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## Complete Summary

#### GUIDELINE TITLE

American Gastroenterological Association medical position statement:
diagnosis and care of patients with anal fissure.

#### BIBLIOGRAPHIC SOURCE(S)

American Gastroenterological Association medical position statement:
Diagnosis and care of patients with anal fissure. Gastroenterology 2003
Jan;124(1):233-4. \[1 reference\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12512045)

#### GUIDELINE STATUS

This is the current release of the guideline.

According to the guideline developer, the Clinical Practice Committee
meets three times a year to review all American Gastroenterological
Association Institute (AGAI) guidelines. This review includes new
literature searches of electronic databases followed by expert committee
review of new evidence that has emerged since the original publication
date.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Acute/chronic anal fissures

#### GUIDELINE CATEGORY

Diagnosis\
Management\
Treatment

#### CLINICAL SPECIALTY

Colon and Rectal Surgery\
Family Practice\
Gastroenterology\
Internal Medicine

#### INTENDED USERS

Physicians

#### GUIDELINE OBJECTIVE(S)

To provide a rational basis for the diagnosis and treatment of patients
with anal fissures

#### TARGET POPULATION

Adult patients with anal fissures

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Diagnosis**

1.  Medical history

2.  Physical examination, including examination under anesthesia as
    warranted

**Treatment**

1.  Conservative care, including fiber supplements, adequate fluid
    intake, sitz baths, topical analgesics

2.  Topical therapy (e.g., glyceryl trinitrate \[GTN\] ointment, calcium
    channel blockers such as nifedipine and diltiazem)

3.  Locally injected botulin toxin

4.  Lateral internal sphincterotomy (LIS)

5.  Isosorbide dinitrate (ISDN), pharmacological sphincter relaxants,
    manual anal dilation, muscarinic agonists, adrenergic agonists and
    antagonists were considered but not recommended

#### MAJOR OUTCOMES CONSIDERED

-   Differential diagnosis of acute versus chronic fissures

-   Symptom relief

-   Healing rates

-   Recurrence rates

-   Postoperative incontinence rates

-   Incidence of underlying pathology such as Crohn´s disease, HIV/AIDS,
    tuberculosis, syphilis, or anal carcinoma in patients with anal
    fissures

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

A MEDLINE search of the English language literature (1980-1999) was
performed using the medical subject terms *anal fissure*
cross-referenced with *etiology*, *treatment*, and *surgery*. From the
reviewed literature, articles of particular importance published in
earlier years were also identified.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Subjective Review

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

This paper was approved by the American Gastroenterological Association
(AGA) Clinical Practice Committee on May 19, 2002 and by the AGA
Governing Board on July 27, 2002.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**Diagnosis**

The diagnosis of fissure is confirmed on physical examination. A fissure
is a split in the squamous epithelium at or just inside the anal verge.
Given this location, fissures are best seen by effacing the anal canal
with opposing traction on the buttocks. Associated physical findings
include a sentinel skin tag just distal to the fissure and a
hypertrophied anal papilla at its proximal margin. Fissures cannot be
visualized with end-viewing endoscopes. In the setting of marked pain or
tenderness, instrumentation of the anal canal is inappropriate; it is
traumatic to the patient and only rarely yields diagnostic information.
When significant anal pain cannot be diagnosed comfortably, examination
under anesthesia is warranted.

The great majority of anal fissures occur in the midline, usually
posteriorly. If they occur off the midline, fissures mandate evaluation
for an underlying diagnosis, such as Crohn\'s disease, HIV/AIDS and
associated secondary infections, ulcerative colitis, tuberculosis,
syphilis, leukemia, or cancer. Signs of chronicity include the sentinel
tag, hypertrophied papilla, fibrosis, and visualization of bare internal
sphincter muscle at the fissure base.

**Treatment Options**

About half of all fissures heal with conservative care, which consists
of fiber supplementation, adequate fluid intake, sitz baths, and topical
analgesics. Acute fissures are more likely to heal than chronic ones. In
most cases, an initial trial of conservative care alone is appropriate,
particularly for acute fissures. The timing and choice of additional
treatment depend on the chronicity of the fissure, the severity of its
symptoms, and the rate and completeness of its response to conservative
care. The following 3 options are acceptable:

1.  **Surgery**

> Most surgeons now favor lateral internal sphincterotomy (LIS) as the
> procedure of choice for anal fissures that do not resolve with
> conservative care or that are simply too painful for conservative
> care. In a minority of patients, LIS is associated with minor, but
> sometimes permanent, defects in continence. Despite this drawback, the
> operation can be recommended for its technical simplicity, minimal
> morbidity, and ability to rapidly ameliorate symptoms, high cure
> rates, and low relapse rates.

