Management of Anal Fissure and Management of Acute Severe Colitis

32 Pages·2008·0.82 MB·English

Colorectal
Disease
Position Statements:
Management of Anal Fissure
Management of Acute Severe Colitis
Contents
Position Statements
1 The Management of Anal Fissure: ACPGBI Position Statement
K. L. R. Cross, E. J. D. Massey, A. L. Fowler, J. R. T. Monson
8 The Management of Acute Severe Colitis: ACPGBI Position Statement
S. R. Brown, N. Haboubi, J. Hampton, B. George, S. P. L. Travis
Positionstatement
The Management of Anal Fissure: ACPGBI Position Statement
K. L. R. Cross
NorthDevonGeneralHospital,Barnstaple,UK
E. J. D. Massey
GloucesterRoyalHospital,Gloucester,UK
A. L. Fowler
GloucesterRoyalHospital,Gloucester,UK
J. R. T. Monson
DivisionofColorectalSurgery,UniversityofRochesterMedicalCenter,Rochester,NewYork,USA
and⁄or noted as Good Practice and⁄or part of NICE⁄
Introduction
SIGN recommendation or Rapid Technology Appraisal
Analfissureisalinearulcerinthesquamousepitheliumof (Table 1).
the anal canal located just distal tothe dentate line. It is
usually located in the posterior midline but occurs
Aetiology
anteriorlyinafifthormoreorpatients.Ittypicallycauses
pain during defaecation which may last for 1–2 h Fissures associatedwith internal analsphincter hypertonia
afterwards [1]. The most consistent finding on physical are probablyischaemic innature(Level IIb,GradeB).
examinationisspasmoftheanalcanalduetohypertonia Theaetiologyofthetypicalfissureisnotclear.Trauma
of the internal anal sphincter. It has been postulated from passing a large or hard stool is a common initiator
that this may either be due to or be the result of [3], but many traumatic fissures heal and others do not.
ischaemia [2]. All management options aim to reduce Resting anal pressure is higher in patients with an anal
analtone.Theyincludegeneralmeasures suchasdietary fissure[4].Ambulatorymanometryhasshownpersisting
fibre supplements, adequate fluid intake, and topical highanalrestingtoneinterpretedasduetohypertoniaof
analgesics, medical treatments such as glyceryl trini- the internal anal sphincter with poor spontaneous relax-
trate(GTN) ointment, calcium channel blockers (eg ation in patients with a chronic fissure [5]. In a study
diltiazem cream) and botulinum toxin. Surgery includes examining the influence of ischaemia, it was found that
lateralsphincterotomy,advancementflapproceduresand the higher the sphincter pressure, the lower the anoder-
fissurectomy. This position statement recommends mal bloodflow. This was most pronounced posteriorly
evidence-based practice associated with these treatment wheremostfissuresoccurandwasfollowedbyareturnof
options. normal bloodflow after sphincterotomy [6]. It was
postulated that the pain caused by anal fissure was
becauseofischaemiculceration,perhapsduetosphincter
Methodology
spasmreducingthebloodflowinvesselspenetratingthe
Searches of the Cochrane Database, Pub Med MED- internal anal sphincter [7] Although this has never been
LINE and EM-BASE were performed using keywords proved with certainty, it remains the most commonly
relevant to each section of this position statement. They supported theory.
were limited to English language articles. Additional Theaetiologyoffissureformationinfemaleswhohave
publications were retrieved from the references cited in hadavaginaldeliverywhethercomplicatedorassistedorin
articles identified from the primary search of the litera- patientswitharectocelemaybedifferent.Scarformation
ture.Allevidencewasclassifiedaccordingtoanaccepted maybeassociatedwithischaemiaandpoorhealing,butin
hierarchy of evidence and recommendations graded additionrestingsphincterpressureislow[8].
