Anal fissure

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D: A longitudinal tear in the squamous epithelium of the distal anal canal. ^^

A: Commonly caused by passage of a large hard stool, resulting in pain and sphincter spasm that interferes with local blood supply and hence, healing. A self-perpetuating cycle of pain, spasm and re-injury results. ^^

A/R: Constipation.

E: Common, occurs at any age, especially 30-50 years and in children, males slightly more commonly than females.

H: Severe acute pain at the anus on defecation that may last from a few minutes to hours, often with a small amount of bleeding (seen as bright red blood streaked on the toilet paper, not mixed with stool). There is subsequent fear ^^ of defecation and constipation.

On inspection, the fissure is visible as a small linear cut, but is often concealed by sphincter spasm. A chronic fissure is often associated with a 'sentinel pile', which is a small skin tag present on the anal verge. Rectal examination may be aided by application of local anaesthetic but is usually not possible due to the severity of the pain.

The anal fissure is nearly always in the midline of the posterior anal margin extending from the anal margin to a point below the dentate line, probably because this region is a vascular watershed and susceptible to poor healing. The fissure is of variable depth with granulation tissue or fibres of the external anal sphincter visible. 10% in women and 1% in men are anterior.

Diagnosis is usually made on history and examination (under anaesthesia if necessary). Fissures that are not in the midline (rare) should be treated with caution and biopsied as may be due to infection (syphilitic chancre, herpes simplex, TB), IBD or malignancy.

Medical: Chemical sphincterotomy by the topical application of 0.2% glyceryl trinitrate ointment. This releases local nitric oxide that mediates smooth muscle relaxation, reducing spasm and allowing healing (major side-effect is headache). Other agents that have been shown to be effective are topical calcium channel blocker, diltiazem and injections of botulinum toxin. Pain relief is given in the form of local anaesthetic gel (1% lignocaine) applied before defecation. Laxatives may be necessary (stool softeners or bulk laxatives) to relieve straining. General advice on the avoidance of constipation should be given (e.g. a high-fibre diet, " water intake and appropriate exercise).

Surgical: When there is failure of conservative treatment. Lateral submucous (internal) sphincterotomy involves division of fibres of the internal sphincter, at the 3 o'clock position, distal to the line of the anal valves. This is an effective procedure, but the patient needs to be warned about the risk of incontinence or flatus for a variable period afterwards. Anal stretches are no longer performed as it has often produced irreparable damage to the anal sphincter.

An abscess or a subsequent fistula may develop (see Fig. 25b). Up to 15% of those undergoing surgery will experience incontinence of flatus.

Generally good with glyceryl trinitrate, which is said to cure up to 60% of anal fissures, may become chronic if left untreated.

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Constipation Prescription

Constipation Prescription

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