What is Hilton's method for treating anal fissures?

Hilton's Method for Treating Anal Fissures

Hilton's method is not a recognized treatment approach for anal fissures in current medical guidelines. Based on comprehensive guidelines from the American Gastroenterological Association and World Journal of Emergency Surgery, there is no mention of a specific "Hilton's method" for treating anal fissures 1.

Evidence-Based Treatment Approaches for Anal Fissures

Initial Non-Operative Management

• Non-operative management is strongly recommended as first-line treatment for acute anal fissures 1
• About 50% of all anal fissures heal with conservative care within 10-14 days 1
• Conservative management includes:
  • Fiber supplementation and adequate fluid intake 1
  • Sitz baths to relax the internal anal sphincter 1
  • Topical analgesics for pain control 1

Pharmacological Treatments

• Topical treatments aim to reversibly decrease resting anal pressure, allowing fissure healing without permanent sphincter damage 1
• Calcium channel blockers (Diltiazem, Nifedipine):
  • Associated with healing rates of 65-95% 1
  • More effective than glyceryl trinitrate with fewer side effects like headache and hypotension 1
  • Recommended for at least 6 weeks, with pain relief typically occurring after 14 days 1
• Glyceryl trinitrate (GTN):
  • Early studies showed 70-80% healing rates, but more recent studies show lower rates (25-50%) 1
  • Common side effect is headache 1
• Botulinum toxin injection:
  • Studies show high cure rates (75-95%) with low morbidity 1
  • Optimal injection location remains controversial 1

Surgical Approaches

• Lateral internal sphincterotomy (LIS) is the gold standard surgical procedure for chronic anal fissures that don't respond to conservative treatment 1, 2
• Surgery is recommended only for:
  • Chronic fissures not responsive after 8 weeks of non-operative management 1
  • Acute fissures with severe pain 1
  • Recurrent fissures despite optimal medical treatment 2
• Manual dilatation is strongly discouraged due to high risk of incontinence 1

Treatment Algorithm

1. Acute anal fissure:

   • Start with conservative management: fiber, fluids, sitz baths, topical analgesics 1
   • If pain control is inadequate, add topical anesthetics and common pain killers 1
   • Consider topical antibiotics in cases of poor genital hygiene 1

2. If no improvement after 2-4 weeks:

   • Add pharmacological therapy:
     • First choice: Topical calcium channel blockers (diltiazem 2% or nifedipine) for 6-8 weeks 1, 3
     • Alternative: Glyceryl trinitrate ointment (0.2-0.25%) 4, 5
     • For refractory cases: Consider botulinum toxin injection 1

3. If no healing after 8 weeks of non-operative management:

   • Consider lateral internal sphincterotomy 1

Important Considerations

• Atypical fissures (not in midline) require evaluation for underlying conditions like Crohn's disease, HIV/AIDS, ulcerative colitis, tuberculosis, syphilis, or cancer 1
• Signs of chronicity include sentinel tag, hypertrophied papilla, fibrosis, and visualization of bare internal sphincter muscle 1
• Surgical treatment carries a small risk of incontinence but has higher healing rates (>90%) compared to medical therapy 5, 6
• Recurrence rates after medical therapy can be significant, with GTN showing recurrence in approximately 50% of initially healed cases 6