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Anal fissure

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An anal fissure is a natural crack or tear in the skin of the anal canal. Anal fissures may be noticed by bright red anal bleeding on the toilet paper, sometimes in the toilet. If acute they may cause severe periodic pain after defecation [1] but with chronic fissures pain intensity is often less. Anal fissures usually extend from the anal opening and are usually located posteriorly in the midline, probably because of the relatively unsupported nature of the anal wall in that location. Fissure depth may be superficial or sometimes down to the underlying sphincter muscle.

Anal fissure
SpecialtyGastroenterology Edit this on Wikidata
anal fissure

Causes

Most anal fissures are caused by stretching of the anal mucosa beyond its capability. For example, anal fissures are common in women after childbirth[2], after difficult bowel movements, and in infants following constipation.[3]

Superficial or shallow anal fissures look much like a paper cut, and may be hard to detect upon visual inspection, they will generally self-heal within a couple of weeks. However, some anal fissures become chronic and deep and will not heal. The most common cause of non-healing is spasming of the internal anal sphincter muscle which results in impaired blood supply to the anal mucosa. The result is a non-healing ulcer, which may become infected by fecal bacteria.[4]

Prevention

For adults, the following may help prevent anal fissure:

  • Avoiding straining when defecating. This includes treating and preventing constipation by eating food rich in dietary fiber, drinking enough water, occasional use of a stool softener, and avoiding constipating agents such as caffeine.[5] Similarly, prompt treatment of diarrhea may reduce anal strain.
  • Careful anal hygiene after defecation, including using soft toilet paper and/or cleaning with water.
  • In cases of pre-existing or suspected fissure, use of a lubricating ointment (e.g. hemorrhoid ointments) can be helpful.
  • In infants, frequent nappy/diaper change can prevent anal fissure. As constipation can be a cause, making sure the infant is drinking enough fluids (i.e. breastmilk, proper ratios when mixing formulas. NOTE: See physician before giving infants any fluids outside breastmilk and/or formula) may thus help avoid fissures. In infants, once an anal fissure has occurred, addressing underlying causes is usually enough to ensure healing occurs.

Treatment

Non-surgical treatment is recommended as first-line treatment of acute and chronic anal fissures.[6][7] Customary treatments include warm sitz baths, topical anesthetics, high-fiber diet and stool softeners.

Surgical treatment, under general anaesthesia, was either anal stretch (Lord's operation) or lateral sphincterotomy where the internal anal sphincter muscle is incised. Both operations aim to decrease sphincter spasming and thereby restore normal blood supply to the anal mucosa. Surgical operations involve a general anaesthetic and can be painful postoperatively. Anal stretch is also associated with anal incontinence in a small proportion of cases and thus sphincterotomy is the operation of choice.

A new medical/surgical development came in 1993 when researchers reported injecting botulinum toxin into the anal sphincter to relax the sphincter and promote fissure healing.[1]

Chemical sphincterotomy

Local application of medications to relax the sphincter muscle, thus allowing the healing to proceed, was first proposed in 1994 with nitroglycerine ointment,[8][9][10][11] and then calcium channel blockers with in 1999 nifedipine ointment,[12][13] and the following year with topical diltiazem.[14] Branded preparations are now available of topical nitroglycerine ointment (Rectogesic as 0.2% in Australia and 0.4% in UK), topical nifedipine 0.3% with lidocaine 1.5% ointment (Antrolin in Italy since April 2004) and diltiazem 2% (Anoheal in UK, although still in Phase III development). A common side effect drawback of nitroglycerine ointment is headache, caused by systemic absorption of the drug, which limits patient acceptability.