A–C on the basis of the level of associated evidence If the fissure is not situated in the midline or if it is
multiple or painless, the association with other patholo-
giesshouldbeconsidered.TheseincludeCrohn’sdisease,
Correspondenceto:J.R.T.Monson,DivisionofColorectalSurgery,Universityof ulcerative colitis, HIV and associated secondary infec-
RochesterMedicalCenter,601ElmwoodAvenue,BoxSURG,Rochester,New
tions, tuberculosis, syphilis, and neoplasia including
York14642,USA.
E-mail:[email protected] leukaemia orcarcinoma.
(cid:2)2008TheAuthors
JournalCompilation(cid:2)2008TheAssociationofColoproctologyofGreatBritainandIreland.ColorectalDisease,10(Suppl.3),1–7 1
Managementofanalfissure K.L.R.Crossetal.
Table1 Levelsofevidenceandgradesofrecommendation.
Levelofevidence Gradeofevidence
I Evidenceobtainedfromasinglerandomized A EvidenceoftypeIorconsistentfindings
controlledtrialorfromasystematicreview frommultiplestudiesoftypeIIa,IIborIII
ormeta-analysisofrandomizedcontrolledtrials
IIa Evidenceobtainedfromatleastonewell-designed B EvidienceoftypeIIa,IIborIIIand
controlledstudywithoutrandomization generallyconsistentfindings
IIb Evidenceobtainedfromatleastoneother C EvidenceoftypeIIaIIborIII
well-designedquasi-experimentalstudy butinconsistentfindings
III Evidenceobtainedfromwell-designed D Littleornosystematicevidence
non-experimentaldescriptivestudies,
suchascomparativestudies,correlation
studiesandcasestudies
IV Evidenceobtainedfromexpertcommittee GP Recommendedgoodpracticebased
reportsoropinionsand⁄orclinical ontheclinicalexperience
experiencesofrespectedauthorities, oftheexpertgroupandotherprofessionals*
casereports
AdaptedfromEcclesM,MasonJ1andNHSExecutive.ClinicalGuidelines:UsingClinicalGuidelinestoimprovepatientcarewithin
theNHS.London:1996.
*Previousexperienceandtheliteratureinthisareasuggeststhatgiventherelativelackofevidenceformanyhealthcareprocedures,
expertopinionandprofessionalconsensusarelikelytobeanimportantpartofthisprocess.
The presence of diseases associated with fissure as
Diagnosis
listed above should be suspected if the patient reports
Diagnosisismadefromthehistoryandexamination(Level generalsymptomsofweightlossorweaknessorabdom-
IV, GradeGP). inal symptoms referable to the gastrointestinal track. A
Anal Fissure is common. It occurs mostly between family history of inflammatory bowel disease or a mor-
the second and fourth decades of life with an equal phologicallyunusualfissureawayfromthemidlineshould
distribution between men and women with a lifetime be regarded with suspicion. At the time of the initial
incidence of 11.1% [9]. The diagnosis is usually consultationitispossibletopassapaediatricproctoscope
suspected on the history alone. The symptoms include todeterminewhethertherectalmucosaisinflamed.This
anal pain during and after defaecation which may last is usuallypain free.
several hours. Bleeding is common and tends to be
bright red and is often seen on the toilet paper. The
Treatment
patient may complain of periodic episodes indicating
chronicity.
Conservative
In most patients physical examination by inspection
ongentletractionofthebuttockswillshowthefissure.A Conservativetreatmentwillhealaproportionofacuteanal
sentinel tag at the distal pole of the fissure, a hypertro- fissures(Level I, GradeA).
phied anal papilla at its proximal extent and the appear- Conservative treatment includes increasing liquid
anceofthecircularfibresoftheinternalsphinctermuscle intake, stool softeners and topical analgesics. In a
initsbaseindicatethatthefissureischronic.Themajority prospective trial dietary bran supplements (5g three
of fissures are in the midline posteriorly, 8% occur both timesaday)andwarmsitzbathsweresuperiorwithfewer
posteriorly and anteriorly [10,11]. recurrences than topically applied local anaesthetic or
Digitalrectalexaminationorendoscopyshouldbenot hydrocortisone cream [12]. Recurrence rates were
be carried out in most patients at the time of the initial reduced from 68–16% at 1 year following continued
consultation owing to the likelihood of causing pain. If conservative management [13].
