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Diagnosis and management of anal fissures

Aimee Lettis gives us short, sharp nuggets of clinical information for sessional GPs.

I’ll cover something you will be familiar with as GPs: anal fissures, as well the new test on the block, faecal calprotectin.

Anal fissures

Maybe not the most glamorous of conditions, but a common (1 in 10 lifetime risk) and painful one! Here, I outline a recent DTB review on the non-surgical management (DTB 2013;51(9):102). But first, a quick refresher:

Aetiology

  • Acute fissures may be caused by passing a hard stool or postpartum, and most heal spontaneously
  • Chronic fissures last for > 6w and usually need treatment.
  • Occasionally fissures indicate an underlying illness such as Crohns, HIV, TB or syphilis.

Presentation

  • Main symptoms are sharp pain and bleeding on defecation, possibly with burning pain afterwards.
  • Examination should reveal a midline fissure, usually posteriorly.

Management of anal fissures

Below is a step-wise approach for primary care. First, a few key points:

  • Conservative and medical treatment heals 50% chronic fissures, but recurrence rates are high (20-30%).
  • Surgery is more effective but carries significant risk of permanent incontinence, especially in women (possibly up to 14%) and has a 33% recurrence rate.
  • Botox has a similar efficacy to GTN and is less risky than surgery.

Step 1: Conservative management for acute and chronic fissures

  • Simple analgesia after defecation.
  • High fibre diet.
  • Increased fluid intake.
  • Warm baths.
  • Topical lidocaine, but may sensitise skin and unlicensed.
  • 80% acute and 50% chronic fissures will heal with these measures.

Step 2: Try 0.4% GTN ointment for chronic fissures - £39 for 30g – licensed

  • Use twice daily for 6w.
  • 30% patients get headaches, most resolve within a few days as tolerance develops.
  • GTN patches are as effective but unlicensed.

Step 3: Try 2% diltiazem ointment - £94-139 for 30g – unlicensed

  • Third-line option as unlicensed and only available as a special, use where GTN not effective after 6w or not tolerated.
  • Apply twice daily for 6w.
  • Similar efficacy to GTN but fewer headaches.

Step 4: Refer to colorectal surgeons if not resolved with 6w of GTN or diltiazem ointment

  • For botox or surgery (lateral internal anal sphincterotomy).

Faecal calprotectin

We all know that IBS and IBD symptoms overlap, making it sometimes difficult to make a diagnosis without colonoscopy. Inflammatory markers may be misleading, giving false positives (they can be raised for many reasons) and false negatives (some patients with IBD have normal results). A test for faecal calprotectin, a protein secreted into the bowel in response to inflammation, was therefore developed. There is a near-patient test, POCT CalDetect which gives a positive or negative result and a lab-based quantitative one, with good sensitivity (93-100%) and specificity (94-95%). The good news is it costs £22-24 per test, compared with £740 for a colonoscopy!

NICE on faecal calprotectin (NICE 2013, DG11)

  • Faecal calprotectin is cost-effective and could significantly reduce numbers of referrals and colonoscopies.
  • Consider a test in adults with recent onset lower GI symptoms where you are considering referral to differentiate between IBS and IBD.
  • Don’t use this test if cancer is suspected, refer via 2WW.

So, a test to consider if you are thinking about referring for colonoscopy and the result would change your management.

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