Rectum
Anal Fissure
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Anal Fissure
, Fissure in Ano, Anal Ulcer, Anal Mucosal Ulcer, Nontraumatic Anal Tear
Pathophysiology
Usually follows
Trauma
or
Diarrhea
l illness
Chronic increase in resting anal pressure
Increased anodermal
Blood Flow
causes fissures
Relative ischemia in posteromedial anal region
Epidemiology
Affects young and middle-aged adults
Men and women are equally affected
Symptoms
Onset after forced hard
Bowel Movement
Bright red
Rectal Bleeding
Pain during
Bowel Movement
Cut with sharp glass sensation
Pain persists for an hour after stooling
Signs
See
Anorectal Exam
Avoid
Anoscopy
if possible
Painful and usually not needed
Use
Local Anesthesia
if performed
Crack or crevice in anoderm at anal verge
Usually in canal midline (anterior 12:00 or posterior 6:00)
Lateral suggests other diagnosis (see differential diagnosis below)
Best seen with lateral traction on opposite buttock
Sentinel pile (distal
Skin Tag
)
Tag-like swelling of fissure end
Results from infection and edema
Findings suggestive of chronic Anal Fissure (>8 weeks)
Anal Papillae Hypertrophy
Sentinel pile or tag (see above)
Exposed anal sphincter muscle
Differential Diagnosis
See
Anorectal Pain
Conditions resulting in lateral Anal Fissure or multiple Anal Fissures
Inflammatory Bowel Disease
(esp.
Crohn's Disease
)
HIV Infection
Tuberculosis
Syphilis
Leukemia
Anorectal cancer
Sexual Abuse (children)
Management
Medical
Early Management (especially if <4 weeks)
Bowel
regimen to allow for at least one soft stool daily without straining
Bulk
Dietary Fiber
to 30 grams/day
Increase fluid intake 64 ounces/day
Sitz baths
Topical
Hydrocortisone
(e.g. Proctofoam HC)
Topical
Lidocaine
(
Xylocaine
5%)
Topical
Calcium Channel Blocker
(see below)
Glyceryl Trinitrate
ointment (compounded by pharmacist)
Apply 0.2% twice daily for 6 weeks
See
Rectal Nitroglycerin
(
Glyceryl Trinitrate
,
Rectiv
)
McLeod (2002) J Gastrointest Surg 6(3): 278-80 [PubMed]
Late Management (esp. >3 months)
Difficult to treat if persistent beyond 3 months
Topical
Calcium Channel Blocker
Preparations (compounded by pharmacist)
Topical
Nifedipine
0.3% or 0.5% and
Lidocaine
1.5% ointment or
Topical
Diltiazem
2% and
Lidocaine
1.5% ointment
Dosing
Apply twice daily for 6 weeks
Efficacy
More effective than
Nitroglycerin Ointment
Resulted in 94.5% rate of healing
Perrotti (2002) Dis Colon Rectum 45:1468-75 [PubMed]
Management
Invasive procedures
Indications
Failure to improve after above management including two cycles of topical
Calcium Channel Blocker
(see above)
Lateral sphincterotomy (preferred)
Efficacy
Fissures heal in 96% of cases
Patients satisfied in 98% of cases
Complications
Recurrent Anal Fissures: 8%
Severe anal
Incontinence
: 1% (more common in women)
References
Nyam (1999) Dis Colon Rectum 42:1306 [PubMed]
Botulinum Toxin Injection
Unclear long term efficacy
Dosing
Initial:
Botulinum Toxin
40 units
Next:
Botulinum Toxin
40 units
Adverse effects
Short term
Fecal Incontinence
in 5-7%
Long term flatus
Incontinence
is uncommon
References
Arroyo (2005) Am J Surg 189:429-34 [PubMed]
Brisinda (2007) Br J Surg 94(2): 162-7 [PubMed]
References
Cohee (2020) Am Fam Physician 101(1):24-33 [PubMed]
Fargo (2012) Am Fam Physician 85(6): 624-30 [PubMed]
Katsinelos (2006) Int J Colorectal Dis 21(2): 179-83 [PubMed]
Madoff (2003) Gastroenterology 124:235-45 [PubMed]
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