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Banding Bulletin – October 2014

Banding Bulletin – October 2014

We hope that this month’s edition of the Banding Bulletin finds you well! In this Bulletin, I’m going to share some of our “tips and tricks” in a case study that I hope will be helpful in caring for your patients. The conference season is also in full force and October is a busy month for CRH in that regard. I’ve included our travel schedule below – if you’ll be in attendance, please come by to say “hello”!!

Case Study – “Tips and Tricks” Revealed!

We’ve identified a number of ”tips and tricks” over the years, and I’m going to include one of my favorites in this first installment. In order to keep things short and sweet, please excuse the “Cliff’s Notes” version as I’ll stay away from my typical ramblings and try to get to the point quickly! As a note, these methods are all “off label” — so none of this is coming from CRH, but rather from a washed up general surgeon.
Case – The anal fissure and the “magic bullet”:

Problem: A 22-year old otherwise healthy male presented to the office with complaints of searing pain on defecation. Evaluation revealed an anal fissure that was exquisitely tender. The exam was quite difficult because of the tenderness, but the fissure was palpated, and there was no evidence of abscess or other cause of this pain. The recommendations for fiber supplementation, additional fluid intake, sitz baths and minimizing time on the commode were given. When I described the need for topical nitrates intra-anally, I received that “you’ve got to be kidding me!” look, as he informed me that there was no way that he was going to be able to insert his finger into the anus because of the pain.


Solution: The patient was given a prescription for 10 day’s worth of hydrocortisone-containing suppositories, topical nitroglycerin ointment, and told to purchase 5% lidocaine cream as well. The lidocaine was to be used as needed, and the NTG was to be placed on the suppository that was then inserted t.i.d. for those 10 days. The suppository acted as both a “delivery agent” for the NTG, as well as providing that short course of topical steroid that does a nice job of cooling off the inflammatory process associated with an angry fissure. After a week to 10 days, the patient improved to the point of no longer needing the “magic bullet”, and simply used the NTG ointment routinely, as he is to complete a 3-month course of the medication. I’ve found that this trick works very well for these patients as well as those who simply refuse to put their finger “back there”. If there isn’t a lot of acute inflammation present, then I’ve suggested that the patient use any OTC suppository that is inexpensive (typically glycerine) to serve that same purpose. I should note that these topical steroids tend to be dramatically over utilized, and that I keep the duration of the treatment very brief – rarely longer than 10 days.

Upcoming Conference Schedule

October is always a busy month for conferences, and this year is no exception, as we’ll be at the American College of Gastroenterology in Philadelphia from 9/19-21 at booth #527 (where we’ll be introducing something new!), and then at the American College of Surgeons in San Francisco at Booth #2535 from 9/27-29. If you are attending, we’ll be there in full force in order to address any questions you might have, provide any needed information, and we will even be able to schedule training or refresher visits if you’d like as well. Please come by and say “hello”!

Please let ME know if we can provide support to you or your practice, or if we can help in any way. We are always happy to hear from you — take care and have a great day.


Mitchel Guttenplan, MD, FACS
Medical Director
CRH Medical Corporation
C: 770.363.0125 F: 770.475.9953

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