anal fissures.pdf

7/16/2015 AnalFissures

http://fitsweb.uchc.edu/student/selectives/Luzietti/Painful_anus_anal_fissures.htm 1/2

AnalFissures

AnalFissures

Etiology

Ananalfissureisatearinthesquamousepithelialmucosaoftheanalcanal.Theyoccurbetweentheanocutaneousjunctionandthedentateline.Thegenerallyacceptedetiologyofanalfissuresisthemechanicaltearingfromthepassageofahardstool,howeverthepathophysiologyislikelytobemultifactorialandmayinvolveanodermalischemia,infection,chronicconstipation,and/orhypertonicityofthesmoothmuscleoftheinternalanalsphincteranditselevatedrestingpressure.

Fissuresmostoftenoccurintheposteriormidline,andthereasonsforthisarebothanatomicandfunctionalinnature.Theposteriorcommissureoftheanodermislesswellperfusedthanotherregions.Furthermore,beforethebranchesoftheinferiorarteryreachtheanoderm,theycourseperpendicularlythroughtheseptaoftheinternalanalsphincter.Thus,flowthroughthesearteriesisthreatenedbyelevatedintramuscularpressureoftheinternalanalsphincter,andinfact,studieshavedemonstratedthatpatientswithanalfissurestendtohaveelevatedanalcanalpressures.

Additionally,womenoccasionallyhaveanteriorfissures,andlateralfissurestypicallysuggestanunusualdiagnosis(Crohn'sdisease,STD,malignancy).

ClinicalPresentation

Acarefulhistoryandphysicalexamwillusuallysuggestthediagnosis.Patientsoftencomplainofahistoryofconstipationorexcessivediarrhea.Painiscommon,particularlywithdefecationandmaybedisproportionatetothesizeofthelesion.Ifbleedingispresent,itisusuallybrightred,andinfact,isthemostcommoncauseofbrightredbloodperrectum(BRBPR)atanyage.

Thediagnosisismadebyinspectingtheanalregion.Gentleretractionofthebuttockswillrevealthetear.Havingthepatientbeardownwillaidinseeingafissureifitispresent.Incaseswhereafissurecannotbyseen,adigitalexamshouldbedonetoruleoutotherpathology.Likewise,ifpainlimitsthediagnosis,anexaminationunderanesthesiawouldbeappropriate.

Ifthefissureischronic,asmall,external,skintag(sentineltag)maybeidentifiedatthebaseofthelaceration.Additionally,ifthefissureexposesinternalsphincterfibersandtherearehypertrophiedanalpapillaatthelevelofthedentateline,thenthistriadoffeaturesisgenerallyconsideredpathognomonicforchronicfissures.

Treatment

Acuteanalfissuresrarelyrequiresurgery.Conservativetreatmentofadietarymodification,stoolsofteners,andSitzbathsusuallysuffice.Symptomsfromanacutefissureusuallyresolveover1014dayswithconservativetreatment,howeveritmaytake68weeksforafissuretoactuallyheal.

Ifafter68weeks,thetearhasnothealed,thefissureisconsideredchronicandmoreactivemeasurescanbeemployed.

7/16/2015 AnalFissures

http://fitsweb.uchc.edu/student/selectives/Luzietti/Painful_anus_anal_fissures.htm 2/2

Chemicalsphincterotomyemployingnitroglycerinointment(NTG)canbeattempted,wheretheointmentisappliedtopicallytohelphealthewound,however,headacheanddiarrheaarecommoncomplications.Topicaldiltiazemcanalsobeused,withlessreportedsideeffects.Lastly,botulinumtoxincanbeinjectedtoreduceinternalsphinctertoneandpromotehealing,howeverthisapproachismoreinvasiveandcostlythanthetopicaltreatments.

Asmentionedabove,surgeryisrarelyneededforanacutefissure,asconservativemanagementusuallysuffices.Ifafissurepersistsdespitemedicalmanagement,thenalateral,internalsphincterotomycanbeperformed.Thepurposeoftheprocedureistocutthehypertrophiedinternalsphincter,therebyreleasingtension,andallowingthefissuretoheal.