31.20.26 Comparison of Effectiveness of Topical and Oral Metronidazole for Reducing Postoperative Pain after Hemorrhoidectomy

Original Article

 

Use of Oral Metronidazole in Hemorrhoidectomy

Comparison of Effectiveness of Topical and Oral Metronidazole for Reducing Postoperative Pain after Hemorrhoidectomy

Sajid Razzaq1, Zardad Khan2, Mohammad Arif Mahmood1, Mohammad Nadeem Khan3, Waheed Iqbal4 and Nasir Zareen1

ABSTRACT

Objective: To compare the effectiveness of oral versus topical metronidazole for reducing postoperative pain in patients undergoing Milligan Morgan hemorrhoidectomy.

Study Design: Randomized controlled trial study.

Place and Duration of Study: This study was conducted at the Department of Surgery, Divisional Headquarter Teaching Hospital Mirpur AJK from July 2019 to June 2020.

Materials and Methods: One hundred and twenty patients of both genders with ages 20 to 60 years undergoing hemorrhoidectomy for 3rd and 4th degree hemorrhoids were enrolled. All the patients were equally divided into two groups, each group contains 60 patients. Group 1 received oral metronidazole postoperatively for 5-days and group 2 received topical metronidazole postoperatively. Postoperative pain was analyzed by VAS on 1st, 3rd and 5th day postoperatively between both groups.

Results: There were 76 (63.33%) male patients and 44 (36.67%) were females with mean age 38.74±11.42 years. 67 (55.83%) patients had 4th degree hemorrhoidal disease and 53 (44.16%) patients had 3rd degree disease. Group 2(topical) patients had significantly lower postoperative pain at 5th day as compared to group 1(oral) patients with p value<0.05.

Conclusion: Topical metronidazole is more effective than oral metronidazole in patients undergoing Milligan Morgan hemorrhoidectomy.

Key Words: MilliganpMorgan hemorrhoidectomy, Post-operative pain

Citation of article: Razzaq S, Khan Z, Mahmood MA, Khan MN, Iqbal W, Zareen N. Comparison of Effectiveness of Topical and Oral Metronidazole for Reducing Postoperative Pain after Hemorrhoidectomy. Med Forum 2020;31(10):111-113.

 

 

INTRODUCTION

Hemorrhoids at 3, 7, and 11 O'clock are symptomatic and prolapsed anal coilings. Among them are secondary haemorrhoids. Patients suffer from fresh rectal bleeding, mucus release, rectal pain irritation, and swelling. Hemorrhoids are four degrees. In the first grade there is no prolapse bleeding per rectum, in the second grade there is spontaneous prolapse, manual haemorrhoids of the third grade and no reduction of the entire prolapse of the fourth grade.1-3

 

 

1. Department of Surgery, SKBZ/Poonch Medical College Rawalakot AK.

2. Department of Surgery / Anaesthesiology3 / Medicine4, Divisional Headquarter Teaching Hospital /MBBS Medical College Mirpur AK.

 

 

Correspondence: Dr. Zardad Khan, Assistant Professor of Surgery, Divisional Headquarter Teaching Hospital /MBBS Medical College Mirpur, AK.

Contact No: 03335202466

Email: surgeon.zardad@gmail.com

 

 

Received:    July, 2020

Accepted:    September, 2020

Printed:        October, 2020

 

 

The key indications in clinical practise are third or fourth-grade internal haemorrhoids4; pain, infections, infection, inflammations, haemorrhage, faecal incontinence, unexposed wounds and urinary retention are the major complications in hemorrhoidectomy.5,6 Spasma of internal anal sphincter appears as the major indicator of hemorrhoidectomy.5 Dolor is the main post-operative problem and it is caused by surgical injury in sensitive anoderm, oedema, spasm, and infection.7 Some remedial options such as GTN 0.1%, topical NSAIDs, calcium channel blockers and metronidazole have been suggested.8 Studies show that metronidazole substantially decreases postoperative pain (p0.004, p0.0011) in all types (topical and oral) and enhances the healing process relative to placebo.9,10 The present study was conducted aimed to compare the efficacy of oral metronidazole versus topical metronidazole for reducing postoperative pain in patients undergoing hemorrhoidectomy.

