Aimee Lettis from the GP Update team 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

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.

The GP Update team run one-day courses, bringing GPs up to date with all the latest evidence and guidelines.

Aimee Lettis

Aimee Lettis from the GP Update team gives us short, sharp nuggets of clinical information for sessional GPs. The GP Update team run one-day courses, bringing GPs up to date with all the latest evidence and guidelines.

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