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Article
CHARACTERISTICS AND CLINICAL MANAGEMENT OF FEMALE PATIENTS WITH FISSURE IN ANO IN AL-KADHIMIYA CITY, BAGHDAD

Author: Qahtan A. Mahdi قحطان عدنان مهدي
Journal: IRAQI JOURNAL OF MEDICAL SCIENCES المجلة العراقية للعلوم الطبية ISSN: P16816579,E22244719 Year: 2013 Volume: 11 Issue: 3 Pages: 238-242
Publisher: Al-Nahrain University جامعة النهرين

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Abstract

Background:Fissure in ano is a common painful anal problem in female patients.Objective:To study the sociodemographic variables of female patients with fissure in ano, and to identified the characteristic of anal fissure and their treatment among those patient in Al-Imamian Al-Kadhimiyian Medical City and two private hospitals.Methods:This is a prospective study that was carried out from May 2008 to May 2011. Two hundred fifty female patients with fissure in ano were interviewed regarding their age, marital state, address, level of education, clinical presentation and the subsequent management.Result:The commonest age of presentation in females was between 21-30 years. 78% of them were living at the peripheral areas of north of Baghdad, and 79.6% were of low level of education (primary school or below). The prevalence was found more in women with high parity especially when their child delivery was supervised by a midwife in their location. All patient has presented with anal pain, 55% were associated with bleeding per rectum and 64.2% with constipation. The location of fissures was 51.6% anterior, 48% posterior, 0.4% lateral in position. Less than half of patients underwent a surgical treatment. 77% of them were treated by lord dilatation under anesthesia and 23% by lateral sphinecteromty.Conclusion:Factors which had an impact on the clinical course and management of fissure in ano in female patients were found to be the social status, the level of education and the parity, therefore to prevent this illness, a cooperation between the heath services and the family health center and the government is necessary in order to overcome such a common problem.Keywords:Fissure in ano, Female

Keywords

Fissure in ano --- Female


Article
Anal Fissure among Female in Erbil City
الشق الشرجي عند الإناث في مدينة أربيل

Author: Bahjat Ahmed Mohammad
Journal: kufa Journal for Nursing sciences مجلة الكوفة لعلوم التمريض ISSN: 22234055 Year: 2013 Volume: 3 Issue: 3 Pages: 21-25
Publisher: University of Kufa جامعة الكوفة

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Abstract

Objectives: to identify the causes of the fissure in ano among child bearing age female in Erbil city because it is very common in the Kurdistan.Methods :- This prospective study of evaluation of fissure in ano among female patients in Erbil city and its surrounding for the period between may 2010 and may 2012, Data collected from 500 cases showed that fissure in ano is most common cause of ano-rectal pain in this locality among child bearing age females from clinic ,Erbil teaching hospital and Erbil gynecological hospital All the patients were interviewed and clinical data were recorded including; age, occupation, marital state, number of children, types of fissure in ano, sites of fissure, associated symptoms, its treatment and recurrence. Period from first onset of symptoms to first medical consultation were recorded and showed that most of them were delayed.Results: from 500 cases showed that fissure in ano is most common cause of ano-rectal pain in this locality among child bearing age females from clinic ,Erbil teaching hospital and Erbil gynecological hospital.Conclusion: the fissure in ano is the most common disease among female childbearing age and usually due to bad post natal careRecommendation: for prevention of this painful condition I advice the gynaecologist and obstetrician to do peri anal care.

الأهداف: هذه دراسة وصفية أجريت لتقييم حالات الفطر الشرجي بين النساء في مدينة اربيل و ضواحيها, الفطر الشرجي هو مشكلة شائعة بين النساء اكثر مما هو في الرجال, وهو تقرح خطي في النصف الأسفل من القنات الشرجية الواقعة في الجدار الخلفي والوسطي.المنهجية: جمعت المعلومات من 500 حالة للفترة الممتدة من ايار 2010- الى ايار 2012 من خمسمائة مريض اجروا مقابلة والفحص السريري وتم تسجيل المعلومات السريرية وكانت تتضمن العمر , محل الإقامة, الوظيفة, الحالة الاجتماعية, عدد الأطفال نوع وموقع فطر الشرجي وكذلك الأعراض المصاحبة والعلاج ورجوع الفطر بعد العلاج مرة أخرى. بالإضافة الى ذلك تم احتساب الفترة الزمنية بين ظهور أول عرض للمرض ومراجعة المريضة للطبيب لغرض العلاج. النتائج: الفطر الشرجي حالة متكررة بين النساء القادرات على الحمل وأظهرت النتائج من مجموع الحالات 76.8% منهم كانوا متزوجات و23.3% كانوا غير متزوجات.الاستنتاج: عدد الأطفال ومكان الولادة والعوامل الاجتماعية والتعليمية هي من العوامل المشاركة في تطور المرض.التوصيات: يجب زيادة التوعية الاجتماعية لهذه المشاكل ومضاعفاتها.

