Anal Fissure
An anal fissure is a tear in the anoderm, typically in the posterior midline. In the first 6 weeks, they will likely resolve with increased fiber and water, laxatives, and topical lidocaine. Chronic anal fissures, however, heal only 35.5 % of the time wit
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Key Concepts • An acute anal fissure (symptoms 6 weeks), topical nitroglycerin or calcium channel blockers are slightly better than placebo in inducing healing. • Injection of botulinum toxin into the internal anal sphincter can heal fissures refractory to topical ointments; though this is not as effective as lateral internal anal sphincterotomy. • Lateral internal anal sphincterotomy is the most effective therapy in healing fissures; there is an increased risk, however, of fecal incontinence. • For anal fissures associated with decreased anal sphincter tone, a dermal advancement flap is a reasonable option.
Definition/Clinical Presentation An anal fissure is a tear in the epithelial lining of the distal anal canal [1]. While this is likely an extremely common condition, it is difficult to know exactly how common. Many people assume this is a hemorrhoidal problem and initially avoid formal evaluation. Further, many fissures will resolve without intervention. Nevertheless, persistent anal pain and bleeding eventually push many patients to seek medical attention. In one single colon and rectal surgery clinic, anal fissures resulted in more than 1200 office visits over a 5-year period [2]. Fissures can be classified as acute vs. chronic and typical vs. atypical. Acute fissures cause bright red bleeding with bowel movements and sharp, burning, tearing anal pain or Electronic supplementary material: The online version of this chapter (doi:10.1007/978-3-319-25970-3_13) contains supplementary material, which is available to authorized users.
spasm that can last for hours after the bowel movement. Physical findings include a linear separation of the anoderm, at times visible with just separation of the buttocks (Figure 13-1). Often, elevated anal resting pressures are appreciated on digital rectal examination. If tolerated by the patient, the suspected diagnosis can be confirmed by visualizing the break in the anoderm with office anoscopy after using an anesthetic lubricant. If only one area can be examined, the posterior midline should be evaluated first, as it is the site of up to 90% of typical anal fissures. The remaining minority of typical fissures are found in the anterior midline [3]. Acute fissures generally resolve within 4–6 weeks of appropriate management; chronic fissures are therefore defined as those producing symptoms beyond 6–8 weeks. Chronic fissures have additional physical findings of an external sentinel tag at the external apex, exposed internal sphincter muscle, and a hypertrophied anal papilla at the internal apex (Figure 13-2). Typical fissures are usually located in the posterior or anterior midline, have the characteristic findings described above, and are not associated with other diseases. In contrast, atypical fissures can occur anywhere in the anal canal (Figure 13-3), can have a wide variety of findings, and can tend to be associated with other diseases, including malignancy, Crohn’s disease, human immunodeficiency virus (HIV) infection, syphilis, and tuberculosis (Figure 13-4).
Pathogenesis Despite the common nature
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