A combined surgical and pharmacological treatment, administered by colorectal surgeons, is direct injection of Botulinum toxin (Botox) into the anal sphincter to relax it. This treatment was first investigated in 1993.[15] Combination of medical therapies may offer up to 98% cure rates.[16]

Surgical Procedures

Surgical intervention may be required for persisting deep anal fissures unresponsive to the above conservative measures. Despite their high success rate (~95%), they are used only after medical treatment has failed due to their potential complications. These include general risks from anesthesia, infection and anal leakage (fecal incontinence). Surgical procedures include:

Lateral Internal Sphincterotomy

Lateral Internal Sphincterotomy (LIS) is the surgical procedure of choice for anal fissures due to its simplicity and its high success rate (~95%). In this procedure the Internal Anal Sphincter is partially divided in order to reduce spasming and thus improve the blood supply to the perianal area. This improvement in the blood supply helps to heal the fissure, and the weakening of the sphincter is also believed to reduce the potential for recurrence.

LIS does, however, have a number of potential side effects including problems with incision site healing and incontinence to flatus and faeces (some surveys of surgical results suggest incontinence rates of up to 36%[17]).

Anal Dilation (or Dilatation)

Anal dilation, or stretching of the anal canal, (Lord's operation) has fallen out of favour in recent years, primarily due to the perceived unacceptably high incidence of fecal incontinence.[18] In addition, anal stretching can increase the rate of flatus incontinence.[19]

In the early 1990s however Norman Sohn and Michael A. Weinstein of Somerset Surgical Associates pioneered a repeatable method of anal dilation which proved to be very effective and showed a very low incidence of side effects[20]. Since then at least one other controlled, randomized study has shown there to be little difference in healing rates and complications between controlled anal dilation and LIS[21], whilst another has again shown high success rates with anal dilation coupled with low incidence of side effects[22].

