Anal Fissure Flashcards
def
an elongated ulcer on the long axis of the lower anal canal
aetiology
traumatic -posterior anal lining - constipation (straining, passing hard stools) -anterior anal lining - childbirth inflammatory -crohns disease -ulcerative colitis
epi
common
<40yrs
incidence 1:350, male:female
history
severe burning pain on defaecation
bleeding per rectum (bright red, small in voiume, on paper)
examination
inspection reveals a sentinel pile (external lump associated with a tear)
chronic fissures may present with a firm ridge
pathogenesis
a mechanical tear occurs in the anal mucosa & the underlying sphincter muscle goes into spasm
the spasm worsens the problem by pulling the edges of the tear apart
poor wound healing due to reduced blood flow in the posterior midline of the anoderm
investigations
diagnosis made on history & examination
management
conservative
-soft, easily passable stools
medical
-topical GTN/diltiazem which reduce spasm or sphincter & increase blood flow to encourage wound healing
surgery
-lateral internal sphincterotomy (internal sphincter is partially divided to reduce spasm, this allows wound healing)
-botulinum toxin to paralyse part of the internal sphincter
complications
chronic fissure & chronic pain
complications of surgery
-faecal incontinence
-bleeding recurrence
prognosis
common recurrence
50% treated with topical nitrates
10% treated with lateral sphincterotomy