logging in or signing up MEDICAL MANAGEMENT OF ANAL FISSURES SANOOPKZ Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 796 Category: Education License: All Rights Reserved Like it (12) Dislike it (0) Added: July 02, 2010 This Presentation is Public Favorites: 2 Presentation Description AN EVIDENCE BASED APPROACH TO MEDICAL MANAGEMENT OF FISSURE IN ANO. Comments Posting comment... By: haitham112002 (12 month(s) ago) your lecture seems of benefit for me and other surgeons with interest in colorectal surgery. kindly allow me to download the lecture . best regards Saving..... Post Reply Close Saving..... Edit Comment Close By: basindhi (13 month(s) ago) nice presentation, would you plz allow me to download Saving..... Post Reply Close Saving..... Edit Comment Close By: ssugaprakash (19 month(s) ago) lockhart mummery theory is good. many examiners are fond of this question Saving..... Post Reply Close Saving..... Edit Comment Close By: SANOOPKZ (19 month(s) ago) thank u-i shall mail u ASAP. Saving..... Post Reply Close Saving..... Edit Comment Close By: shaby (19 month(s) ago) could u send this ppt on my email which is impktun@gmail.com Saving..... Post Reply Close Saving..... Edit Comment Close loading.... See all Premium member Presentation Transcript Slide 1: FISSURE IN ANO ETIOPATHOGENESIS AND MEDICAL MANAGEMENT DR SANOOP K ZACHARIAH WHAT IS AN ANAL FISSURE ? : WHAT IS AN ANAL FISSURE ? A SPLIT/CRACK/LINEAR ULCER SKIN LINED DISTAL ANAL CANAL BELOW THE DENTATE LINE EXTENDING TO THE ANAL VERGE SENSITIVE STRATISFIED EPITHELIUM(ANODERM) COMPONENTS OF DEFINITION SIGNIFICANCE? : SIGNIFICANCE? SMALL LESION WITH SIGNIFICANTLY DISTRESSING SYMPTOMS TYPES/CLASSIFICATION : TYPES/CLASSIFICATION Based On Duration ACUTE CHRONIC -> 6 -8 WEEKS Based On Eitiology PRIMARY(IDIOPATHIC) SECONDARY INCIDENCE : INCIDENCE M:F 1:1 COMMONEST CAUSE OF RECTAL BLEED IN INFANTS YOUNG ADULTS MIDDLE AGED LOCATION : LOCATION COMMONEST -POSTERIOR(M&F) FEMALES - 10% ANTERIOR MALES- 1% ANTERIOR ABNORMAL LOCATIONS CONSIDER SECONDARY FISSURES ETIOLOGY : ETIOLOGY UNKNOWN CONSTIPTION DIARRHOEA HARD STOOLS INTERNAL SPHINCTER ABNORMALITIES LOCAL ISCHAEMIA POOR ANAL MUCOSAL SUPPORT ANTIBODIES TRAUMA NEOPLASIA IBD PRIOR ANAL SURGREY ANAL INTERCOURSE STD TB PRIMARY SECONDARY CONCEPTS : CONCEPTS LOCKHART MUMMERY’ S (ANATOMICAL CONCEPT) ELLIPTICAL EXTERNAL SPHINCTER POOR ANAL MUCOSAL SUPPORT POSTERIORLY POSTERIOR FISSURE REDUCED ANO DERMAL BLOOD FLOW : REDUCED ANO DERMAL BLOOD FLOW Post mortem angiographic studies-klosterhalfen -85%of specimens(dis colo rectum ,19893;32-43) Histologic studies on cadavers- Doppler flowmetry study-schouten & colleagues dis colo rectum 1994;37;664 LESSER PERFORATING ARTERIOLES AND BLOOD FLOW IN POSTERIOR MIDLINE OF THE ANAL CANAL PERPENDICULAR INF.RECTAL ARTERY FECAL MASS COMPRESSING ARTERY SPHINCTER HYPERTONIA : SPHINCTER HYPERTONIA INCREASED RESTING ANAL CANAL PRESSURES IN FISSURES OVERSHOOT PHENOMENON(REFLEX SPINCTER SPASM) PERSISTENT SPHINCTER HYPERTONIA