Keywords

fissure --- ano --- female.


Article
Factors That Predict The Morbidity of Colostomy in Patient with Ano-Rectal Malformation in Children in Baghdad

Author: Amer Abd Allah Ejrish
Journal: Medical Journal of Babylon مجلة بابل الطبية ISSN: 1812156X 23126760 Year: 2016 Volume: 13 Issue: 2 Pages: 294 -306
Publisher: Babylon University جامعة بابل

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Colostomyis surgically fashioned colo-cutanous fistula for the diversion of the feces and flatus away from distal pathology or a surgical site either temporary or permanent type, indication of colostomies in our study were ARM.Identify the most common complication of colostomy in patient with ARM and how to be avoided, and which colostomy type carries a low risk of complication.Prospective study of 100 cases ARM that underwent colostomy was conducted at Medical City Children Welfare Teaching Hospital of department of pediatric surgery between January 2014 – November 2015.Most of colostomies (75%) were done in the neonatal period and mainly for recto urethral fistula in male (45%), the most common type of colostomy was a loop sigmoid colostomy (69%) this may be due to simplicity in creation and closure, in addition to surgeon's preference.Divided colostomy was done in 26 patients, and mainly for male patients. Seventy patients (70%) develop different complications and the most common were prolapsed (39%).others were skin excoriation, UTI, wound sepsis, parastomal hernia and bleeding.Prolapsed and skin excoriation were most in loop colostomies, while skin dehiscence was commonly seen in divided types. Associated anomalies were seen to be related to increase incidence of colostomy related complication. Mortality rate was (5%); the causes of death were septicemia, associated congenital anomaly and complex malformation.To decrease the incidence of prolapsed, it better to created divide rather than loop sigmoid colostomy for complete diversion of faces. We recommend divided proximal sigmoid colostomy for complete diversion of feces for protect definitive PSARP.


Article
Clinical and epidemiological patterns of ano-genital warts among male patients in Erbil city, Iraq

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ABSTRACTBackground and objectives: Ano-genital warts consist of epidermal and dermal papules or nodules on the perineum, genitalia, crural folds, and anus. Up to the researchers' knowledge, no study concerning the genital warts in Erbil city was published, which was a motivation to study this problem, regarding the epidemiological and clinical patterns of this disease in Erbil city.Patients and methods: This is a cross-sectional study; the data collected conveniently from male patients that have clinical features of genital warts attending two private dermatology clinics in Erbil city from 15th June 2009 through 15th June 2011. Results: In this study, 45 male adults were included; their ages ranged from 20 to 49 years, with mean± SD of 29.8 ± 6.017. The highest rate of genital wart was among age group of 25-29 years (35.6%). Other statistics are; (71.1%) of study sample were married; (40%) were alcoholics; (88.9%) were not using condom in their sexual contact, (66.7%) had more than one sexual partner, (53.3%) of the cases were illiterate or have primary school education and no one of the cases was homosexual. Sixty percent of the lesions were papular in shape, (53.3%) were affecting more than one site of external genitalia, (91%) of the patients had multiple warts, (11.1%) had past history of one of STIs (sexually transmitted infection), (15.6%) of the cases were associated with other sexually transmitted infections and all the cases were contracted through sexual contact.Conclusion: The study concluded that the genital warts are low or infrequent in Erbil city when compared to other areas. The existence of traditional inhibition imposed by the religion and the society on the sexual behavior may be a factor in the low rate of the disease in this community.

