7/16/2015 AnalFissures
http://fitsweb.uchc.edu/student/selectives/Luzietti/Painful_anus_anal_fissures.htm
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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.
