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Query: UMLS:C0018681 (headache)
 56,091 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Nitric oxide has emerged as one of the most important neurotransmitters mediating internal anal sphincter relaxation. The effect of glyceryl trinitrate, a nitric oxide donor, on anal tone was examined. Maximum resting pressure, predominantly a function of the smooth muscle internal anal sphincter, was measured before and 20 min after application of 0.2 per cent glyceryl trinitrate ointment in ten patients. Pressure decreased by a mean of 27 per cent (95 per cent confidence interval 18-36 per cent) (P = 0.0004) after administration of the drug. A further 20 patients were then randomized to either active or placebo ointment. Anal pressure was significantly decreased (P = 0.002) in those who received 0.2 per cent glyceryl trinitrate, but there was no significant reduction in the control patients. Mild headache occurred in two patients who were given the active preparation and in one who received placebo. Manometry was repeated 9h after application of glyceryl trinitrate and showed a sustained decrease in pressure in two patients. Topical glyceryl trinitrate may have a role in the treatment of anal fissure, haemorrhoids, certain types of constipation and anal pain. It may also reduce injury to the internal sphincter during peranal operations.
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PMID:'Reversible chemical sphincterotomy' by local application of glyceryl trinitrate. 795 27

The aetiology of anal fissure is unclear, but there is an association with high maximum resting pressure (MRP). Internal sphincterotomy reduces MRP and heals fissure through an increase in local blood supply. Glyceryl trinitrate (GTN) is a nitric oxide donor which contributes to internal anal sphincter relaxation via a non-adrenergic non-cholinergic pathway. GTN ointment was applied topically in different concentration to the anal margin in patients with chronic anal fissure to monitor its effect primarily on MRP and secondarily on fissure healing. Nineteen patients with chronic anal fissure were treated with ointment containing increasing concentrations of GTN (0.2-0.8 per cent) to produce a reduction in MRP of greater than 25 per cent. The actual dose of GTN varied as no standard delivery system has been developed, but a 'typical amount' of GTN ointment weighed about 200 mg. In 15 of 19 patients, a concentration greater than 0.2 per cent was required to lower the MRP by at least 25 per cent. The minimum concentration of GTN that reduced the resting pressure by at least 25 per cent was prescribed and local application was carried out by the patient twice daily for 6 weeks. At 6 weeks, nine patients had healed, six required sphincterotomy and four were lost to follow-up. Eight of the nine patients with healed fistula required a GTN concentration of 0.3 per cent or more. Sixteen patients were resistant to the usually effective does of 0.2 per cent GTN. In three there was tachyphylaxis and the duration of action of GTN was less than the 12 h described previously in control patients. Two patients did not fulfil the study because of headache.
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PMID:Topical glyceryl trinitrate in the treatment of chronic anal fissure. 869 36

Anal fissure is often treated surgically by sphincterotomy. There is growing concern over the effects of this procedure on continence. Nitric oxide donors such as glyceryl trinitrate are thought to cause a reversible 'chemical sphincterotomy', capable of healing the fissure. Twenty-one consecutive patients with chronic anal fissure (13 women, mean age 36 years) were treated for 4-6 weeks with 0.2 per cent glyceryl trinitrate ointment applied to the fissure twice daily. Maximum anal resting pressure (MARP) was measured before and after application of the ointment at the first visit. There were 16 posterior and five anterior fissures. Mean(s.d.) MARP fell from 118.7(45.0) to 70.3(34.1) cmH2O over 20 min after application of the ointment (P < 0.001). Healing was complete in 11 patients at 4 weeks and in 18 at 6 weeks. The fissure recurred in four patients after cessation of treatment; three were successfully treated by further glyceryl trinitrate. Mild headache occurred in four patients. Anal fissure can be successfully treated with 0.2 per cent glyceryl trinitrate ointment applied topically.
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PMID:Use of glyceryl trinitrate ointment in the treatment of anal fissure. 869 37