الخلاصةالأهداف: الفالول الجنسي يتكون من حبوب من بشرة أو أدمة الجلد ينتشر في المناطق التناسلية للإنسان. حسب معرفة الباحثين لا يوجد بحث منشور حول هذا المرض في مدينة أربيل، مما شجعهم لأجراء هذا البحث لتسليط الضوء على هذا المرض من خلال هذا البحث.المرضى والطرق: تم جمع المعلومات من عينة مقطعية من المرضى المصابين بالفالول ألجنسي المراجعين للعيادة الخاصة لإثنين من أطباء الجلدية في مدينة أربيل.النتائج: شارك في هذا البحث 45 شخص بالغ ذكر، تراوحت أعمارهم من 20 – 49 سنة وبمعدل الأعمار والانحراف المعياري 29.8 ± 6.017. أكثر المصابين كانوا من أعمار 25 - 29 سنة (35.6%)، 71.1% كانوا متزوجين، 40% من متناولي المشروبات الكحولية، 88.9% لا يستعملون الواقي الذكري أثناء الجماع، 66.7% لديهم أكثر من شريك جنسي و 53.3% كانوا إما أميين أو من الحاصلين على الشهادة الابتدائية. كان شكل الفالول في 60% من المرضى حبيبيا، وكان 53.3% من الفالول في أكثر من موقع واحد، 91% لديه أكثر من فالول واحد، 61.3% كان لديه تأريخ مرضي في السابق حول إصابته بأحد الأمراض الجنسية الانتقالية، 15.6% كانوا مصابين بمرض آخر من الأمراض الجنسية الانتقالية وكل المصابين أصيبوا عن طريق التماس الجنسي.الإستنتاج: أن نسبة المصابين بهذا المرض قليلة في مجتمع الدراسة، مقارنة بباقي المجتمعات، وقد يكون ذلك بسبب العادات والتقاليد الاجتماعية والدينية التي تحد من حرية وتجاوز العلاقات الجنسية.


Article
Fistulotomy Versus Fistulectomy As a Primary Treatment of Low Fistula in Ano

Author: Zuhair Bashir Kamal
Journal: Iraqi Academic Scientific Journal المجلة العراقية للاختصاصات الطبية ISSN: 16088360 Year: 2012 Volume: 11 Issue: 4 Pages: 510-515
Publisher: The Iraqi Borad for Medical Specialization المجلس العراقي للاختصاصات الطبية

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ABSTRACT:BACKGROUND:Fistula in ano is common surgical condition that is treated by different surgical modalities.OBJECTIVE:Is to compare the outcome and complications of fistulotomy and fistulectomy as primary treatment of low fistula in ano.PATIENTS AND METHODS:A prospective randomized study was done on 76 patients of low fistulae in ano who were admitted to the surgical department at Alkindy teaching hospital from January 2009-January 2010.Fistulotomy was done in 32 patients, and fistulectomy was done in 44 patients.Patients were followed up post operatively for one year and the healing time was estimated in both groups and complication rate was recorded including bleeding, infection, incontinence and recurrence.RESULTS:Out of 76 patients included in this study,65 patients( 85.53%) were found intraoperatively to have intersphincteric fistulae and 11 patients(14.47%) were low tansphincteric fistulae.The operating time for fistulotomy (15-25 minutes) was shorter than that for fistulectomy (20-35 minutes).The healing time was found to be shorter in fistulotomy group (26.38 days) than that of fistulectomy(38.64 days).The complications which were recorded include bleeding occurred in only one out of 44 patients (2.27%) following fistulectomy, while no bleeding developed following fistulotomy.Infection developed in one case out of 32 (3.12%) following fistulotomy and one case out of 44 (2.27%) following fistulectomy.Two cases out of 32 (6.25%) developed minor incontinence following fistulotomy and 5 cases out of 44 (11.36%) following fistulectomy.Recurrence developed in 2 cases out of 32 (6.25%) of fistulotomy and 3 cases out of 44 (6.82%) following fistulectomy. The recurrence in both groups developed within 4-6 weeks following surgery.CONCLUSION:Fistulotomy can be used as a primary treatment of low fistula in ano as the operating time is shorter and it takes shorter period of time for the wound to heal and the incidence of complications is comparable to that of fistulectomy.