Evidence from physiologic studies Arabi et al 1977(AM J SURG 1977 64;92-5) Gibbons & Reed-perfusion probes,1986(BR J SURG,198673;443-5) Nothmann & collaegues-ballon manometry,1974(GASTROENTEROLOGY67;216-20) Keck & colleagues-computer assisted studies,1995(DIS COLON RECTUM 32-43) CLINICAL FEATURES : CLINICAL FEATURES PAIN(DYSCHEZIA) BLEEDING ACUTE FISSURES P A I N (DYSCHEZIA) BLEEDING ACUTE FISSURES CHRONIC FISSURES : CHRONIC FISSURES PAIN DISCHARGE PRURITIS SENTINEL PILE/TAG SECONDARY CHANGES SENTINEL TAG HYPERTROPHIC ANAL PAPILLA ABSCESS LOW FISTULA DIAGNOSIS : DIAGNOSIS HISTORY EXAMINATION INSPECTION DRE-??ACUTE(local anesthetic) CHRONIC PROCTOSCOPY UNDER ANAESTHESIA SIGMOIDOSCOPY(WHEN IN DOUBT) ACUTE- MAXIMAL TENDERNESS OVER THE FISSURE CHRONIC- SECONDARY CHANGES OBVIOUS, CANOE SHAPED ULCER, BUTTON HOLE DEFORMITY VISCIOUS CYCLE : VISCIOUS CYCLE AIMS OF MANAGEMENT : AIMS OF MANAGEMENT RELIEF OF PAIN RELAXATION OF THE INTERNAL SPHINCTER HEALING OF THE FISSURE PREVENT RECURRANCE BREAK VISCIOUS CYCLE : BREAK VISCIOUS CYCLE RELEIVE SPASM AND THE FISSURE WILL HEAL MEDICAL MANAGEMENT : MEDICAL MANAGEMENT FIRST LINE AGENTS SECOND LINE AGENTS GENERAL MEASURES CHEMICAL SPHINCTEROTOMY GENERAL MEASURES : GENERAL MEASURES Adequate fluid intake (6-8 glasses of liquids) Fiber rich diet ( vegetables, fruits, brown rice) Bulk forming agents (psyllium husk, bran) Stool softeners (Lactulose) Local anesthetic agents (Lignocaine 5%) Sitz bath 80% OF FISSURES WILL RESOLVE Slide 19: AVOID CONSTIPATION CHEMICAL SPHINCTEROTOMY : CHEMICAL SPHINCTEROTOMY AIMS TO REDUCE RESTING ANAL CANAL PRESSURE(REVERSIBLE) INCREASE PERFUSION PROMOTE PAINLESS DEFECATION ENVIORONMENT FOR HEALING AGENTS : AGENTS GLYCERINE TRINITRATE(GTN) CALCIUM CHANNEL BLOCKERS(CCB) BOTULINUM TOXIN(BTX) GTN : GTN NITRIC OXIDE DONOR INHIBITORY NEURO TRANSMITTER DIFFUFFES ACROSS MUCOSA RELAXES INTERNAL SPHINCTER VASODILATATION DECREASES RESTING PRESSURE CURE RATE 68% AFTER 8 WEEKS 2- 6 HOURS DURATION REC . DOSE 0.2% CREAM L.A, B.D / T.I.D, 6 - 8 WEEKS HEAD ACHE A PROMINENT SIDE EFFECT ( 27% – 34%) CA CHANNEL BLOCKERS : CA CHANNEL BLOCKERS NIFEDIPINE & DILTIAZEM( ANTIHYPERTENSIVE VASODILATORS) NIFEDIPINE 20 MG B.D / 0.5% CREAM B.D, 4 - 6 WEEKS DILTIAZEM 60MG B.D / 2% CREAM B.D, 4-6 WEEKS (knight & coworkers-75%healing) L.A BETTER THAN ORAL MEDICATIONS SIDE EFFECTS …… HEAD ACHE, POSTURAL HYPOTENSION CA-IONS SMOOTH MUSCLE CONTRACTION L TYPE CHANNELS SIGNIFICANT RESTING PRESSURE BOTOX : BOTOX CLOSTRIDIUM BOTULINUM INHIBITS ACETYLCHOLINE RELEASE AT THE NMJ INCREASES BLOOD FLOW 30 UNITS (10 – 100 UNITS) OF BOTULINUM TOXIN A INJECTED INTO THE INTERNAL SPHINCTER, ON EITHER SIDE OF THE FISSURE, ONCE A MONTH AVERAGE HEALING RATES OF 47% - 65% UNTOWARD EFFECTS FLATUS INCONTINENCE, MUSCLE WEAKNESS, FAECAL SOILING, LOCAL EFFECTS INCREASE IN RESIDUAL URINE FIRST REPORTED – JUST AND SCHIMRIGK , 1993,DIS.COLON.RECTUM NEWER AGENTS : NEWER AGENTS SILDENAPHIL(VIAGRA) TOPICAL SILDENAPHIL(phosphdiesterase-5 