2.  **Topical Therapy**

> Topical therapy is directed at reversibly decreasing resting anal
> pressure, with a goal of allowing fissure healing without permanent
> sphincter damage. Several preparations have been tested, especially
> nitroglycerin ointment (glyceryl trinitrate \[GTN\]). Early
> enthusiastic trials (healing rates of 70% to 80%) have been tempered
> by more recent studies showing lower (25% to 50%) healing rates. Side
> effects, particularly headache, have been reported in a variable
> number of patients, but they only infrequently require cessation of
> therapy. Topical calcium channel blockers appear to be as effective as
> topical GTN, but have fewer associated side effects. Long-term failure
> rates with topical therapy may be significant and require further
> study. NOTE: According to the guideline developer, currently neither
> appropriate diluted GTN nor topical calcium channel blocker
> preparations are commercially available in the United States.

3.  **Botulin Toxin**

> A relatively small number of studies have shown high cure (75% to 95%)
> and low morbidity rates with locally injected botulin toxin (BT). The
> optimal location of injection (internal vs. external sphincter)
> remains controversial. Long-term studies of relapse rates and careful
> evaluation of BT´s effect on continence, particularly in comparison to
> sphincterotomy, are needed.

**Choice of Treatment**

There is no proven optimal treatment for anal fissure; each of the 3
options discussed has its own unique merits and disadvantages. Standard
conservative care is risk-free, but has a relatively low success rate
and takes a long time. In contrast, LIS carries a risk of permanent
minor sphincter impairment, but works rapidly and effectively. Until
recently, the algorithm for fissure treatment was simple: choose
standard conservative care for patients with acute fissures, tolerable
levels of pain, or compromised sphincter function; choose LIS if pain
levels mandate immediate action or if conservative care fails.

Topical therapy and BT injection both represent efforts to achieve
prompt but temporary sphincter relaxation, combining the safety of
nonoperative treatment with the high cure rate and rapid effect of LIS.
Promising results have been published, but a number of uncertainties
remain. For topical therapy, these uncertainties include: Why the broad
range of reported success rates, and what type of success can the
practicing clinician expect? What is the best topical agent? What are
the long-term relapse rates? For BT: Where exactly should it be
injected? Will careful questioning of treated patients uncover subtle
alterations in continence similar to those detected after LIS? Will
there be relapses over the long term? Most importantly, will the
striking results of BT injection hold up, as more centers report on
larger series of patients?

Presently, topical therapy and BT injection should be considered
acceptable options, even if not entirely proven, for the treatment of
anal fissure. Their low morbidity profiles allow them to be used as
first-line treatment, not merely as salvage treatment for failed
conservative care. However, further experience will be necessary to
determine their definitive role in the algorithm of fissure therapy.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is not specifically stated for each
recommendation.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Appropriate diagnosis and treatment of acute and chronic anal fissures

#### POTENTIAL HARMS

Side effects of treatment of anal fissures including incontinence
(related to surgical interventions) and headaches (related to the use of
topical therapies such as nitroglycerin ointment).

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

The anal fissure literature is replete with retrospective case series;
until recently, few randomized controlled studies were reported. Given
these constraints, it was necessary to accept imperfectly designed or
imperfectly conducted studies as part of the available fund of
knowledge.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

American Gastroenterological Association medical position statement:
Diagnosis and care of patients with anal fissure. Gastroenterology 2003
Jan;124(1):233-4. \[1 reference\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12512045)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2003 Jan

#### GUIDELINE DEVELOPER(S)

American Gastroenterological Association Institute - Medical Specialty
Society

#### SOURCE(S) OF FUNDING

American Gastroenterological Association Institute

#### GUIDELINE COMMITTEE

American Gastroenterological Association Patient Care Committee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

Not stated

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

According to the guideline developer, the Clinical Practice Committee
meets three times a year to review all American Gastroenterological
Association Institute (AGAI) guidelines. This review includes new
literature searches of electronic databases followed by expert committee
review of new evidence that has emerged since the original publication
date.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [American Gastroenterological
Association Institute (AGAI) Gastroenterology journal Web
site](http://www.gastrojournal.org/article/PIIS0016508503500348/fulltext).

Print copies: Available from the American Gastroenterological
Association Institute, 4930 Del Ray Avenue, Bethesda, MD 20814.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   Madoff RD, Fleshman JW. AGA technical review on the diagnosis and
    care of patients with anal fissure. Gastroenterology 2003
    Jan;124(1):235-45.

Electronic copies: Available from the [American Gastroenterological
Association Institute (AGAI) Gastroenterology journal Web
site](http://www.gastrojournal.org/article/PIIS001650850350035X/fulltext).

Print copies: Available from the American Gastroenterological
Association Institute, 4930 Del Ray Avenue, Bethesda, MD 20814.

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on August 20, 2003.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

#### NGC DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008