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Identifying the best therapy for chronic anal fissure.

ABSTRACT: Chronic anal fissure (CAF) is a painful tear or crack which occurs in the anoderm. The optimal algorithm of therapy for CAF is still debated. Lateral internal sphincterotomy (LIS) is a surgical treatment, considered as the 'gold standard' therapy for CAF. It relieves CAF symptoms with a high rate of healing. Chemical sphincterotomy (CS) with nitrates, calcium blockers or botulinum toxin (BTX) is safe, with the rapid relief of pain, mild side-effects and no risk of surgery or anesthesia, but is a statistically less effective therapy for CAF than LIS. This article considers if aggressive treatment should only be offered to patients who fail pharmacological sphincterotomy. Aspects of anal fissure etiology, epidemiology and pathophysiology are considered with their meaning for further management of CAF. A molecular model of chemical interdependence significant for the chemistry of CAF healing is examined. Its application may influence the development of optimal therapy for CAF. BTX is currently considered the most effective type of CS and discussion in this article scrutinizes this method specifically. Although the effectiveness of BTX vs. LIS has been discussed, the essential focus of the article concerns identifying the best therapy application for anal fissure. Elements are presented which may help us to predict CAF healing. They provide rationale for the expansion of the CAF therapy algorithm. Ethical and economic factors are also considered in brief. As long as the patient is willing to accept the potential risk of fecal incontinence, we have grounds for the 'gold standard' (LIS) as the first-line treatment for CAF. The author concludes that, when the diagnosis of the anal fissure is established, CS should be considered for both ethical and economic reasons. He is convinced that a greater understanding and recognition of benign anal disorders by the GP and a proactive involvement at the point of initial diagnosis would facilitate the consideration of CS at an earlier, more practical stage with improved outcomes for the patient.

SUBMITTER: Madalinski MH

PROVIDER: S-EPMC3091162 | biostudies-literature | 2011 Apr

REPOSITORIES: biostudies-literature

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Identifying the best therapy for chronic anal fissure.

Madalinski Mariusz H MH

World journal of gastrointestinal pharmacology and therapeutics 20110401 2

Chronic anal fissure (CAF) is a painful tear or crack which occurs in the anoderm. The optimal algorithm of therapy for CAF is still debated. Lateral internal sphincterotomy (LIS) is a surgical treatment, considered as the 'gold standard' therapy for CAF. It relieves CAF symptoms with a high rate of healing. Chemical sphincterotomy (CS) with nitrates, calcium blockers or botulinum toxin (BTX) is safe, with the rapid relief of pain, mild side-effects and no risk of surgery or anesthesia, but is a ...[more]

PMID: 21577312

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Project description:BackgroundPsychological models are used to understand and predict behaviour in a wide range of settings, but have not been consistently applied to health professional behaviours, and the contribution of differing theories is not clear. This study explored the usefulness of a range of models to predict an evidence-based behaviour -- the placing of fissure sealants.MethodsMeasures were collected by postal questionnaire from a random sample of general dental practitioners (GDPs) in Scotland. Outcomes were behavioural simulation (scenario decision-making), and behavioural intention. Predictor variables were from the Theory of Planned Behaviour (TPB), Social Cognitive Theory (SCT), Common Sense Self-regulation Model (CS-SRM), Operant Learning Theory (OLT), Implementation Intention (II), Stage Model, and knowledge (a non-theoretical construct). Multiple regression analysis was used to examine the predictive value of each theoretical model individually. Significant constructs from all theories were then entered into a 'cross theory' stepwise regression analysis to investigate their combined predictive value.ResultsBehavioural simulation - theory level variance explained was: TPB 31%; SCT 29%; II 7%; OLT 30%. Neither CS-SRM nor stage explained significant variance. In the cross theory analysis, habit (OLT), timeline acute (CS-SRM), and outcome expectancy (SCT) entered the equation, together explaining 38% of the variance. Behavioural intention - theory level variance explained was: TPB 30%; SCT 24%; OLT 58%, CS-SRM 27%. GDPs in the action stage had significantly higher intention to place fissure sealants. In the cross theory analysis, habit (OLT) and attitude (TPB) entered the equation, together explaining 68% of the variance in intention.SummaryThe study provides evidence that psychological models can be useful in understanding and predicting clinical behaviour. Taking a theory-based approach enables the creation of a replicable methodology for identifying factors that may predict clinical behaviour and so provide possible targets for knowledge translation interventions. Results suggest that more evidence-based behaviour may be achieved by influencing beliefs about the positive outcomes of placing fissure sealants and building a habit of placing them as part of patient management. However a number of conceptual and methodological challenges remain.

Project description:Fluid assisted Alpine fissure-vein and cleft formation starts at prograde, peak or retrograde metamorphic conditions of 450-550 °C and 0.3-0.6 GPa and below, commonly at conditions of ductile to brittle rock deformation. Early-formed fissures become overprinted by subsequent deformation, locally leading to a reorientation. Deformation that follows fissure formation initiates a cycle of dissolution, dissolution/reprecipitation or new growth of fissure minerals enclosing fluid inclusions. Although fissures in upper greenschist and amphibolite facies rocks predominantly form under retrograde metamorphic conditions, this work confirms that the carbon dioxide fluid zone correlates with regions of highest grade Alpine metamorphism, suggesting carbon dioxide production by prograde devolatilization reactions and rock-buffering of the fissure-filling fluid. For this reason, fluid composition zones systematically change in metamorphosed and exhumed nappe stacks from diagenetic to amphibolite facies metamorphic rocks from saline fluids dominated by higher hydrocarbons, methane, water and carbon dioxide. Open fissures are in most cases oriented roughly perpendicular to the foliation and lineation of the host rock. The type of fluid constrains the habit of the very frequently crystallizing quartz crystals. Open fissures also form in association with more localized strike-slip faults and are oriented perpendicular to the faults. The combination of fissure orientation, fissure quartz fluid inclusion and fissure monazite-(Ce) (hereafter monazite) Th-Pb ages shows that fissure formation occurred episodically (1) during the Cretaceous (eo-Alpine) deformation cycle in association with exhumation of the Austroalpine Koralpe-Saualpe region (~ 90 Ma) and subsequent extensional movements in association with the formation of the Gosau basins (~ 90-70 Ma), (2) during rapid exhumation of high-pressure overprinted Briançonnais and Piemontais units (36-30 Ma), (3) during unroofing of the Tauern and Lepontine metamorphic domes, during emplacement and reverse faulting of the external Massifs (25-12 Ma; except Argentera) and due to local dextral strike-slip faulting in association with the opening of the Ligurian sea, and (4) during the development of a young, widespread network of ductile to brittle strike-slip faults (12-5 Ma).Supplementary informationThe online version contains supplementary material available at 10.1186/s00015-021-00391-9.

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Identifying the best therapy for chronic anal fissure.

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Identifying the best therapy for chronic anal fissure.

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