Anal Fissures

Question 1

What is the defn of an anal fissure?

Answer 1

split in anoderm distal to the dentate line. Usually d/t trauma, 90% occ in post anal midline

Question 2

How does a pt with an anal fissure present clinically?

Answer 2

tearing pain w/ defecation
sev anal spasm that last for hrs afterward
bright PR bleed
perianal pruritis and/or skin irritation

Question 3

Discuss what is noted on PE for an acute as well as chr anal fissure

Answer 3

Acute:
superficial tear (usually post) - if lat consider 2ndary cause. Pts unable to tolerate DRE

Chr:
hypertrophied w/ skin tags +/or papillae
boat shaped; punched out; exposing int sphincter (see white posteriorly); sentinel skin tag; hypertrophic anal papilla

Question 4

What are some of the causes of a secondary anal fissure?

Answer 4

Crohn's ds
extra-pulmonary TB
Anal SCC
Anorectal Fistula
Infxns - CMV, HSV, chlamydia + syphilis

Question 5

What is the mx for an anal fissure?

Answer 5

if rectal bleeding -> offer colonoscopy
most will heal on their own w/in 1-2 days
90% pts heal w/ medical tx: lifestyle mod (increased fibre etc); sitz baths; topical nifedipine ointment; GTN paste, botox

if they don’t heal, it’s bc of spasm of int sphincter -> surgical intervention = lat int sphincterectomy