Anal Fissure

Definition
A traumatically induced longitudinal tear in the epithelium of the distal anal canal. Extends from the anal verge cephaled up to the dentate line.

Epidemiology
Very common anorectal condition often confused with hemorrhoids
Exact incidence is unknown. Patients often treat with home remedies and do not seek medical care
Common in infants 6–24 months;
ot common in children, suspect abuse or trauma.
Elderly are spared owing to lower resting pressure in the anal canal.
Male = Female, but women are more likely to get anterior midline tears (25% vs 8%).
Prevalence
80% of infants, usually self-limited
20% of adults, the majority of whom do not seek medical advice, have symptoms referable to the anorectum.

Classsification
Posterior >90%, Anterior >10% (10% of female fissures, 1% of male fissures)
Acute <6 weeks, Chronic > 6 weeks

Pathophysiology
High resting pressure within the anal canal can lead to ischemia of the anodermal tissues resulting in splitting of the tissues with passage of stool. Exposed internal sphincter muscle spasms causing the knifelike pain.

Aetiology- risk factor
Passage of hard stool
Chronic diarrhea
Childbirth (accounts for 10% of chronic anal fissures)
Habitual use of cathartics
Anal trauma (can occur with anal intercourse or a rectal examination using a speculum or digit)
Causes of anal fistula include opened perianal or ischiorectal abscesses, which drain spontaneously through these fistulous tracts.
Anal fissures can be observed in patients with syphilis and other sexually transmitted diseases,tuberculosis, leukemia, inflammatory bowel disease such as Crohn disease, previous anal surgery, HIV, and other conditions or diseases.

Presentation
Anal pain with stool
‘Knife-like’, ‘passing glass’
Persists post defecation
Relieved by a sitz bath
Pruritis, prolapse, swelling
Bright red rectal bleeding

Diagnosis

History	of painful defecation Pain post defecation Blood on toilet paper
Examination	Spasm anus, Sentinel pile, Midline fissure, Hypertrophied papilla
Procedure	Avoid anoscopy or endoscopy initially unless necessary for other diagnoses. Some patients may require exam under anesthesia to diagnose properly.

Ddx
Thrombosed external hemorrhoid: swollen painful mass, no fissure
Perirectal abscess: Sinus tract with purulent drainage rather than a fissure
Pruritus ani: Shallow excoriations rather than a fissure

Management

General measures	Wash area with warm water; high-fiber diet; avoid constipation
First line	Stool softeners (docusate) Fiber supplements (psyllium) Topical analgesics (2% lidocaine gel)
Second line	glyceryl trinitrate (GTN) Good healing (75% by the 2ndweek and 54% 6 weeks) rate 25% relapse Side effect profile poor: 24-75% patient described headache Diltiazem Topically twice daily for 4weeks Heals 70-90% of fissure Very few side effects Botulinum Toxin Correct the precipitating factor Topical treatment – GTN, Diltiazem, Botulin Toxin Only if medical treatment fails should surgery be considered The original topical therapy Good healing rate 25% relapsed Side effect profile poor 24-75% patients described headache Calcium channel blockers e.g., nifedipine, Cardizem, oral or topical; no better than nitrates
Lateral internal Sphincterotomy	Indication Chronic anal fissure which has failed to respond to medical management Rarely in acute anal fissure Contraindications poor sphincter tone previous obstetric injury history of traumatic childbirth Procedure Jack-knife position Can be done in OPD Open or closed technique Division of IAS to the level of the dentate ONLY Fissurectomy Complications Infection Fissure-fistula Faecal incontinence 1-60% immediately post op Mainly females Self limiting generally Overall <1% If it is done CORRECTLY Recurrence or nonhealing of the fissure
Manage faecal incontinence	Multidisciplinary: surgeon, continence nurse/stoma therapist, radiologist, electro physiologist, physiotherapist, dietician Sacral nerve stimulation Neuromodulation S3 or S4 nerve root Trial possible- under skin electrode, stimulator carried for 2 weeks Approx 70% good response permanent implant of pacemaker like device(picture)- next to tail bone Other surgery Colostomy Cecostomy with antegrade enema program Stimulated graciloplasty Artificial anal sphincter Temperature-controlled radiofrequency energy (SECCA) Antegrade continent enema stoma. This procedure is often necessary in addition to others when fecal incontinence is complicated by neuropathy and/or an incomplete internal anal sphincter.

Complications
Constipation or fecal impaction may occur.
The pain from an anal fissure can be so overwhelming that it discourages people from defecating.
Acute fissures can become chronic.
Sentinel pile can result.
Permanent skin tag can result.
Fistulas may form.
Without treatment, chronically infected fistulas may cause systemic illness.
Carcinoma has been reported in chronic untreated anorectal fistulas.

Prognosis
Most uncomplicated fissures resolve in 2-4 weeks with supportive care.
Fissures that heal with conservative treatment have a reoccurrence rate of up to 27%.
Chronic anal fissures frequently require surgical treatment.
Surgical treatment of anal fissures is associated with some degree of incontinence in 30% of patients.
Prognosis for fistulas is excellent after surgery.