Anal Fissure Flashcards
Definition
An elongated ulcer which occurs in the long axis of the lower anal canal.
Incidence
*Sex: males and females are equally affected. *Age: - Most common in middle aged. - Not common in elderly. - Not rare in children.
Etiology are
A-No definitive cause
B-definitive cause
A-No definitive cause is found in the majority postulated mechanisms are
*Trauma:
- Hard stool (in constipated patients) ) injury to the least supported site, i.e., midline posterior fissure.
- Repeated deliveries ) damage of perineal body ) loss of ant. Anal support — midline anterior fissure.
*lschemia:
- May play a role in development of the condition.
- Midline posterior fissurea is the most common as it is least vascular.
B-definitive cause is found in a minority
is found in a minority.
*IBD especially Crohn’s disease
*STDs
*latroqenic.
- Large enema, endoscope.
- Post hemorroidectomy: removal of too much skin –> stenosis –> injury of mucosa by hard stools. These fissures may be at any site & even multiple
pathogenesis
It is a vicious circle Pain is the main pathogenic factor in acute fissure)
Pathology I Site:
*Usually in the midline.
- Midline posteriorly (90%)
- Midline anteriorly (10oh): Especially common in multiparous females.
- Anterior and posterior fissures may coexist.
*May be anywhere as in Crohn’s disease.
Pathological changes:
*Acute Fissure
- Superficial tear present in the sensitive part (below dentate line) —> pain.
- Pain —> spasm of internal sphincter —> J blood flow —> prevents healing of fissure.
*Chronic Fissure
-lf acute fissure is not treated well, it will proceed to chronic stage with secondary pathological changes:
a- Margins: become indurated, thick and fibrotic.
b- At the upper end of fissure: an anal papilla may develop.
c- At the lower end of fissure: sentinel pile (skin tag) may develop.
Symptoms
- Pain:
- ls the main symptom.
- Character: sharp, agonizing.
- Site: localized to the anus, can radiate to the coccyx or to the genitalia.
- Starts: at defecation.
- Lasts: for about t hour after defecation, and ends suddenly.
- Course: may have remissions for days or weeks.
2.Constipation:
The severe pain forces the patient to postpone defecation –> more constipation –> inc fissure (vicious circle).
3.Bleeding:
-Only a slight streak of blood (bright red) on the surface of the stool.
4.Slight anal discharqe and pruritis:
-lf an abscess forms and bursts, there will be purulent discharge.
5.Reflex svmptoms:
Burning micturition, dysmenorrhea and pain along the thighs
Signs ln acute anal fissure:
- ln acute anal fissure: .
* lnspection:
- The anal verge is tightly contracted, puckered anus.
- lf the 2 gluteal folds are gently pulled laterally, a small tear will be seen.
- DRE:
- Better to be avoidedE, as it is very painful.
- lf it is essential to exclude other pathology, it should be done under general anesthesia.
Signs ln Chronic anal fissure:
- in chronic fissure:
* inspection:
- The fissure can be seen.
- An anal papilla or a sentinel pile may be present.
- DRE:
- Fissure is fibrotic & indurated (Button hole induration).
- Sphincter is fibrosed.
DD
Of painful anal conditions
- Anal fissure.
- Perianal suppuration.
- Prolapsed strangulated piles.
- Acute perianal hematoma.
- Carcinoma of the anus.
- Proctalgia fugax (idiopathic).
- Crohn’s disease
Complications
1- Fissure abscess ) fistula.
2- Acquired megacolon.
Invetigation
- It is a clinical diagnosis, however, if multiple and in uncommon site —> Search for a specific cause e.g. Crohn’s disease —> biopsy
- Preoperative lnvestigations: CBC , LFTs, ….
ttt of acute fissure
(Essentially medica!, but sometimes surgery is needed)
*Life style chanqes:
-High fiber diet (fruits. vegetables & cereals).
Aim: to make stool bulky & avoid constipation
-Laxatives (e.q. lactulose syrup)
Aim: to soften the stool
-Sittinq in a warm bath after using the toilet.
Aim: relieve the spasm & pain
aim of medical ttt
advantage of medical ttt
surgical ttt
