Comparative Study between the Use of Topical GlycerylTrinitrate Vs. Topical Diltiazem in Treatment of Acute Anal Fissure

AbstractBackground: Acute anal fissure is a painful conditioncommonly results due to an increase in internal anal sphincterpressure. It is a painful condition which leads to significantmorbidity mostly in young adults. It is a split in the mucosaof the distal anal canal that can progress to form a chroniclinear ulcer. The common symptoms are severe pain on orafter defecation and bleeding per anus.Aim of Study: The main aim of this study is to evaluatethe efficacy and adverse effects of topical 2% Diltiazem (Calcium channel blocker) and topical 0.2% Glyceryl trinitrate (GTN), when administered as single agents in the treatmentof acute anal fissure.Patients and Methods: 40 Patients with acute anal fissurewere enrolled in the study. They were randomized using aclosed envelop technique into two group (20 patients each):Group A (2% Diltiazem users), and Group B (0.2% Glyceryltrinitrate users). Pain was evaluated using a pain Visual AnalogScale (VAS), we also evaluated the anal bleeding, constipation,perianal itching (anal pruritus) before, during and after thetopical medications are used, and the results of each topicalmedications as healing, recurrence rates, onset of relief ofsymptoms, onset required to achieve complete healing, numberand severity of side effects as (headache, postural hypotension,flushing, allergy, GIT upset) or ineffectiveness.Results: Both 0.2% glyceryl trinitrate ointment and 2%diltiazem ointment are equally effective concerning pain relief,and recurrence rates, while higher healing rates with topicalDiltiazem (DTZ) than topical Glyceryl Trinitrate (GTN) wererecorded (85% compared to 75% respectively). However,headache is a troublesome side effect with topical glyceryltrinitrate. Accordingly, topical 2% diltiazem is preferable asthe treatment of choice for acute anal fissure.Conclusion: Although surgical management like analdilatation and open or closed sphincterotomy are a one-timesolution with good symptomatic relief, it may be complicated by complications of wound healing, and permanent incontinence of flatus or faeces. The preferable treatment of acute anal fissure is becoming more medical since it is cost-effective. Both 0.2% glyceryl trinitrate ointment and 2% diltiazem ointment are equally effective in concerning pain relief, healing and recurrence rates. However, headache is a troublesome side effect in patients treated with topical glyceryl trinitrate.Therefore, when considering medical management for treatingacute anal fissure, topical 2% diltiazem is the treatment ofchoice.