title: The role of topical diltiazem in the treatment of chronic anal fissures that have failed glyceryl trinitrate therapy.
abstract: OBJECTIVE
  The treatment of anal fissures has evolved over the last 5 years with the development of topical treatments aimed at reducing sphincter hypertonia. This is thought to improve anal mucosal blood flow and promote healing of the fissure. This study reports the use of topical diltiazem in patients with chronic anal fissures that have failed previous treatment with topical 0.2% glyceryl trinitrate (GTN).
  
  
  METHODS
  Forty-seven patients with chronic anal fissure who had previously failed at least one course of topical GTN were recruited prospectively from a single centre. Patients were instructed to apply 2 cm (approximately 0.7 g) of 2% diltiazem cream to the anal verge twice daily for eight weeks. Symptoms of pain, bleeding and itching were recorded on a linear analogue score prior to starting the cream and then repeated at 2 weekly intervals. Patients were asked to report side-effects throughout the study period. Healing of the fissure was assessed after 8 weeks of treatment.
  
  
  RESULTS
  Forty-six patients completed treatment; of these, 22 had healed fissures (48%). Ten of the 24 patients with persistent fissures were symptomatically improved and wished no further treatment. Of the 14 patients who remained symptomatic, one was given a repeat course of 0.2% glyceryl trinitrate with subsequent healing of the fissure, 10 were recruited into an ongoing study involving injections of botulinum toxin into the internal anal sphincter and three were referred for surgery.
  
  
  CONCLUSIONS
  This study shows that topical 2% diltiazem is an effective and safe treatment for chronic anal fissure in patients who have failed topical 0.2% GTN. The need for sphincterotomy can be avoided in up to 70% of cases.
authors.affiliation: Department of Surgery, University Hospital, Queens Medical Centre, Nottingham, UK. nyree.griffin@nottingham.ac.uk
authors.forename: N
authors.initials: N
authors.lastname: Griffin
authors.forename: A G
authors.initials: AG
authors.lastname: Acheson
authors.forename: M
authors.initials: M
authors.lastname: Jonas
authors.forename: J H
authors.initials: JH
authors.lastname: Scholefield