Purpose: Chronic anal fissure is a common medical problem affecting approximately 10% of the US population. Both Botulinum Toxin Type A (BT-a) and topical nitroglycerine (NTG) have been studied separately for the treatment of chronic anal fissures Objective. To determine if the combination of BT-a and NTG offers any benefit over the use of BT-a alone in the treatment of anal fissures. Methods: This was a randomized, double-blinded, placebo-controlled study. Twenty-eight (28) patients with chronic anal fissures (all with symptoms of anal pain, rectal bleeding for >6 weeks, and classic signs of anal fissures on physical exam) completed the study. At the initial study visit, all patients were injected with 25U of BT-a in areas of exposed muscle fibers of the internal anal sphincter. All patients were placed on a stool softener (100mg docusate sodium, 3 times a day) and psyllium fiber once a day. Patients were then randomized to receive 6-week topical therapy of either placebo ointment or 0.2% NTG ointment applied twice daily to the anal sphincter. Patients returned for follow-up at weeks 2, 8, and 12. Results: Of the 28 patients who completed the study (29 enrolled; 1 lost to follow-up), 17 (61%) healed completely. Complete healing of anal fissure was experienced by 53.8% (7/13) patients receiving NTG and 66.7% (10/15) of patients receiving Placebo (p = 0.70). Of the 11 patients that did not heal, 5 and 6 had received topical placebo and topical NTG, respectively. The median time to heal was 8 weeks. Healing was accompanied by reduction of pain and rectal bleeding in all subjects. Conclusions: This investigation confirms results of previous studies with BT-a; that it is a highly effective medical therapy for healing of anal fissures. Additionally, combining topical NTG therapy with BT-a injects provides no additional therapeutic benefit beyond that achieved with BT-a injections alone. Further investigation into the optimal injection paradigm of BT-a for the treatment of chronic anal fissure is warranted.

A comparison of combination of botox (botulinum toxin) and nitroglycerin in the treatment of chronic anal fissures

Listeria monotogenes bacteria-ascites developed in a 73-year-old man who had cholangiocarcinoma and liver metastasis. Spontaneous bacterial peritonitis (SBP) is a frequent complication in patients with chronic liver disease and ascites. L. peritonitis has been reported in only <30 cases world-wide. Our patient represents a unique case of L. peritonitis without peritoneal fluid analysis consistent with spontaneous bacteria peritonitis. However, the culture of the ascitic fluid provided the final diagnosis in this case.

Spontaneous rectus sheath hematoma and an anterior pelvic hematoma as a complication of anticoagulation

Adeonigbagbe, Olusegun MD1; Khademi, Ali MD1; Washington, Morris MD1; Karowe, Matthew MD1; Gaultieri, Nicholas MD1; Robilotti, James MD1 Author Information