inhibitor) REDUCES RESTING ANAL PRESSURE SIGNIFICANTLY (TORABADELLA ET AL 2004) INDORAMIN MINOXIDIL HYPERBARIC OXYGEN L-ARGININE (NITRIC OXIDE PRECURSOR HEALING WITHOUT HEADACHE) OBSELETE AGENTS : OBSELETE AGENTS SCLEROTHERAPY BETHENECOL CREAM SOLCODERM ANAL DILATORS EVIDENCE : EVIDENCE COCHRANE DATABASE SYSTEMATIC REVIEW:2007 NON SURGICAL THERAPY FOR ANAL FISSURE Nelson R 1966 to May 2006 54 Randomized Controlled Trials 48 different comparisons 3904 patients 11 AGENTS (BRAN,GTN,CCB(DTZ,NP),LIGNOCAINE,MINOXIDIL,INDORAMIN,SURGERY ETC) EVIDENCE… : MOST ACUTE FISSURES CAN BE MANAGED BY GENERAL MEASURES BULKING AGENTS ( BRAN ) BETTER THAN OTHERS FAILURES TO BE MANAGED BY CHEMICAL SPINCTEROTOMY COMBINATION OF MODALITIES WORK BETTER MEDICAL THERAPY MAY OFFER CHANCE FOR CURE BTX,DTZ,GTN EFFICACY EQUAL AND BETTER THAN PLACEBO NO MEDICAL THERAPY CAME CLOSE TO EFFICACY OF SURGICAL SPHINCTEROTOMY EVIDENCE… Slide 29: summary MANAGEMENT OF ANAL FISSURES Slide 30: Irrespective to the approach to treatment, every patient, physician and surgeon should accept the validity of the concept that when pain resulting from anal fissure is intolerable, when the fissure has been unresponsive to non operative management, when the fissure has been present from a long time or when the fissure recurs after non operative management, an operative approach is indicated M.L.Corman.Colon and Rectal Surgery.5th Edn.Lippincott,Williams and Wilkins; 1998 Thank u : Thank u You do not have the permission to view this presentation. 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MEDICAL MANAGEMENT OF ANAL FISSURES SANOOPKZ Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 796 Category: Education License: All Rights Reserved Like it (12) Dislike it (0) Added: July 02, 2010 This Presentation is Public Favorites: 2 Presentation Description AN EVIDENCE BASED APPROACH TO MEDICAL MANAGEMENT OF FISSURE IN ANO. Comments Posting comment... By: haitham112002 (12 month(s) ago) your lecture seems of benefit for me and other surgeons with interest in colorectal surgery. kindly allow me to download the lecture . best regards Saving..... Post Reply Close Saving..... Edit Comment Close By: basindhi (13 month(s) ago) nice presentation, would you plz allow me to download Saving..... Post Reply Close Saving..... Edit Comment Close By: ssugaprakash (19 month(s) ago) lockhart mummery theory is good. many examiners are fond of this question Saving..... Post Reply Close Saving..... Edit Comment Close By: SANOOPKZ (19 month(s) ago) thank u-i shall mail u ASAP. Saving..... Post Reply Close Saving..... Edit Comment Close By: shaby (19 month(s) ago) could u send this ppt on my email which is impktun@gmail.com Saving..... Post Reply Close Saving..... Edit Comment Close loading.... See all Premium member Presentation Transcript Slide 1: FISSURE IN ANO ETIOPATHOGENESIS AND MEDICAL MANAGEMENT DR SANOOP K ZACHARIAH WHAT IS AN ANAL FISSURE ? : WHAT IS AN ANAL FISSURE ? A SPLIT/CRACK/LINEAR ULCER SKIN LINED