Article
The Association between Anorectal Abscesses and Development of Fistula in-Ano
العلاقة بين الخراج حول الشرج والناسور الشرجي

Author: Majeed H. H. Al-Amiri د. مجيد حمود حمادي العامري
Journal: IRAQI JOURNALOF COMMUNITY MEDICINE المجلة العراقية لطب المجتمع ISSN: 16845382 Year: 2013 Volume: 26 Issue: 2 Pages: 184-187
Publisher: Al-Mustansyriah University الجامعة المستنصرية

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Abstract:Background: - Anorectal abscesses are associated with a fistula in ano in a large percentage of patients. Fistula in –ano complicates 30-50 % of anorectal abscesses. Objective: - to establish the true frequency of fistula-in-ano in the patients with anorectal abscesses and to correlate these findings with relapse rate and microbiology.Patients and Methods: - This cross-section study was done in surgical department of Al-Yarmouk teaching hospital. From January 2006 to December 2011. The patients were examined in knee-elbow position or left lateral position for anorectal abscesses and fistula. The clinical finding was studied and all the risk factors were studied too.Results: - One-hundred and four patients with an anorectal abscesses; 76 male and 28 female patients with a mean age of 49.5 years (range 15-84 Years). There was perianal abscesses in 46 patients (44.23%), ischiorectal abscesses in 34 patients (35.69%), and submucosal in 24 Patients (23.07%). Fistula –in-ano developed in 29 patients (27.88%). Conclusion:-this cross-section study had shown that a relatively large percentage of anorectal abscess are associated with anal fistula. As the abscess resolves with proper drainage, we encourage the selective use of antimicrobial agents on a case-by-case basis. Key words: Anorectal abscess, fistula -in-ano.

خلفية البحث: هناك علاقة بين الاصابة بخراج حول الشرج وظهور الناسور الشرجي في نسبة مهمة من المرضى.الهدف: الهدف من الدراسة لمعرفة النسبة المئوية للاصابة بناسور شرجي في المرضى المصابين بخراج حول الشرج.المرضى وطرائق البحث: هي دراسة مستقبلية أجريت على 104 حالات لمرضى مصابين بخراج حول الشرج وتمت دراسة الحالات في قسم الجراحة لمستشفى اليرموك التعليمي . للفترة من كانون الثاني 2006 ولغاية كانون الأول 2011.104 مرضى مصابين بخراج حول الشرج 76 ذكر و 28 أنثى , أعمارهم تتراوح بين 15-84 سنة ومعدل العمر 49,5 سنة .وتم فحص المخرج لمعرفة هل توجد فتحة لناسور شرجي مع الخراج وكذلك تم فحصهم بناظور المقعد لمعرفة هل توجد فتحه ناسور داخلية مع الخراج .النتائج: وتبين ظهور الناسور الشرجي في 29 حالة مرضية أي بنسبة 27,06 % من اصل المرضى الكلي.وكانت فترة رقودهم في المستشفى تتراوح بين 2-15 يومأ .وتم دراسة الأعراض السريرية والفحص السريري ودراسة العوامل التي تؤدي الى ظهور الخراج ومضاعفاته.الكلمات المفتاحيه: خراج حول الشرج, الناسور الشرجي


Article
Chemical sphincterotomy is good alternative option to surgery In Management of chronic fissure in ana

Author: Ali Mahmood Ghazi علي محمد غازي
Journal: AL-yarmouk Journall مجلة كلية اليرموك الجامعة ISSN: 20752954 Year: 2017 Volume: 9 Issue: 9 Pages: 95-100
Publisher: College Yarmouk University كلية اليرموك الجامعة

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Anal fissure is a common disorder which may cause symptoms at any age. Internal anal sphincterotomy is the gold standard surgical treatment which lowers the resting anal pressure and effectively heals the majority of fissures. However the post operative period may be marked by surgical risks, complications and late incidence of incontinence that is some times permanent. These complications have led to a search for alternative therapies for the treatment of chronic anal fissure. Chemical sphincterotomy has been tried using a variety of novel agents including topical glyceryl trinitrate (GTN), calcium channel blockers such as nifedipine or diltiazem and botulinum toxin. Some of these agents were found to be effective in healing chronic anal fissure with negligible side effects and are now considered as first line treatment for chronic anal fissure

استخدام العلاج الكيماوي في علاج الفطر الشرجي المزمن كبديل للعملية الجراحية وتبين لي ذلك من خلال دراسة اجريتها على مرضى في مستشفى الثورة التعليمي البيضاء ليبيا وفي مستشفى الكرامة التعليمي بغداد وعيادتي على مرضى يعانون من مرض الفطر الشرجي المزمن وعددهم 105 مرضى. النتائج سبعون مريض من مجموع مائه وخمسة مرضى استخدموا العلاج لمدة شهر ونصف تماثلوا للشفاء التام وكانت الدراسة من كانون الأول 2009 الى 2016. استنتاجات نستنتج من الدراسة بان العلاج الكيماوي للفطر الشرجي المزمن فعال وامن وبدون مضاعفات مقارنه بالعملية الجراحية التي ممكن يحدث فيها مضاعفات كعدم السيطرة على الهواء الذي يخرج من الشرج او البراز.