MATERIALS AND METHODS

This randomized controlled trial was conducted at Department of Surgery, Divisional Headquarter Teaching Hospital Mirpur AK from 1st July 2019 to 30th June 2020. A total of 120 patients of both genders with ages 20 to 60 years were enrolled in this study. Patient’s detailed demographics including age, sex, and body mass index were recorded. Patients with emergency hemorrhoidectomy, diabetic patients, patients with renal failure and non-compliance patients were excluded. All the patients were received elective Milligan-Morgan hemorrhoidectomy under general anesthesia. Patients were divided into two groups 1 and 2, each group contains 60 patients. Group 1 received oral metronidazole postoperatively for 5-days and group 2 received topical metronidazole postoperatively. Postoperative pain was analyzed by VAS on 1st, 3rd and 5th day postoperatively between both groups. Data was analyzed by SPSS 24.

RESULTS

Seventy-six (63.33%) were male patients and 44 (36.67%) were females with mean age 38.74±11.42 years. Mean BMI of patients was 24.52±2.86 kg/m2. 67 (55.83%) patients had 4th degree hemorrhoidal disease and 53 (44.16%) patients had 3rd degree disease (Table 1). At first postoperative day, mean pain score in group 1 was 6.89±1.76 and in group 2 it was 6.42±1.38, no significant difference was observed at first postoperative day. At 3rd postoperative day, mean pain score in group 1 was 3.96±1.28 and in group 2 it was 2.74±1.06, a significant difference was observed between two groups with p value 0.024. At 5th postoperative day, mean score in group 1 was 3.08±0.24 and in group 2 it was 2.14±0.26, a significant difference was observed between both groups with
p value 0.01 (Table 2).

Table No.1: Details of enrolled patients

Variable

No.

%

Mean age (years)

38.74±11.42

Mean BMI (Kg/m)

24.52±2.86

Gender

Male

76

63.33

Female

44

36.67

Hemorrhoid degree

3rd

53

44.16

4th

67

55.83

Table No.2: Comparison of postoperative pain score between both groups

Variables

Group 1

Group 2

P-value

At 1st postoperative day

6.89±1.76

6.42±1.38

>0.05

At 3rd postoperative day

3.96±1.28

2.74±1.06

0.024

At 5th postoperative day

3.08±0.24

2.14±0.26

0.01

DISCUSSION

Post-operative pain control is the most critical problem after hemorrhoidectomy. This pain tends to be multifactorial and depends on individual tolerance, mode of anaesthesia and surgical technique. Besides the spasm of an anal sphincter, the two main causes are after surgical discomfort. Majority of patients were male 76 (63.33) as compared to females 44 (36.67). Results of this study showed similarity to many other previous studies in which population of male patients was high 55% to 70% as compared to females and average age of patients was 40years.11,12

In this study, we found 67 (55.83%) patients had 4th degree hemorrhoidal disease and 53 (44.16%) patients had 3rd degree disease. A study conducted by Hyder et al13 reported that 59.67% patients had 3rd degree and 40.32% had 4th degree hemorrhodal disease. We found that, at first postoperative day, mean pain score in group 1 was 6.89±1.76 and in group 2 it was 6.42±1.38, no significant difference was observed at first postoperative day. The study by Neogi et al14 indicates that metronidazole (oral and topical) significantly reduces postoperative pain but showed no difference in between oral and topical metronidazole. At 3rd postoperative day, mean pain score in group 1 was 3.96±1.28 and in group 2 it was 2.74±1.06, a significant difference was observed between two groups with p value 0.024.These results showed similarity to previous study, conducted by Ala et al.15 At 5th postoperative day, mean score in group 1 was 3.08±0.24 and in group 2 it was 2.14±0.26, a significant difference was observed between both groups with p value 0.01. These results were similar to Grekova et al.16 A study conducted by Elton et al17 reported topical glyceryl trinitrate for pain after haemorrhoidectomy. We found that group 2 topical metronidazole patients had
lower postoperative pain as compared to oral metronidazole patients, showed similarity to other previous studies.18-20
.

CONCLUSION

Topical metronidazole is more effective than oral metronidazole in patients undergoing Milligan Morgan hemorrhoidectomy.

Author’s Contribution:

Concept & Design of Study:

Sajid Razzaq

Drafting:

Zardad Khan, Mohammad Arif Mahmood

Data Analysis:

Mohammad Nadeem Khan, Waheed Iqbal and Nasir Zareen

Revisiting Critically:

Sajid Razzaq

Final Approval of version:

Sajid Razzaq

Conflict of Interest: The study has no conflict of interest to declare by any author.

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