The categorisation of the quality of the evidence (into high, moderate, low, or very low) reflects the quality of evidence available for our chosen outcomes in our defined populations of interest. We have performed a GRADE evaluation of the quality of evidence for interventions included in this review ( see table In addition we use a regular surveillance protocol to capture harms alerts from organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA), which are added to the reviews as required. We included systematic reviews of RCTs and RCTs where harms of an included intervention were studied, applying the same study design criteria for inclusion as we did for benefits. There was no minimum length of follow-up required to include studies. Study design criteria for inclusion in this review were: published systematic reviews of RCTs and RCTs in any language, including non-blinded or "open" studies, and containing at least 20 individuals, of whom more than 80% were followed up. Selected studies were then sent to the contributor for additional assessment, using pre-determined criteria to identify relevant studies. Abstracts of the studies retrieved from the initial search were assessed by an information specialist. We also searched for retractions of studies included in the review. An additional search within The Cochrane Library was carried out for the Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment (HTA). The following databases were used to identify studies for this systematic review: Medline 1966 to August 2009, Embase 1980 to August 2009, and The Cochrane Database of Systematic Reviews, Is(1966 to date of issue). This review deals only with chronic anal fissures.Ĭlinical Evidence search and appraisal August 2009. Most published studies only require the presence of one of these signs or symptoms of chronicity to classify a fissure as chronic. Chronic anal fissures have distinct anatomical features, such as visible sphincter fibres at the fissure base, anal papillae, sentinel piles, and indurated margins. Chronic anal fissures: Fissures persisting for longer than 4 weeks, or recurrent fissures, are generally defined as chronic. Acute fissures are believed to often heal spontaneously. Acute anal fissures have sharply demarcated, fresh mucosal edges, often with granulation tissue at the base. It is not clear what the best treatment strategy is in people who present with a painless anal fissure and in whom an atypical aetiology has been ruled out. Treatments for atypical fissures are not included in this review. Atypical fissures may be caused by malignancy, chemotherapy, STIs, inflammatory bowel disease, or other traumas. Multiple fissures, and large, irregular, or large and irregular fissures, or fissures off the midline, are considered atypical. People with an anal fissure usually experience pain during defecation and for 1 to 2 hours afterwards. An anal fissure is an ulcer or tear in the squamous epithelium of the distal anal canal, usually in the posterior midline.
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