Anal fissure Flashcards
what causes primary anal fissures?
trauma (passing hard stools, prolonged diarrhea, vaginal delivery, anal sex)
what causes secondary anal fissures?
previous anal surgical procedures
inflammatory bowel dx (Crohns)
Granulomatous dx (extrapulm TB and sarcoidosis)
Malignancy (squamous cell anal cancer, leukemia)
Communicable dx (HIV infection, syphilus, chlamydia)
how to prevent anal fissure?
proper anal hygiene to keep area dry by wiping with moist cloth
high fiber diet and adequate fluid intake to prevent constipation
avoiding anal trauma
avoid straining during defecation
clinical presentation of anal fissure:
tearing pain after bowel movements
bright red blood on toilet paper or stool surface
possible perianal pruritis and skin irritation
acute fissure usually appearing in the posterior anal midline
chronic fissure with raised edges exposing the white internal anal sphincter fibers.
why is the posterior anal midline affected most?
because of less wound healing and less blood supply to other areas.
atypical features that should be evaluated are:
anal fissures with atypical features: lateral or anterior, multiple painless and very deep and recurrent
rectal bleeding: requires sigmoidoscopy if <50 or colonoscopy if >50 yrs
failure to respond after 8 weeks of
optimal medical therapy (topical vasodilators, nitroglycerin, nifedipine, stool softners, and advice to supplement fiber intake)
crohn’s can present as
anal fissures in 80% of cases as posterior midline fissures.
Diagnosis of anal fissure is by:
clinical exam and history showing anal laceration
who should get further evaluation when they have anal fissure?
rectal bleeding and age greater than 50
get sigmoidoscopy and colonoscopy
lateral and anterior fissures + any features of IBS need colonoscopy and small bowel imaging to rule out IBS
how to treat anal fissure
- topical nitroglycerin cream to improve blood flow to anal area and promote wound healing and preferred in acute fissures
also do dietary changes
- botulism toxin injection can allow for healing and this is mean for people who don’t respond to nitroglycerin cream
what is the role for hydrocortisone cream for anal fissures?
not for anal fissures
and used for treatment in inflamed hemorrhoids or as adjunctive treatment for ulcerative colitis.
prevention of anal fissure?
constipation avoidance with increased fiber and fluid intake and avoiding anal trauma
keep anal area dry and clean
when do we get surgery?
lateral sphincterotomy - people who have anal fissures despite medical treatment or for chronic issues.
do we ever use oral metronidazole for anal fissures
no.
it’s meant for a treatment for non complicated perianal fistulas in Crohn’s disease following drainage of abscesses.
