Dd Fissura Ani.docx

ANAL FISSURE DEFINITION Anal fissure is a tear in the anoderm distal to the dentate line. It can be categorized as acute or chronic.Acute fissures present with anal pain, spasm, and/or bleeding with defecation. The diagnosis can typically be confirmed by physical examination and anoscopy in the office if tolerated by the patient. By gentle separation of the buttocks and examination of the anus, a linear separation of the anoderm can be identified at the lower half of the anal canal. Approximately 90% of anal fissures in both men and women are located posteriorly in the midline. Anterior fissures occur in 10% of patients, more commonly women. Fewer than 1% of fissures are located off a midline position or are multiple in number. These atypical fissures may be associated with Crohn’s disease, sexually transmitted diseases (human immunodeficiency disease [HIV], syphilis, or herpes), anal cancer, or tuberculosis. Whereas acute fissures typically heal with medical management after 4 to 6 weeks, chronic fissures persist beyond 6 weeks. Chronic fissures are also associated with raised edges, exposed internal sphincter muscle, distal sentinel tag, and hypertrophied anal papilla at the internal apex. An anal fissure is a tear in the opening of the anus that can cause pain, itching, and bleeding. Anal fissures arecommonin infants but less so in older children.They occur in adults of all ages. The pain, which can be quite severe, usually occurs during and after a bowelmovement. The most common cause of anal fissures is constipation, but diarrhea can be a cause as well. Anal fissures often result from a cycle in which you have pain as a result of constipation, avoid having a bowel movement, and thus worsen the constipation. Treatment involves changing your diet to eliminate diarrhea orconstipation, or topical medications to help heal the tear.However,some people need surgery totreat an anal fissure. Anal fissures are not associated with cancer, but you should always talk to your doctor if you have bleeding with a bowelmovement.

EPIDEMIOLOGY The incidence of fissura ani is 1 in 350 people. The frequency of occurrence of fissure ani is similar between men and women. Fissura ani is more likely to occur at a younger age and middle age. ETIOLOGY Most fissura ani occurs because the anal mucosa strain exceeds its ability. Once a fissura occurs, it will form a vicious circle. With the pain when the deficiency then the patient will be afraid for deficiency, this will cause the stool becomes hard and hard stool will increase sphincter activity. Fissura ani can be caused by various causes :  idiopathic  irritation due to diarrhea  partus injury  use of laksative  iatrogenic  inflammatory bowel diseases  sexually transmitted diseases SYMPTOMS AND DIAGNOSIS The most common symptoms are pain when having a bowel movement and blood on the toilet tissue. Acute anal fissures usually get better quickly.Achronic fissure, which can be more difficult to treat,is one that has lasted more than 6 weeks. A doctor can usually easily see if you have an anal fissure. To make the diagnosis, he or she might use an instrument called an anoscope to examine the anal canal.

CAUSES Constipation can cause the skin of the anus to tear. When that happens, the pain of a bowel movement can cause spasms in the anal sphincter muscle.This in turnmeansthat less blood flowstothe area,making it more difficult for the fissure to heal.The pain can also cause people to resist having a bowel movement, which worsens the constipation. Other causes include diarrhea and Crohn disease. If you have anal pain for more than 10 days, you should see a doctor to rule out an infection, a complicationof inflammatory bowel disease, a hemorrhoidal condition, or anal cancer. PATHOGENESIS Despite extensive investigation of this disease, the exact etiology of anal fissure remains unclear. It appears that constipation with passage of hard stools or anal trauma may instigate the fissure. However, in many instances patients do not report constipation or may have a history of watery diarrhea. In addition, many fissures heal within weeks whereas others go on to become chronic in nature. Various studies have suggested that both anorectal mechanics and blood flow to the anal canal may play a role in anal fissure development. Initial reports from the 1970s and 1980s have implicated internal sphincter hypertonia in anal fissure pathogenesis. More recent studies have used anorectal manometry to demonstrate hypertonia of the internal sphincter and have shown fewer internal anal sphincter relaxations in patients with chronic anal fissures. In addition, relative ischemia of the posterior anal canal has been implicated in chronic, nonhealing anal fissures. Postmortem angiography of the inferior rectal artery has demonstrated that the posterior commissure of the anal canal is poorly perfused in 85% of patients compared with other sections. Anal hypertonicity may aggravate perfusion to the anal canal. Pressure on the vessels passing perpendicularly through the internal anal sphincter muscle during increased sphincter tone may compromise perfusion to the posterior commissure where blood flow is already sparse. Doppler laser flow studies have clearly shown lower anodermal blood flow at the fissure site compared with the posterior commissure of controls. Internal sphincterotomy, the gold standard for the treatment of anal fissure, has been shown to decrease internal sphincter pressures and increase anodermal blood flow.7 In addition, it has been demonstrated that administration of anesthesia both decreases anal pressure and increases anodermal blood flow. The pathophysiology of anterior fissures may be different than chronic posterior fissures. Jenkins and colleagues showed that anterior fissure patients were significantly more likely to have occult external sphincter injury and impaired external sphincter function compared with posterior fissure patients. In addition, anterior fissures were identified in a younger and predominantly female group of patients. In these patients, maximum squeeze pressure was significantly lower compared with the posterior fissure group. Also, maximum resting pressure was not significantly elevated compared with controls, but was significantly elevated in posterior fissures. These findings may have important implications for the management and treatment of this common subgroup of anal fissure patients.

