title: Endosonographic and manometric evaluation of internal anal sphincter in patients with chronic anal fissure and its correlation with clinical outcome after topical glyceryl trinitrate therapy.
abstract: OBJECTIVE
  Anorectal pressure studies have demonstrated internal anal sphincter (IAS) hypertonia in patients with chronic anal fissure. It is unknown however, if these changes in IAS function are associated with any abnormality in sphincter morphology. The first aim was to investigate the clinical characteristics and the manometric and endosonographic findings of the IAS in a cohort of patients with chronic anal fissure. The second aim was to investigate the association between these findings and the outcome with topical Glyceryl trinitrate (GTN) therapy.
  
  
  METHODS
  All patients who presented with chronic anal fissure from November 1999 to May 2004 were included after failure of conservative therapy. Anorectal manometry and anal endosonography were performed before treatment with 0.2% GTN ointment twice daily was initiated. Patients were evaluated after 8 weeks.
  
  
  RESULTS
  One hundred and twenty-four patients (66 women, mean age, 45.2 +/- 14.8 years) were included. Hypertonia of the IAS was found in 84 (68%) patients. The mean maximum IAS thickness was 3.6 +/- 0.76 mm (1.6-5.5). An abnormally thick IAS, adjusted by age, was observed in 113 (91.1%) patients. We found no correlation between resting pressure and IAS thickness (r = 0.074; p = 0.41). At 8 weeks, 52 patients (42%) had healed with complete symptoms resolution. No statistically significant differences were observed when clinical features and manometric and endosonographic findings were compared between healing and no-healing fissures.
  
  
  CONCLUSIONS
  The majority of patients with chronic anal fissure present an abnormally thick IAS. Clinical, manometric and endosonographic features had no association with outcome after GTN treatment.
authors.affiliation: Colorectal Surgery Unit, Department of Surgery, Hospital del Mar, Passeig Marítim, 25-29, 08003, Barcelona, Spain.
authors.forename: Marta
authors.initials: M
authors.lastname: Pascual
authors.forename: Miguel
authors.initials: M
authors.lastname: Pera
authors.forename: Ricard
authors.initials: R
authors.lastname: Courtier
authors.forename: Mariá José
authors.initials: MJ
authors.lastname: Gil
authors.forename: David
authors.initials: D
authors.lastname: Parés
authors.forename: Sonia
authors.initials: S
authors.lastname: Puig
authors.forename: Montserrat
authors.initials: M
authors.lastname: Andreu
authors.forename: Luis
authors.initials: L
authors.lastname: Grande
mesh_terms: D000287:Administration, Topical; D000328:Adult; D001003:Anal Canal / Q000000981:diagnostic imaging / Q000187:drug effects* / Q000503:physiopathology; D002908:Chronic Disease; D019160:Endosonography; D005260:Female; D005401:Fissure in Ano / Q000000981:diagnostic imaging / Q000188:drug therapy* / Q000503:physiopathology; D006801:Humans; D008297:Male; D008365:Manometry; D008875:Middle Aged; D005996:Nitroglycerin / Q000008:administration & dosage*; D009824:Ointments; D011312:Pressure; D011446:Prospective Studies; D016896:Treatment Outcome; D014665:Vasodilator Agents / Q000008:administration & dosage*
chemical_list: D009824:Ointments; D014665:Vasodilator Agents; D005996:Nitroglycerin