First Edition 2008
possible, the split in the bowel lining at the anus
a large amount infrequently. Oral tablets such as
may be visible by parting the buttocks. Internal
diltiazem and nifedipine can also be tried. All these
examination by sigmoidoscopy or colonoscopy
agents (ointments and tablets) should be ceased
at least 24 hours before using medication for
appearance of the anal area) is recommended to
erectile dysfunction (eg. Viagra, Cialis, Levitra).
exclude other causes of pain and bleeding from the
The passage of a proctoscope (an instrument
designed to examine the back passage) under
sedation can help to relax the sphincter and aid healing. Vigorous anal dilatation, which had
Initial management is directed at minimising
been practised in the past, should be avoided,
further local trauma, providing adequate pain
as it may damage the anal sphincter further,
What is it?
relief, relaxing the anal sphincter spasm and
predisposing you to loss of bowel control.
An anal fissure is a split in the lining of the bowel
that occurs just inside the back passage. It is usually
Fissures resistant to these initial conservative
caused by the passage of hard stool (related to
Stools must be kept soft (the passage of hard stool
may undo weeks or months of healing). Laxatives
other therapies, including botulinum toxin
Occasionally a fissure will heal without difficulty
and fibre supplements are recommended to assist
(Botox®) injections or even surgery. However
but often a cycle of pain and muscular spasm of the
with easier evacuations, and need to be continued
it is important that an adequate trial of these
anus develops. The combination of anal pain and
for some weeks or months after symptoms resolve
conservative measures is attempted first as the
spasm makes it difficult to open your bowels well
to prevent recurrent fissure formation, especially if
majority of fissures will heal with analgesia,
creating a vicious cycle of worsening constipation
you have a tendency to constipation.
relief of constipation and the regular use
and harder stools leading to more pain and damage
of Rectogesic®. Whilst Botox® and surgery
when you do open your bowels. This muscular
Pain relief measures such as regular warm salted
each have a role in the treatment of resistant
spasm is also thought to reduce blood flow to the
baths, local anaesthetic creams, and oral pain
fissures, they should not be viewed as a “quick
area contributing to poor healing of the fissure.
medications (analgesics) may be necessary, especially when the pain and spasm are severe.
fix” approach for all fissures as each has the
Be aware that codeine or other strong pain killers
possibility of leading to further damage to the
Typical symptoms of a fissure include stinging,
can cause worsening of constipation which may
anal sphincter muscle and the potential for the
tearing or burning pain when passing a bowel
make the problem worse. Simple analgesics such
later development of poor bowel control.
motion (stool), often with a small amount of bright
as paracetamol will not cause constipation.
bleeding on the stool. The pain may be very severe and throbbing preventing sleep. Constipation often
Relaxing the anal sphincter helps with decreasing
THE MOST COMMON SYMPTOMS
precedes the development of a fissure and the
spasm of the muscle of the anal sphincter and
include stinging, tearing or burning
presence of pain with a fissure often compounds
may allow increased blood flow to the base of the
pain when passing a bowel motion
the problem of constipation. Anal tags may develop
fissure. Glyceryl trinitrate 0.2% (Rectogesic®)
next to long-standing anal fissures and these may
ointment relaxes the smooth muscle of the anal
predispose to moistness and irritation of the skin
sphincter muscle. It should be applied 2-3 times
a day but may cause headaches, especially at first. Headaches can be diminished by applying
the ointment with a finger wrapped in clingwrap
Often the anal region is too painful to allow the
and starting with a lower dose and persisting.
doctor to examine the area properly or conduct
It is best to use a small amount frequently and
an internal examination. If an examination is
gradually increase the amount rather than using
An information leaflet for patients and interested members of the general public prepared by the Digestive Health Foundation
This information booklet has been designed by the Digestive Health Foundation as an aid to people who need a PEG tube or for those who wish to know more about it.
This is not meant to replace personal advice from your medical practitioner.
The Digestive Health Foundation (DHF) is an educational body committed to promoting better health for al Australians by promoting education and community health programs related to the digestive system.
The DHF is the educational arm of the Gastroenterological Society of Australia the professional body representing the specialty of gastrointestinal and liver disease in Australia. Members of the Society are drawn from physicians, surgeons, scientists and other medical specialities with an interest in GI disorders.
Since its establishment in 1990 the DHF has been involved in the development of programs to improve community awareness and the understanding of digestive diseases.
Research and education into gastrointestinal disease are essential to contain the effects of these disorders on all Australians.
Further information on a wide variety of gastrointestinal conditions is available on our website.
Phone: (02) 9256 5454
Facsimile: (02) 9241 4586
cannot be completely comprehensive
145 Macquarie Street
SYDNEY NSW 2000
Lyme : démarches diagnostiques,thérapeutiques et préventivesR. Cohen, CHI, Créteil« Borréliose de Lyme : démarches diagnostiques, thérapeutiques et préventives », 16e Conférence deconsensus en pathologie infectieuse, 13 décembre 2006 www.infectiologie.com/site/medias/_documents/consensus/2006-lyme-long.pdf transmise par la piqûre d’une tique. Ellepeut survenir à tout âge, mais
Comunicato Ufficiale N° 28 del 30/01/2003 1. COMUNICAZIONI DELLA F.I.G.C. 1.1 Elenco sostanze vietate e dei metodi proibiti in materia di doping Si riporta qui di seguito il comunicato ufficiale n. 110/A del 18.12.2002, riguardante l’argomento sopra “COMUNICATO UFFICIALE N. 110/A preso atto che la Giunta Nazionale del CONI ha recepito, con delibera n. 735/2002, l’elenco aggiorna-