the fissure is seen on inspection then treatment can be
initiated.Ifitisnotapparentthenanexaminationunder
MedicalTherapies
anaesthetic should beadvised tomake thediagnosis and
also to exclude anorectal sepsis which is associated with Relaxation of internal anal sphincter tone is achieved
fissure ormay bepresent in its ownright. by the reduction of intracellular calcium in the
(cid:2)2008TheAuthors
2 JournalCompilation(cid:2)2008TheAssociationofColoproctologyofGreatBritainandIreland.ColorectalDisease,10(Suppl.3),1–7
K.L.R.Crossetal. Managementofanalfissure
smooth muscle cells thereby reducing muscle tone. This Calcium channel blockers, such as diltiazem and
can be achieved by nitric oxide donation using GTN or nifedipine improve fissure healing by inhibiting calcium
by direct intracellular calcium depletion using calcium ion entry through voltage-sensitive areas of vascular
channel blockers (diltiazem or nifedipine). Irreversible smooth muscle causing muscle relaxation and vascular
acetylcholine neuromuscular blockade using botulinum dilatation. In a randomized comparison of topical
toxin also reduces resting tone. diltiazem 2% with topical GTN 0.2% applied twice
daily there was no difference in healing rates [20].
Glyceryl trinitrate Diltiazem is, however, rarely associated with headache,
Topical GTN heals anal fissure better than placebo, and only occasionally associated with pruritis ani [21].
irrespective of dose but is associated with headache in Diltiazem 2% and GTN 0.2% are unlicensed so
around 25%ofpatients (Level 1,GradeA). individual drug and therapeutics hospital guidelines
Glycerine trinitrate is a vasodilator and causes will dictate availability. Oral nifedipine has been shown
relaxation of smooth muscle. When applied topically to give good healing rates, but is associated with
to the anus two to three times daily, the internal greater systemic side effects than the topical prepara-
sphincter is relaxed and the fissure heals significantly tion [22]; a similar finding was seen with oral
better than placebo. Healing occurs in only 60% of diltiazem [23].
patients in the short-term, with recurrence rates of
around one-third over 18 months. Patients with recur- Botulinum toxin
rence may respond to further GTN, but a proportion Botulinumtoxinisassociatedwithasimilarrateofhealing
will require sphincterotomy [14]. The dose of GTN ofanalfissureasGTNbutismoreexpensive.Itmaybeused
(0.2% or 0.4%) does not influence the efficacy but for a fissure resistant to topical GTN or diltiazem. The
increases the incidence of side effects, particularly technique,doseandsiteofinjectiondonotaffecttherateof
headache which occurs in about a quarter of patients healing (Level 1,GradeA).
[15,16]. Commercially available GTN ointment (‘Rec- Contraction of the internal sphincter is mediated by
togesic’ 0.4%) is often more easily available than 0.2% sympathetic neuronal activation. Botulinum toxin irre-
GTN ointment, Loder, 1994 p. 51 Watson, 1996 versibly binds to presynaptic nerve terminals preventing
p. 173 [17] and [18]. Meta-analysis has shown that acetylcholine release and thereby stopping neural trans-
topical GTN twice daily is effective although the mission. Botulinum toxin thus induces a relative hypo-
placebo response is around 30% (Fig. 1). tonia, reducing resting anal canal pressure. This effect
lastsfor2–3monthsuntilacetylcholinereaccumulatesin
Calcium channel blockers the nerveterminals [24].