DISTAL ANAL CANAL BELOW THE DENTATE LINE EXTENDING TO THE ANAL VERGE SENSITIVE STRATISFIED EPITHELIUM(ANODERM) COMPONENTS OF DEFINITION SIGNIFICANCE? : SIGNIFICANCE? SMALL LESION WITH SIGNIFICANTLY DISTRESSING SYMPTOMS TYPES/CLASSIFICATION : TYPES/CLASSIFICATION Based On Duration ACUTE CHRONIC -> 6 -8 WEEKS Based On Eitiology PRIMARY(IDIOPATHIC) SECONDARY INCIDENCE : INCIDENCE M:F 1:1 COMMONEST CAUSE OF RECTAL BLEED IN INFANTS YOUNG ADULTS MIDDLE AGED LOCATION : LOCATION COMMONEST -POSTERIOR(M&F) FEMALES - 10% ANTERIOR MALES- 1% ANTERIOR ABNORMAL LOCATIONS CONSIDER SECONDARY FISSURES ETIOLOGY : ETIOLOGY UNKNOWN CONSTIPTION DIARRHOEA HARD STOOLS INTERNAL SPHINCTER ABNORMALITIES LOCAL ISCHAEMIA POOR ANAL MUCOSAL SUPPORT ANTIBODIES TRAUMA NEOPLASIA IBD PRIOR ANAL SURGREY ANAL INTERCOURSE STD TB PRIMARY SECONDARY CONCEPTS : CONCEPTS LOCKHART MUMMERY’ S (ANATOMICAL CONCEPT) ELLIPTICAL EXTERNAL SPHINCTER POOR ANAL MUCOSAL SUPPORT POSTERIORLY POSTERIOR FISSURE REDUCED ANO DERMAL BLOOD FLOW : REDUCED ANO DERMAL BLOOD FLOW Post mortem angiographic studies-klosterhalfen -85%of specimens(dis colo rectum ,19893;32-43) Histologic studies on cadavers- Doppler flowmetry study-schouten & colleagues dis colo rectum 1994;37;664 LESSER PERFORATING ARTERIOLES AND BLOOD FLOW IN POSTERIOR MIDLINE OF THE ANAL CANAL PERPENDICULAR INF.RECTAL ARTERY FECAL MASS COMPRESSING ARTERY SPHINCTER HYPERTONIA : SPHINCTER HYPERTONIA INCREASED RESTING ANAL CANAL PRESSURES IN FISSURES OVERSHOOT PHENOMENON(REFLEX SPINCTER SPASM) PERSISTENT SPHINCTER HYPERTONIA Evidence from physiologic studies Arabi et al 1977(AM J SURG 1977 64;92-5) Gibbons & Reed-perfusion probes,1986(BR J SURG,198673;443-5) Nothmann & collaegues-ballon manometry,1974(GASTROENTEROLOGY67;216-20) Keck & colleagues-computer assisted studies,1995(DIS COLON RECTUM 32-43) CLINICAL FEATURES : CLINICAL FEATURES PAIN(DYSCHEZIA) BLEEDING ACUTE FISSURES P A I N (DYSCHEZIA) BLEEDING ACUTE FISSURES CHRONIC FISSURES : CHRONIC FISSURES PAIN DISCHARGE PRURITIS SENTINEL PILE/TAG SECONDARY CHANGES SENTINEL TAG HYPERTROPHIC ANAL PAPILLA ABSCESS LOW FISTULA DIAGNOSIS : DIAGNOSIS HISTORY EXAMINATION INSPECTION DRE-??ACUTE(local anesthetic) CHRONIC PROCTOSCOPY UNDER ANAESTHESIA SIGMOIDOSCOPY(WHEN IN DOUBT) ACUTE- MAXIMAL TENDERNESS OVER THE FISSURE CHRONIC- SECONDARY CHANGES OBVIOUS, CANOE SHAPED ULCER, BUTTON HOLE DEFORMITY VISCIOUS CYCLE : VISCIOUS CYCLE AIMS OF MANAGEMENT : AIMS OF MANAGEMENT RELIEF OF PAIN RELAXATION OF THE INTERNAL SPHINCTER HEALING OF THE FISSURE PREVENT RECURRANCE BREAK VISCIOUS CYCLE : BREAK VISCIOUS CYCLE RELEIVE SPASM AND THE FISSURE WILL HEAL MEDICAL MANAGEMENT : MEDICAL MANAGEMENT FIRST LINE AGENTS SECOND LINE AGENTS GENERAL MEASURES CHEMICAL SPHINCTEROTOMY GENERAL MEASURES : GENERAL MEASURES Adequate fluid intake (6-8 glasses of liquids) Fiber rich diet ( vegetables, fruits, brown rice) Bulk forming agents (psyllium husk, bran) Stool softeners (Lactulose) Local anesthetic agents (Lignocaine 5%) Sitz bath 