lebedeva Y, Bordunovsky VN, Telesheva LF, Bychkovskikh VA. The effects of topical application of metronidazole for treatment of chronic anal fissure: A randomized, controlled pilot study. Indian J Gastroenterol 2015;34:152-57. doi: 10.1007/s12664- 015-0559-2, PMID 25925729

Garg P. Local and oral antibiotics with avoidance of constipation (LOABAC) treatment for anal fissure: A new concept in conservative management. Indian J Surg 2016;78:80. doi: 10.1007/s12262-015- 1319-3, PMID 27186052

Suevarna R, Hanumanthappa MB. Panchami. Topical diltiazem versus topical Glyceryl trinitrate (GTN) in the treatment of chronic anal fissure: Prospective study. Int J Biol Med Res 2012;3:1747-50.

Mert T. The importance of topical metronidazole in the treatment of acute anal fissure: A double-blind study controlled for prospective randomization. Ann Coloproctol 2022;10:1-7. doi: 10.3393/ac.2021.00675.0096, PMID 35038820

Shahid MH, Javed S, Javed S, Khan AZ, Kaiser A, Mithany RH. Comparative Efficacy of topical metronidazole and Glyceryl trinitrate versus topical Glyceryl trinitrate alone in the treatment of acute anal fissure: A randomized clinical trial. Cureus 2022;14:e31812. doi: 10.7759/cureus.31812, PMID 36440295

Karapolat B. Could local antibiotics be included in the treatment of acute anal fissure? Turk J Surg 2018;34:286-9. doi: 10.5152/ turkjsurg.2018.3988, PMID 30248299

Ansari NA, Bhore A, Musa O. A comparative study of topical diltiazem (2%) with topical Glyceryl trinitrate (0.2%) as a conservative treatment for anal fissure. J Clin Diagn Res 2020;14:PC08-11. doi: 10.7860/ JCDR/2020/44238.13855