A chronic anal fissure may be regarded as an ischaemic ulcer. Until recently, its treatment necessitated surgical intervention to lower the tension of the internal sphincter (lateral internal sphincterotomy), or manual dilatation of the anus. A disadvantage of both methods is the risk of permanent sphincter injury resulting in reduced continence. Local application of ointment containing nitroglycerin (glyceryltrinitrate) or isosorbide dinitrate reduces the pressure at rest in the anal canal and increases the anodermal blood circulation. Both ointments in most patients lead to healing of the chronic anal fissure. Nitroglycerin ointment in a prospective, randomized trial brought about better healing than placebo treatment. The advantage of the ointment treatment, the needlessness of sphincterotomy, is particularly important in cases of existing sphincter abnormalities. It has the disadvantage that it takes longer for the fissure pain to abate. The principal side effect is headache. In over 50% of the patients the treatment has to be continued for longer than 6 weeks. Little is known as yet about the risk of recurrence. Before surgical interventions as the treatment of first choice can be definitely replaced by treatment with nitrate ointment the good results of the ointment treatment have to be confirmed. Also, more has to be found out about the risk of recurrence, the optimal duration of the treatment and the choice of the type of nitrate ointment.
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PMID:[The treatment of chronic fissure in ano with nitrate ointment]. 1022 Nov 3

Lateral internal sphincterotomy has been the standard treatment for chronic anal fissure, but fissure healing rates of up to 80% with topical glyceryl trinitrate (GTN) treatment have suggested that this operation may become redundant. We evaluated the results of topical treatment of chronic anal fissures with 0.2% GTN for 6 weeks in the outpatient clinical setting, outside the confines of a randomized clinical trial. The role of lateral internal sphincterotomy in the GTN era was also assessed. GTN induced fissure healing in 21 of 49 consecutive patients. Fissures healed spontaneously in 2 patients who discontinued GTN because of headache. Lateral internal sphincterotomy was performed in 26 patients who had persistent symptoms after 6 weeks of GTN therapy. At the 6-week post-sphincterotomy review, all fissures had healed and there were no complications. In this study topical GTN for treatment of chronic anal fissure in the outpatient setting was not as effective as demonstrated in controlled clinical trials. Lateral internal sphincterotomy is still a good therapeutic option, especially in patients not responding to GTN.
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PMID:Lateral internal sphincterotomy is not redundant in the era of glyceryl trinitrate therapy for chronic anal fissure. 1045 Jan 95

Several treatments for anal fissure offer different responses and risks for complications. Reversible chemical sphincterotomy with topical nitroglycerin is an alternative to surgical sphincterotomy. The aim of this observational prospective study was to compare the effectiveness of topical nitroglycerin with the conventional medical treatment. Forty-three patients with anal fissure were treated: 22 (16 chronic and 6 acute) received 0.25% nitroglycerin topically, and 21 (16 chronic and 5 acute) received conventional treatment. Nitroglycerin or placebo was administered in two daily applications for two weeks. Median follow-up was 39 weeks. Healing rate with NTG was 75% for chronic and 83% for acute fissures, but recurrence rate for chronic fissures at 9 months was 67%. Healing rate with placebo for chronic fissures was only anecdotical (1 out of 16 patients). Headache as side effects occurred in 17 cases (77%). In conclusion, both treatments were effective for acute fissures, whereas for chronic ones NTG had a high healing rate but also a high recurrence rate.
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PMID:Long-term results of topical nitroglycerin in the treatment of chronic anal fissures are disappointing. 1187 81

This study explores the evidence-based background for treating chronic anal fissure with topically applied nitroglycerin (NTG): in part the general effect of NTG and in part how its effect compares to that of surgery, which has been claimed to have long-term complications like incontinence for flatus and faeces. Ten randomised clinical trials published up to July 2001 were retrieved. In five of six studies, NTG had an effect on healing that was better than that of placebo or lignocaine. Headache is a common side effect of the treatment. Lateral internal sphincterotomy, the operation of choice for chronic anal fissure, and topical NTG were compared in four trials. Surgery had a better healing rate, but more late complications. The results suggest that in 31-65% of patients an operation could be avoided with NTG therapy. Topically applied 0.2% nitroglycerin three times a day for four weeks is therefore the primary choice in the treatment of anal fissures. But the possibility still remains that the observed effect of NTG may be the outcome of publication bias.
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PMID:[Treatment of chronic anal fissure with topically applied nitroglycerin ointment. A systematic review of evidence-based results]. 1221 50

