Anal fissure

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Overview

Anal fissure
ICD-10 K60.0-K60.2
ICD-9 565.0
DiseasesDB 673
MedlinePlus 001130
eMedicine med/3532  ped/2938 emerg/495

Template:Search infobox An anal fissure is an unnatural crack or tear in the anus skin. As a fissure, these tiny tears may show as bright red rectal bleeding and cause severe periodic pain after defecation.[1] The tear usually extends from the anal opening and located posteriorly in the midline. This location is probably because of the relatively unsupported nature of the anal wall in that location.

Causes

Most anal fissures are caused by stretching of the anal mucosa beyond its capability. Various causes of this fissure include:

Many acute anal fissures will heal spontaneously. Some fissures become chronic and will not heal. The most common cause for this is spasm of the internal anal sphincter muscle. This spasm causes poor blood flow to the anal mucosa, hence producing an ulcer which does not heal since it is deprived of normal blood supply.

Anal fissures are common in women after childbirth,[2] and following constipation in infants.[3]

Prevention

In infants under one year old, frequent diaper change can prevent anal fissure. For adults, the following can help prevent fissure:

  • Treating constipation by eating food rich in dietary fiber, avoiding caffeine (which can increase constipation),[4] drinking a lot of water and taking stool softener.
  • Treating diarrhea promptly.
  • Lubricating the anal canal with KY Jelly or other water-based lubrication before inserting anything (ex: vibrator, penis) into your anal canal.(petroleum jelly is not recommended because it can harbor harmful bacteria).
  • Avoiding straining or prolonged sitting on the toilet.
  • Using a moist wipe instead of perfumed and harsh toilet paper.
  • Keeping the anus dry and hygienic.
  • When using Analpram (cream) do not use the dispenser which can injure the area. Instead use a finger to insert a pea size amount of cream.
  • Carmex lip ointment (the version without sunscreen-protection chemicals) also helps and is much less expensive than Analpram ($70.00 small tube).

Treatment

For many years up until 1995, customary treatment included warm baths, topical anesthetics, stool bulking agents, mechanical anal stretching, and, sometimes, surgery.[1] In 1995, doctors began using nitroglycerine cream (topical 1 percent isosorbide dinitrate) but found it less acceptable for long-term use due to patients developing a tolerance to the drug.[1] In 1998, Italian researchers reported injecting botulinum toxin into the anal sphincter to promote healing by relieving anal spasm through relaxation of the muscle.[1]

Symptomatic

Most anal fissures are shallow or superficial (less than a quarter of inch or 0.64 cm deep). These fissures self-heal within a couple of weeks. Furthermore, treatment used for hemorrhoid such as eating a high-fiber diet, using stool softener, taking pain killer and having a sitz bath can help.

Pediatric

Anal fissures in infants usually self-heal without anything more than frequently changing diapers and treating constipation if the cause.

Chemical sphincterotomy

Painful deep chronic fissures, on the other hand, will not heal because of poor blood supply caused by sphincter spasm. Traditionally surgical operations were required which are both painful and associated with various longterm complications, particularly incontinence in a small proportion of cases. Local application of medications to relax the sphincter muscle, thus allowing the healing to proceed, was first proposed in 1994 with nitroglycerine ointment,[5][6][7] in 1999 with nifedipine ointment,[8][9] and the following year with topical diltiazem.[10] Branded preparations are now available of topical nitroglycerine ointment (Rectogesic as 0.2% in Australia and 0.4% in UK) and diltiazem 2% (Anoheal in UK although still in Phase III development).

Botulinum toxin injection, administered by colorectal surgeons, can also be used to relax the sphincter muscle and its use for this condition was first investigated in 1993.[11] Combination of medical therapies may offer up to 98% cure rates,[12] These medical treatments are used as first line therapy in treating chronic anal fissures,[13] although a Cochrane Collaboration review of published research has questioned the effectiveness of medical treatments compared to surgery.[14]

Surgical sphincterotomy

Surgical intervention may be required for persisting deep anal fissures unresponsive to the above conservative measures. Procedures include:

  • Internal lateral sphincterotomy or excising a portion of the sphincter
  • Anal dilation or stretching of the anal canal is no longer recommended because of the unacceptably high incidence of fecal incontinence.[15] In addition, anal stretching can increase the rate of flatus incontinence.[16]

Despite the high success rate of these surgical procedures (~95%), there are potential side effects, which include: risks from anesthesia, infection and anal leakage (fecal incontinence).

References

  1. ↑ 1.0 1.1 1.2 1.3 Gott M.D., Peter H. (March 5, 1998) The Fresno Bee New thearpy 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. PMID 12004215.
  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.
  4. ↑ Basson, Marc D. , "Constipation" emedicine [1]
  5. ↑ 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. PMID 7953427.
  6. ↑ 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. PMID 8696736.
  7. ↑ 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.
  8. ↑ 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. PMID 10458123.
  9. ↑ 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.
  10. ↑ 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. PMID 11052511.
  11. ↑ Jost W, Schimrigk K (1993). "Use of botulinum toxin in anal fissure". Dis Colon Rectum. 36 (10): 974. PMID 8404394.
  12. ↑ 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.
  13. ↑ 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.
  14. ↑ Nelson R (2006). "Non surgical therapy for anal fissure". Cochrane database of systematic reviews (Online) (4): CD003431. PMID 17054170.
  15. ↑ 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.
  16. ↑ Sadovsky R (2003). "Diagnosis and management of patients with anal fissures - Tips from Other Journals" (Reprint). American Family Physician. 67 (7): 1608. Unknown parameter |month= ignored (help)

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