DIAGNOSIS 1. Anamnesis  Pain in the rectal region, usually described as burning, feeling cut, or torn like a feeling. The pain is in line with intestinal contractions; anal spasm should be suspected of fissura ani.  Constipation due to fear of pain.  Feces hard  Bleeding red bloody red on the surface of the stool. Blood usually does not mix with feces.  Mucoid discharge  Pruritus 2. Physical examination On inspection often found skin tags, fissura, and hypertrophy papilla. In most patients can be made fissura ani diagnosis only by inspection alone. The examination is done by slowly pulling the buttocks to see if there are skin tags, discharges, or blood. In the rectal plug, the fingers are inserted through the lateral section first to reduce the tenderness. The margins of fissura can be palpable irregular with tenderness that is very painful. Fissura ani acute looks eritem and bleed easily. In chronic fissures, pain is not so great that rectal examination can be performed. Fissura ani chronicles are characterized by three classic symptoms of deep ulcers, sentinel pile (which is formed when the fissura base is edematous and hypertrophic), the Papilla anal is enlarged. Proctoscopy is also performed in the same way, ie topical anesthesia and pressure on the contralateral side. The use of adult protoscopy in acute circumstances is usually not possible by krn sgt pain. Usually by using infant sigmoidoscopy Llyod-Davies can be seen abnormalities in the rectal mucosa & anal canal.

Protoskopy 3. supporting examination The diagnosis of fissura ani is not only based on anamnesis and physical examination alone. Investigations to support the diagnosis of fissura ani are necessary to know more precisely the cause and accuracy of the diagnosis. The laboratory examination that can be done on fissura ani patients is by performing blood count and blood culture. Which of these examinations can be considered the number of white blood cells. DIFERENSIAL DIAGNOSIS The differential diagnosis consists of injuries or other anal fractures, such as tuberculosis, syphilis, AIDS, or proctitis. An anal fissure is sometimes accompanied by internal hemorrhoids. If there are complaints of pain in people with hemorrhoids there is usually a fissure, because the internal hemorrhoids do not cause pain. THE MANAGEMENT OF ANAL FISSURES Initial management involves lifestyle changes and symptomatic relief Advise the patient to increase dietary fibre and fluid intake to keep bowel motions soft. The importance of correct anal hygiene and the need to keep the anal area dry should be emphasised. Regular sitz baths (sitting in warm water up to the hips) can help to relax the sphincter. The patient should also be advised to avoid undue straining during bowel movements. If lifestyle and dietary interventions are insufficient, or if the fissure is severe, a stool softener, e.g. oral docusate sodium, and mild local analgesia, e.g. lidocaine (not subsidised), may be prescribed. More intensive treatment may be required in some patients If the fissure fails to heal within three to six weeks, topical nitrates or topical calcium channel blockers should be used. All topical treatments for anal fissures should be applied for at least six weeks to allow re-epithelialisation of the fissure.

A topical nitrate, e.g. glyceryl trinitrate 0.2% ointment (see opposite), should be considered if the fissure has been present for at least three weeks. The patient should insert 1 – 1.5 cm of ointment into the anal canal, three times daily. Nitrate ointment increases blood flow to the anus and reduces pain on defecation. Dose escalation is not recommended as it does not increase the healing rate and may lead to more adverse effects. Headache is the most common adverse effect, and advising the patient to stop the medicine for a day or two if headaches become intolerable is recommended. Topical calcium channel blockers are also commonly used to manage anal fissures, although this is an unapproved use. If the use of topical nitrates has not improved symptoms or where the adverse effects of nitrates are intolerable, topical diltiazem 2% (requires pharmacy preparation), two to three times daily, may be used. The most common adverse effect is headache, although this has a lower incidence than with topical nitrates. What to do if medical management fails to resolve symptoms If the fissure has not healed after six to eight weeks of topical treatment and dietary changes, the patient should be referred to secondary care to assess the appropriateness of other treatments, usually botulinum toxin or surgery. Botulinum toxin injected into the internal anal sphincter is used to paralyse the sphincter for several months. This treatment is most useful for females where the anal sphincter has been damaged following childbirth. Surgical techniques commonly used for anal fissures which aim to relax the internal sphincter include; open lateral sphincterotomy, closed lateral sphincterotomy and posterior midline sphincterotomy. Surgery is consistently superior to medical management options, although it should only be considered in people with chronic, non-healing anal fissures where medical treatments have failed. There is a slight risk of flatus and faecal incontinence following surgery.

PROGNOSIS Almost 1-6% of patients have a recurrence of anal fissures after sphincterotomy. The risk of recurrence is greater after sphincter dilatation. If a patient has a relapse after sphincterotomy, there may be a recurrence of an underlying disease or an incorrect or incomplete initial sphincterotomy. Medical management should be tried again, but if no help is obtained, the surgeon should evaluate whether the initial sphincterotomy is sufficient. Palpation evaluation can be performed under general anesthesia or by performing an endothermic anal ultrasonogram. If sphincterotomy is incomplete, it can be done on the first side, or again on the other side. If the first sphincterotomy is adequate, a second sphincterotomy may be performed on the other side. (Perry B, Dykes S, Buie D, Rafferty J. Practice parameters for the management of anal fissures (3rd revision). Dis Colon Rectum 2010;53:1110–5.

Nelson R, Thomas K, Morgan J, Jones A. Non-surgical therapy for analfissure. Cochrane Database Syst Rev 2012;(2):CD003431 Brunicardi, Andersen, Billiar, Dunn, Hunter, Pollock. 2005. Colon, Rectum, and Anus. In Schwartz’s Principles of Surgery. 8th edition. Vol 2. USA: McGraw-Hill. P 1057-70.)