Topical diltiazem has similar efficacy to GTN but with There are many different published techniques for
fewer side effects and should be recommended as first injecting botulinum toxin. The dose has varied from
line treatment in the management of anal fissure. 10–100 u (mean 23 u based on 20 trials) with a mean
Patients should be warned about pruritis ani (Level 1, healingrateof75.6%andarangeof44–100%irrespective
Grade A). ofthetechnique.Mostfrequentlytheinjectionhasbeen
Figure1 Topicalglyceryltrinitrate:fis-
surehealing.(CourtesyofProfessorNel-
son[19].)
(cid:2)2008TheAuthors
JournalCompilation(cid:2)2008TheAssociationofColoproctologyofGreatBritainandIreland.ColorectalDisease,10(Suppl.3),1–7 3
Managementofanalfissure K.L.R.Crossetal.
carried out on either side of the fissure into the internal withasignificantlyhigherrateofincontinencetoflatus.It
sphincter. Botulinum toxin has been shown to be as should be reserved for patients who fail medical treatment
effective than GTN in the primary healing of fissure (Level 1,GradeA).
[25,26], and appears to be as effective for a fissure Lateral sphincterotomy has been shown to be more
resistant to GTN [27]. There is no difference in healing effective than medical management (Fig.2). One study
rates between the different commercially available prod- reported an 85% cure rate, with 5% showing persistence
ucts including Botox or Dysport [28]. Botox costs and 10% recurrence. There was however a significant
approximately £200⁄100u. Grouping of patients on continence disturbance with 30% of patients having
the same operating list and follow-up at the same difficulty controlling flatus, 20% soiling, and 3–10%
outpatient clinic improves cost effectiveness, as one vial having episodes of leakage which appeared to depend
canbeused totreat fourpatients. on whether a closed or open lateral sphincterotomy had
been carried out. Overall there was a 90% patient
Suggested recommendation for medical management satisfaction rate [29]. A meta-analysis of the four
Anacutefissureshouldinitiallybetreatedwithincreased randomized controlled trials assessing open vs closed
intake of oral fluids, fibre, stool softeners and analgesics lateral sphincterotomy found no significant difference,
combined with the local application of diltiazem 2% buttherewasatrendtogreaterhealingandgreaterflatus
cream. A chronic fissure should be managed with incontinence in the open group [29]. By limiting the
diltiazem 2% topically twice daily for 6–8weeks where sphincterotomytothelengthofthefissure,healingrates
such a prolonged treatment schedule is clinically more are not reduced but the frequency of incontinence is
acceptable.Failureorrecurrenceaftertheapplicationofa lessened [31].
topical preparation should be treated with botulinum Basedontheevidence,theoptimalsurgicaltechnique
toxin 20–25u in two divided doses injected into the shouldinvolvetheuseofananalretractortoidentifythe
internal sphincter on either side of the fissure. Failed intersphincteric groove followed by an incision over the
medical management or recurrence warrants anorectal groove at 3 o’clock with blunt dissection of the internal
physiological testing in females, or in males having had sphincterawayfromthemucosa.Theinternalsphincteris
previous analsurgery. thendividedtothelengthofthefissure,butfornomore
than half the length of the sphincter. No difference in
healingorcomplicationshasbeenfoundwhethertheanal
Surgery
skin incision isclosed or not.
The aim of surgery is to reduce resting anal canal tone
due to the internal anal sphincter thereby increasing Fissurectomy
bloodsupplytotheanodermtoimprovehealing.Surgical Fissurectomy with or without posterior sphincterotomy
options includelateral sphincterotomy, fissurectomy and hasbeenfoundtobeusefulwhenthefissureisassociated
advancementflapprocedures.Inthepastanaldilatation, withafistula[32],butposteriorsphincterotomyhaslost
posterior sphincterotomy have been used, but there is favour as it may cause a ‘keyhole deformity’ resulting in
littleevidencetosupporttheircontinueduse.Inpatients mucous leakage in up to a third of patients [33].
withalowrestingpressureananaladvancementflapisa Fissurectomy includes excision of the fibrotic edge of
logical option. the fissure, curettage of its base, and excision of the
sentinelpileand⁄oranalpapillaifpresent.Whenusedin
Lateral sphincterotomy association with botulinum toxin in the treatment of a
Lateral sphincterotomy heals more anal fissures with lower chemicallyresistantfissure,itappearstoenhancehealing
recurrence than medical management but is associated while, avoiding therisk ofasphincterotomy [34].