Botulinum toxin is a dreaded biological toxin elaborated by Clostridium botulinum. The action of this toxin is to cause paralysis of both voluntary and involuntary muscles. The unique property of paralysing capability of muscles has been used for the benefit of human beings. Dr Allan Scot, an ophthalmologist, first used the toxin in a patient with squint in 1981 and since then the botulinum toxin is being used in various disorders characterised by muscle overactivity such as spasticity in both children and adult, dystonic conditions such as blepharospasm, cervical dystonia, spasmodic dysphonia, writer's cramp, etc, hemifacial spasm and headache. Its main action is at the terminal nerve endings of myoneural junction and it prevents release of acetylcholine from vesicles thus causing chemical denervation. Its action persists for 3 to 4 months on an average. Its side effects such as drooping, diplopia, dysphagia, depending on the sites of injection, are few and usually transient. Generalised anaphylaxis is almost unknown. Now botulinum toxin is being used in non-neurological conditions where muscles are under spasmodic state such as achalasia cardia, anal fissure, spasm of urethral sphincter, etc. Because of wider safety range and fewer complications, botulinum toxin has been an important therapeutic armamentarium in different branches of medicine and surgery.
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PMID:Botulinum toxin: a dreaded toxin for use in human being. 1245 15

Botulinum toxin, the most potent known biological neurotoxin, holds great promise in the therapy of many diseases. It has been used effectively to treat strabismus, dystonias and other movement disorders, and spasticity. However, a number of potential new therapeutic indications have emerged and attracted a considerable amount of interest from the scientific community. These emerging indications included treatment for conditions associated with pain (e.g. headaches, myofascial pain, chronic low back pain), hypersecretion of glands (e.g. hyperhidrosis, sialorrhea, intrinsic rhinitis), and excessive or dyssynergic muscle contraction, and for cosmesis (e.g. myokymia, bruxism, anal fissure). There is a need for more controlled clinical trials, dose-ranging studies to determine optimal treatment, validated clinical scales and studies developed to assess the value of electromyographic guidance and skill of investigators on the outcome of treatment for some of these diseases. The long-term cost effectiveness of treatment and immunoresistance from repeated injections are also important clinical issues to address.
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PMID:Emerging therapeutic applications of botulinum toxin. 1260 5

Diagnosis of chronic anal fissure is easy and common in clinical practice. Little is known about the etiology and pathogenesis of this disorder. Current investigations consider anal sphincteric hypertonia and ischemia as primary factors in the appearance and maintenance of this lesion. Recurrence rate after healing is high, so anal fissure may be a chronic disease that evolves depending on sphincteric features. Conservative measures to avoid constipation, including fiber intake, are useful to improve symptomatology, achieve healing, and reduce recurrence. Surgical treatment is the most effective procedure for chronic anal fissure. Lateral internal sphincterotomy achieves healing in most cases (more than 95%) and the recurrence rate is low (1% to 3%). However, permanent fecal incontinence may appear after surgery and available data about this complication are controversial. In recent years, chemical sphincterotomy has been developed as an option in the treatment of chronic anal fissure. This medical option aims to achieve the effectiveness of surgery without side effects, by means of a temporary decrease of anal pressures that allows fissures to heal. Local injection of botulinum toxin into the anal sphincter is the most successful medical option, nearly as effective as surgery and without significant adverse effects (transitory episodes of mild fecal incontinence). Although more studies are needed to establish the method of administering this treatment, in our opinion botulinum toxin is an effective option in a high percentage of cases, especially in patients who risk developing incontinence. Compared with botulinum toxin, topical nitroglycerine ointments, which produce a transitory sphincteric relaxation, have the advantage of being a simple and accessible procedure. However, we think that this option should not be a first choice because its effectiveness is lower compared with surgery (about 60% to 70%), its compliance with the application could be poor, and it has a greater percentage of side effects (eg, headache). Other topical treatments (eg, calcium channel antagonist or cholinergic agonists agents) appear to be as effective as nitroglycerine agents and do not have significant adverse effects, but little data exist about these options. In our opinion, treatment of chronic anal fissure must be individualized, depending on the clinical profile of patients. Medical treatment, especially injection of botulinum toxin, should be taken into account if risk for developing incontinence is suspected.
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PMID:Chronic Anal Fissure. 1274 25


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