Article
Fistula in Ano; the Correlation of Pre-Operative Magnetic Resonance Imaging with Video Assisted Anal Fistula Treatment Findings

Authors: Hussain J K Alsalami --- Laith A S Alshareefi --- Falah D Salih
Journal: Karbala Journal of Medicine مجلة كربلاء الطبية ISSN: 19905483 Year: 2017 Volume: 10 Issue: 3 Pages: 3804-3809
Publisher: Kerbala University جامعة كربلاء

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background: Fistula-in-ano (FIA) is a common medical problem. Magnetic resonance imaging (MRI) is an excellent modality for the pre-operative evaluation of this condition. Video assisted anal fistula treatment (VAAFT) is a relatively new modality introduced in 2006, and is both diagnostic and operative.Aim: To correlate MRI findings with video assisted anal fistula treatment findings.Patients and methods: Thirty-five patients with clinically diagnosed FIA, had a pelvic MRI followed by VAAFT surgery.Results: Mean age was 42 years. In one case both MRI and VAAFT revealed a sinus. In 29 cases (82.8 %) there was concordance regarding the presence of an FIA, both tracts and internal openings. In 5 cases (14.2%), there was no concordance regarding the presence of an internal opening.Conclusion: MRI is essential in the pre-operative assessment of FIA especially for clinically complex fistulas.


Article
Augmented Pressure Distal Colostogram
الظغط المعزز في الاشعة الملونة للجزء البعيد من مفاغرة القولون

Authors: Ahmed .A. Khalaf احمد عبود خلف --- Hassan K. Katea حسين كريم كاطع --- Jinan Naif جنان نايف
Journal: Journal of the Faculty of Medicine مجلة كلية الطب ISSN: 00419419 Year: 2014 Volume: 56 Issue: 3 Pages: 268-272
Publisher: Baghdad University جامعة بغداد

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Background: Anorectal malformations (ARMs) represent a complex group of congenital anomalies resulting from abnormal development of the hindgut, allantois and Mullerian duct, leading to incomplete or partial urorectal septal malformations .Objectives: The objective of this study is the accurate demonstration of the anatomy of the level of rectal atresia and any associated recto-urinary fistula by using APDC for optimal surgical management using APDC .Patients and methods: This is a prospective study including sixty-five male patients with high ARMs who were admitted to the department of pediatric surgery in Children Welfare Teaching Hospital in Medical City Complex - Baghdad - Iraq ; during the period from April 2009 to November 2011 ; they were subjected to divided descending colostomy in the postnatal period ;Augmented-Pressure Distal Colostogram (APDC) was performed at a later age for demonstration of the level of rectal atresia and the presence of the recto-urinary fistulas which then were confirmed at operation. Results: Rectourinary fistulas were demonstrated in 52 patients (80%) by APDC technique and were confirmed at operation in each case. In the remaining 13 patients (20%), this technique failed to demonstrate a fistula, in 8 of them no fistula was identified during operation or thereafter , while in the remaining 5 patients fistulas were detected during operation . Conclusion: The APDC readily demonstrated the level of the rectal atresia and the associated recto-urinary fistulas in the majority of the patients , providing a road map for definitive surgical repair of ARMs.Keywords: augmented pressure distal colostogram (APDC), ano rectal malformations(ARMs).