Figure2 Glyceryltrinitratevssphinc-
terotomy:fissurehealing.(Courtesyof
ProfessorNelson[30]).
(cid:2)2008TheAuthors
4 JournalCompilation(cid:2)2008TheAssociationofColoproctologyofGreatBritainandIreland.ColorectalDisease,10(Suppl.3),1–7
K.L.R.Crossetal. Managementofanalfissure
Anal dilatation erate reluctance to defaecate is not uncommon. It is
Anal dilatation heals fewer fissures and is associated with important to palpate the abdomen for signs of faecal
higher rates of incontinence than lateral sphincterotomy loading.Anacutefissureusuallyhealsin10–14dayswith
andisnormallynotindicatedinthemanagementofanal conservativemanagement,includingdietarymodification
fissures (Level1, GradeA). and osmotic laxatives [42]. If the fissure persists for 6–
Manualdilatationoftheanusdoesnotappeartoheal 8 weeks chemical sphincterotomy should be considered.
analfissurealthoughitmayleadtosignificantsymptom- GTN 0.2% topically twice daily has been shown to be
atic relief. However, when uncontrolled, digital anal effective in treating children [43]. There is little infor-
stretch can cause sphincter disruption and incontinence mation on diltiazem or botulinum toxin treatment in
[35]. Different techniques of anal dilatation have been children.
tried. These include the use of an anal dilator as Surgery is rarely indicated. Anal dilatation in the
outpatienttreatment[36],dilatationinconjunctionwith management of constipation and faecal soiling has not
sphincterotomy [37] and gentle dilatation under total beenfoundtobebeneficialandisassociatedwithahigh
neuromuscularblockade[38].Thelastofthesereported rate of recurrence [44]. For an indolent fissure resistant
a retrospective review which showed minimal inconti- to healing, fissurectomy and lateral sphincterotomy have
nence. In a meta-analysis anal dilatation caused signifi- been found to be beneficial [45,46]. The surgical
cantly more incontinence and healed fewer fissures than technique is thesame asforadults.
sphincterotomy [30]. Forfurtherfulltextreferenceinformation,pleaserefer
to the recently published systematic review by Bhardwaj
Anal advancement flap Rand ParkerMC[47].
Ananal advancementflap iseffective inhealing ananal
fissure and is followed by minor complications only. It
Management algorithim
shouldberecommendedinpatientswithalowrestinganal
Acute
pressure (Level 1, Grade A). Various flaps have been
described but a rotational or V–Y flap may reduce
Conservative
complications (LevelIII, GradeB).
An island flap in which a circumcised area of perianal Chronic
skin is advanced proximally tocover the fissure has been
shown to be effective in healing with no incidence of Diltiazem 2%/GTN
incontinence [39,40]. An alternative to this is a V–Y BD 2/12
advancement flap or a rotational flap, which are both Patient wants operation
associated with lower rates of donor site wound compli- understanding risks
cations, reported tobeas highas 60%[41]. Botulinum toxin (repeat)
‘Ideal’ management recommendations
Female post-partum
Lateral sphincterotomy should be used when medical Male previous anal surgery
managementfailsinmenorwomenwithnormaltohigh
resting tone. An alternative may be fissurectomy and Lateral sphincterotomy Anorectal physiology
botulinumtoxin.Inpatientswithlowanalrestingtonean
anal advancement flap is a preferable option (see man-
High Low
agement algorithm). pressure pressure
Consider fissurectomy and
Botulinum toxin
Anal fissure in children
Lateral sphincterotomy Anal advancement flap
Fissureinchildrenshouldbetreatedconservativelyinitially.