See also

References

  1. ^ a b Gott M.D., Peter H. (March 5, 1998) The Fresno Bee New therapy coming for anal fissures. Section:Life; Page E2
  2. ^ Abramowitz L, Sobhani I, Benifla JL; et al. (2002). "Anal fissure and thrombosed external hemorrhoids before and after delivery,". Dis. Colon Rectum. 45 (5): 650–5. doi:10.1007/s10350-004-6262-5. PMID 12004215. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
  3. ^ Martínez-Costa C, Palao Ortuño MJ, Alfaro Ponce B; et al. (2005). "[Functional constipation: prospective study and treatment response]". Anales de pediatría (Barcelona, Spain) (in Spanish; Castilian). 63 (5): 418–25. PMID 16266617. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link) CS1 maint: unrecognized language (link)
  4. ^ Collins EE, Lund JN.A review of chronic anal fissure management.Tech Coloproctol. 2007 Sep;11(3):209-23.
  5. ^ Basson, Marc D., "Constipation" @ emedicine
  6. ^ Nelson R.Non surgical therapy for anal fissure.Cochrane Database Syst Rev. 2006 Oct 18;(4):CD003431
  7. ^ Haq Z, Rahman M, Chowdhury R, Baten M, Khatun M (2005). "Chemical sphincterotomy--first line of treatment for chronic anal fissure". Mymensingh Med J. 14 (1): 88–90. PMID 15695964.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  8. ^ Loder P, Kamm M, Nicholls R, Phillips R (1994). "'Reversible chemical sphincterotomy' by local application of glyceryl trinitrate". Br J Surg. 81 (9): 1386–9. doi:10.1002/bjs.1800810949. PMID 7953427.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  9. ^ Watson S, Kamm M, Nicholls R, Phillips R (1996). "Topical glyceryl trinitrate in the treatment of chronic anal fissure". Br J Surg. 83 (6): 771–5. doi:10.1002/bjs.1800830614. PMID 8696736.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  10. ^ Simpson J, Lund J, Thompson R, Kapila L, Scholefield J (2003). "The use of glyceryl trinitrate (GTN) in the treatment of chronic anal fissure in children". Med Sci Monit. 9 (10): PI123–6. PMID 14523338.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  11. ^ Lund JN, Scholefield JH.A randomised, prospective, double-blind, placebo-controlled trial of glyceryl trinitrate ointment in treatment of anal fissure.Lancet. 1997 Jan 4;349(9044):11-4.
  12. ^ Antropoli C, Perrotti P, Rubino M, Martino A, De Stefano G, Migliore G, Antropoli M, Piazza P (1999). "Nifedipine for local use in conservative treatment of anal fissures: preliminary results of a multicenter study". Dis Colon Rectum. 42 (8): 1011–5. doi:10.1007/BF02236693. PMID 10458123.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  13. ^ Katsinelos P, Kountouras J, Paroutoglou G, Beltsis A, Chatzimavroudis G, Zavos C, Katsinelos T, Papaziogas B (2006). "Aggressive treatment of acute anal fissure with 0.5% nifedipine ointment prevents its evolution to chronicity". World J Gastroenterol. 12 (38): 6203–6. PMID 17036396. Retrieved 2009-05-12.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  14. ^ Carapeti E, Kamm M, Phillips R (2000). "Topical diltiazem and bethanechol decrease anal sphincter pressure and heal anal fissures without side effects". Dis. Colon Rectum. 43 (10): 1359–62. doi:10.1007/BF02236630. PMID 11052511.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  15. ^ Jost W, Schimrigk K (1993). "Use of botulinum toxin in anal fissure". Dis Colon Rectum. 36 (10): 974. doi:10.1007/BF02050639. PMID 8404394.
  16. ^ Tranqui P, Trottier D, Victor C, Freeman J (2006). "Nonsurgical treatment of chronic anal fissure: nitroglycerin and dilatation versus nifedipine and botulinum toxin" (PDF). Canadian journal of surgery. Journal canadien de chirurgie. 49 (1): 41–5. PMID 16524142. Retrieved 2009-05-12.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  17. ^ Wolff BG, Fleshman JW, ASCRS, Beck DE, Church JM. "The ASCRS Textbook of Colon and Rectal Surgery": 180. Retrieved 2009-07-15. {{cite journal}}: Cite journal requires |journal= (help)CS1 maint: multiple names: authors list (link)
  18. ^ Kotlarewsky M, Freeman JB, Cameron W, Grimard LJ (2001). "Anal intraepithelial dysplasia and squamous carcinoma in immunosuppressed patients" (PDF). Canadian journal of surgery. Journal canadien de chirurgie. 44 (6): 450–4. PMID 11764880. Retrieved 2009-05-12.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  19. ^ Sadovsky R (2003). "Diagnosis and management of patients with anal fissures - Tips from Other Journals" (Reprint). American Family Physician. 67 (7): 1608. Retrieved 2009-05-12. {{cite journal}}: Unknown parameter |month= ignored (help)
  20. ^ Sohn M, Weinstein MA. "Anal Dilatation for Anal Fissures" (PDF). Retrieved 2009-07-15. {{cite journal}}: Cite journal requires |journal= (help)
  21. ^ Yucel T, Gonullu D, Oncu M, Koksoy FN, Ozkan SG, Aycan O (2009). "Comparison of controlled-intermittent anal dilatation and lateral internal sphincterotomy in the treatment of chronic anal fissures: a prospective, randomized study". Int J Surg. 7(3) (3): 228–31. doi:10.1016/j.ijsu.2009.03.006. PMID 19361582. {{cite journal}}: |access-date= requires |url= (help); Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  22. ^ Renzi A, Brusciano L, Pescatori M, Izzo D, Napolitano V, Rossetti G, del Genio G, del Genio A (2005). "Pneumatic balloon dilatation for chronic anal fissure: a prospective, clinical, endosonographic, and manometric study". Diseases of the Colon and Rectum. 48(1) (1): 121–6. PMID 15690668. {{cite journal}}: |access-date= requires |url= (help); Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)

Anal fissure treatment algorithm - Lund JN, Nyström PO, Coremans G, Herold A, Karaitianos I, Spyrou M, Schouten WR, Sebastian AA, Pescatori M.An evidence-based treatment algorithm for anal fissure.Tech Coloproctol. 2006 Oct;10(3):177-80.

  • "Anal Fissure". Hemorrhoids In Plain English. Retrieved December 15, 2005.
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