80% OF FISSURES WILL RESOLVE Slide 19: AVOID CONSTIPATION CHEMICAL SPHINCTEROTOMY : CHEMICAL SPHINCTEROTOMY AIMS TO REDUCE RESTING ANAL CANAL PRESSURE(REVERSIBLE) INCREASE PERFUSION PROMOTE PAINLESS DEFECATION ENVIORONMENT FOR HEALING AGENTS : AGENTS GLYCERINE TRINITRATE(GTN) CALCIUM CHANNEL BLOCKERS(CCB) BOTULINUM TOXIN(BTX) GTN : GTN NITRIC OXIDE DONOR INHIBITORY NEURO TRANSMITTER DIFFUFFES ACROSS MUCOSA RELAXES INTERNAL SPHINCTER VASODILATATION DECREASES RESTING PRESSURE CURE RATE 68% AFTER 8 WEEKS 2- 6 HOURS DURATION REC . DOSE 0.2% CREAM L.A, B.D / T.I.D, 6 - 8 WEEKS HEAD ACHE A PROMINENT SIDE EFFECT ( 27% – 34%) CA CHANNEL BLOCKERS : CA CHANNEL BLOCKERS NIFEDIPINE & DILTIAZEM( ANTIHYPERTENSIVE VASODILATORS) NIFEDIPINE 20 MG B.D / 0.5% CREAM B.D, 4 - 6 WEEKS DILTIAZEM 60MG B.D / 2% CREAM B.D, 4-6 WEEKS (knight & coworkers-75%healing) L.A BETTER THAN ORAL MEDICATIONS SIDE EFFECTS …… HEAD ACHE, POSTURAL HYPOTENSION CA-IONS SMOOTH MUSCLE CONTRACTION L TYPE CHANNELS SIGNIFICANT RESTING PRESSURE BOTOX : BOTOX CLOSTRIDIUM BOTULINUM INHIBITS ACETYLCHOLINE RELEASE AT THE NMJ INCREASES BLOOD FLOW 30 UNITS (10 – 100 UNITS) OF BOTULINUM TOXIN A INJECTED INTO THE INTERNAL SPHINCTER, ON EITHER SIDE OF THE FISSURE, ONCE A MONTH AVERAGE HEALING RATES OF 47% - 65% UNTOWARD EFFECTS FLATUS INCONTINENCE, MUSCLE WEAKNESS, FAECAL SOILING, LOCAL EFFECTS INCREASE IN RESIDUAL URINE FIRST REPORTED – JUST AND SCHIMRIGK , 1993,DIS.COLON.RECTUM NEWER AGENTS : NEWER AGENTS SILDENAPHIL(VIAGRA) TOPICAL SILDENAPHIL(phosphdiesterase-5 inhibitor) REDUCES RESTING ANAL PRESSURE SIGNIFICANTLY (TORABADELLA ET AL 2004) INDORAMIN MINOXIDIL HYPERBARIC OXYGEN L-ARGININE (NITRIC OXIDE PRECURSOR HEALING WITHOUT HEADACHE) OBSELETE AGENTS : OBSELETE AGENTS SCLEROTHERAPY BETHENECOL CREAM SOLCODERM ANAL DILATORS EVIDENCE : EVIDENCE COCHRANE DATABASE SYSTEMATIC REVIEW:2007 NON SURGICAL THERAPY FOR ANAL FISSURE Nelson R 1966 to May 2006 54 Randomized Controlled Trials 48 different comparisons 3904 patients 11 AGENTS (BRAN,GTN,CCB(DTZ,NP),LIGNOCAINE,MINOXIDIL,INDORAMIN,SURGERY ETC) EVIDENCE… : MOST ACUTE FISSURES CAN BE MANAGED BY GENERAL MEASURES BULKING AGENTS ( BRAN ) BETTER THAN OTHERS FAILURES TO BE MANAGED BY CHEMICAL SPINCTEROTOMY COMBINATION OF MODALITIES WORK BETTER MEDICAL THERAPY MAY OFFER CHANCE FOR CURE BTX,DTZ,GTN EFFICACY EQUAL AND BETTER THAN PLACEBO NO MEDICAL THERAPY CAME CLOSE TO EFFICACY OF SURGICAL SPHINCTEROTOMY EVIDENCE… Slide 29: summary MANAGEMENT OF ANAL FISSURES Slide 30: Irrespective to the approach to treatment, every patient, physician and surgeon should accept the validity of the concept that when pain resulting from anal fissure is intolerable, when the fissure has been unresponsive to non operative management, when the fissure has been present from a long time or when the fissure recurs after non operative management, an operative approach is indicated M.L.Corman.Colon and Rectal Surgery.5th Edn.Lippincott,Williams and Wilkins; 1998 Thank u : Thank u