Ifitfailstorespond,localGTNorcalciumchannelblockers
should be tried. Lateral sphincterotomy or fissurectomy
Conflicts of Interest
should be reserved for those failing to heal with medical
treatment (LevelIIa, GradeB). Nonedeclared
Most fissures occur in children aged between 6 and
24 months usually as a result of a mechanical tear. If
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JournalCompilation(cid:2)2008TheAssociationofColoproctologyofGreatBritainandIreland.ColorectalDisease,10(Suppl.3),1–7 7
Positionstatement
The Management of Acute Severe Colitis: ACPGBI Position
Statement
S. R. Brown
SheffieldTeachingHospitals,Sheffield,UK
N. Haboubi
TraffordHospitalsNHSTrust,Manchester,UK
J. Hampton
SheffieldTeachingHospitals,Sheffield,UK
B. George
JohnRadcliffeHospital,Oxford,UK
S. P. L. Travis
JohnRadcliffeHospital,Oxford,UK
steroids of severe colitis has remained unchanged for
Introduction
50 years[9].Furthermore,nonspecialistmanagementof
‘Acute severe colitis’ (formerly known as fulminant severe colitis still carries high risk. Of 32 admissions (in
colitis) is a potentially life-threatening condition that 25patients)forseverecolitisundergeneralphysiciansina
constitutes a medical and surgical emergency. The small UK district general hospital between 1994 and
majority of cases are due to ulcerative colitis (UC), 2000, sixpatients died[10].
although other causes such as Crohn’s colitis and Perhaps more than any other condition, severe acute
pseudomembranous colitis (PMC)canresult in asimilar colitis requires the highest level of cooperation between
clinicalpicture.Theconditioniscommon;theprevalence surgeonandphysicianandspecialistmanagementforthe
isaround15%[1].AsaveryroughestimatefortheUK, most favourable outcome. This position statement sets
thereareabout2500admissionsperyear[2,3]oraround out to examine the current literature on this condition
onepatientper22 000population(about12patientsper andtoprovideanevidence-baseuponwhichpractitioners
year for a District General Hospital). More precise data canbase individual management.
will result from the UK National IBD Audit (http://
ibdaudit.rcplondon.ac.uk/2006/).
Methodology
Tounderstandtheimplicationsofcurrentmedicaland
surgicaltherapy,themanagementfirstneedstobeplaced Organized searches of the Cochrane Database, MED-
in historical context. In 1933, the mortality in the first LINE and EM-BASE were performed using keywords
yearafteracutepresentationwas75%[4]andoftheorder relevant to each section of this position statement.
of 50% following ileostomy. With the introduction of SearcheswerelimitedpredominantlytoEnglishlanguage
excision of the disease by colectomy by Miller etal. [5] articles. Additional publications were retrieved from the
towards the end of the 1940s, the mortality rate fell to references cited in articles identified from the primary
5%. This was achieved by other units at the time, search of the literature. All evidence was classified
although, in some, mortality was still over 20% in the according to an accepted hierarchy of evidence and
early 1950s [6]. In 1955, the introduction of steroid recommendationsgradedA–Conthebasisofthelevelof
therapy was reported to reduce the mortality of severe associated evidence and⁄or noted as Good Practice
colitisfrom24%to7%,[7]anditisnowlessthan1%in and⁄or part of NICE⁄SIGN recommendation or Rapid
specialist centres [8]. Nevertheless, the response to Technology Appraisal (Table 1) [11,12]. The five main
sections addressed within this statement are medical
diagnosis and assessment (ST), pathological diagnosis
Correspondenceto:MrS.R.Brown,DepartmentofSurgery,NorthernGeneral
(NH), radiological diagnosis (JH) nonsurgical manage-
Hospital,HerriesRd,SheffieldS57AU,UK.
E-mail:[email protected] ment (ST) and surgical management (BG).
(cid:2)2008TheAuthors
8 JournalCompilation(cid:2)2008TheAssociationofColoproctologyofGreatBritainandIreland.ColorectalDisease,10(Suppl.3),8–29