الخلفية: ان حالات تشوه المستقيم والشرج تمثل مجموعة معقدة من التشوهات الخلقية الناتجة عن التطور الشاذ في المعي المؤخر السفلي وقناة مولر من ما يؤدي الى تشوهات غير كاملة او جزئية في الحاجز البولي المستقيمي هدف الدراسة: ان الاظهار الدقيق للمستوى التشريحي للرتق المستقيمي وتحديد وجود اي ناسور بين المستقيم والجهاز البولي التناسلي امر ضروري للاجراء الامثل لعلاج هذه الحالات باستعمال الضغط المعزز في الاشعة الملونة للجزء البعيد من مفاغرة القولون .APDCالمرضى وطرق العمل: دراسة مستقبلية شملت 65 مريضا من الذكور مع تشوهات المستقيم والشرج من النوع العالي والذين تم معالجتهم في قسم جراحة الاطفال في نستشفى حماية الاطفال التعليمي في مجمع مدينة الطب - بغداد - العراق ، للفترة ما بين نيسان 2009 الى تشرين الثاني 2011 . كل المرضى خضعوا لعمليات مفاغرة القولون التي اجريت لهم في فترة ما بعد الولادة ثم اجري لهم فحص الضغط المعزز في الاشعة الملونة للجزء البعيد من مفاغرة القولون في سن متأخرة لاظهار المستوى التشريحي للرتق المستقيمي وتحديد وجود اي ناسور بين المستقيم والجهاز البولي التناسلي والذي تم تأكيده في عماية رأب الشرج والقولون السهمي الخلفي .النتائج: اثبت وجود ناسور المستقيم والمجرى البولي في 52 مريض (80%)عن طريق تقنية الضغط المعزز في الاشعة الملونة للجزء البعيد من مفاغرة القولون والذي تم تأكيده بعد ذلك في عملية رأب الشرج والقولون السهمي الخلفي في كل حالة على حدة.اما في المرضى ال13 المتبقين (20%)حيث فشلت هذه التقنية في اثبات وجود ناسور ، تبين انه لم يتم تحديد اي ناسور في 8 منهم لا في اثناء العملية ولا بعدها ، في حين تم اكتشاف الناسور في المرضى ال5 المتبقين اثناء العملية .الاستنتاج: اظهرت دراستنا هذه ان استعمال الضغط المعززفي الاشعة الملونة للجزء البعيد من مفاغرة القولون يوضح وبدقة المستوى التشريحي للرتق المستقيمي ويحدد وجود اي ناسور بين المستقيم والمجرى البولي وهو بذلك يقدم خريطة واضحة المعالم للعمليات الجراحية المثلى لهذه التشوهات .وهي تقنية بسيطة نسبيا ول تحدث اي مضاعفات اثناء استخدامها .مفتاح الكلمات: الضغط المعزز في الاشعة الملونة للجزء البعيد من مفاغرة القولون APDCتشوه المستقيم والشرج ARM


Article
Anal Fissure: Is it becoming a medical disorder?

Author: Ali Al-shaham, CABS*. Kadhim Jawad, CABS**, Serene A.A, MS***
Journal: Al-Kindy College Medical Journal مجلة كلية الطب الكندي ISSN: 18109543 Year: 2014 Volume: 10 Issue: 2 Pages: 1-4
Publisher: Baghdad University جامعة بغداد

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Abstract

An anal fissure which does not heal with conservative measures as sits baths and laxatives is a chronic anal fissure. Physiologically, it is the high resting tone of the internal anal sphincter that chiefly interferes with the healing process of these fissures. Until now, the gold standard treatment modality is surgery, either digital anal dilatation or lateral sphincterotomy. However, concerns have been raised about the incidence of faecal incontinence after surgery. Therefore, pharmacological means to treat chronic anal fissures have been explored.A Medline and pub med database search from 1986-2012 was conducted to perform a literature search for articles relating to the non-surgical treatment of chronic anal fissure.Pharmacological sphincterotomy using Glyceryl trinitrate , Isosorbide dinitrate or calcium channel blockers are exciting alternative treatment , that relaxes the anal sphincter and, therefore, promote healing, the drawback of such medications are headache and poor compliance. With the introduction of Botulinum toxin as mean of chemical sphincterotom, topical injection of Botulinum toxin reduces the anal hypertonia which lasts for few months, allows the fissure to heal, thus eliminating the need for surgery without incidence of incontinence. Cure rates are over 60%, and the procedure can be repeated safely. Therefore, Botulinum toxin is a reasonable first-line management of chronic anal fissure and the relapses can be managed by surgeryKeywords: Non-surgical treatment of anal fissure, fissure in ano, sphicterotomy,botulinum toxin in anal fissures, glyceryl trinitrate. Chemical sphincteratomy, pharmacological sphincteratomy.

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