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Management of Anal Fissure

Dr. Navaneethakrishnan and Dr. Shanmuga Sankar Ram

Page 2

Topics

Diagnosis:

Investigations have a limited role. Accurate history taking and examination is essential.

History should include?

  1. Character of the pain.
  2. Relationship to defecation.
  3. Presence or absence of bleeding or discharge.
  4. Change in bowel habit.
  5. Presence of swelling – skin tag or papilla at the anal opening.

Examination should include

  1. Inspection of the anal canal in good light.
  2. Digital examination is contra indicated to avoid severe pain.
  3. Full ano rectal examination with proctoscopy and sigmoidoscopy should be done only under anesthesia.

Differential Diagnosis:

  1. Crohn’s disease – appearance of fissure is atypical, the lesion being indolent and indurated – often having multiple fissures at any position and large oedematous skin tags.
  2. Ulcerative colitis — Fissure is sometimes associated and it is mild form.
  3. Tuberculous ulcer of the anal canal – it is very rare nowadays and it is a chronic indurated lesion confirmed by biopsy.
  4. Syphilitic ulcer – almost painless fissure – most often the fissure extends out on to the skin or higher above the muco cutaneous junction.
  5. Lympho granuloma venerum is rare.
  6. Carcinoma of the anal margin . It does not usually have the typical appearance nodular or more raised.

Treatment:

It may be conservative or operative. Aim of the treatment is to relieving spasm of the internal sphincter.

Conservative treatment: Uncomplicated recent fissures without sphincteric spasm respond to conservative treatment. Half the simple acute fissures without features of chronicity heal spontaneously. If pain is not severe local anaesthetic ointment, anti-inflammatory drugs and stool softeners may help for healing. Glyceryl trinitrate ointment 0.2 % ointment has recently been used successfully, since this causes a reduction in anal canal pressure and improves healing. Recently it was found that injection of Botulinum Toxin A is more effective than topical nitroglycerin.

Operative treatment: Resistant, recurrent or chronic fissures require operative intervention. Operation includes , excision of the irritable ulcer and division of at least part of the muscular ring on which it lies. ( external sphincter is the muscular ring ) Spincterotomy entails dividing the internal sphincter unto the level of dentate line. Posterior Spincterotomy: Division of the sphincter through the base of the fissure is of no longer favored since disturbance of continence. Lateral Spincterotomy: may be performed as an open operation or closed as a subcutaneous Spincterotomy. In the open operation internal sphincter is identified through a small circumferential incision and divided under direct vision. Sub-cutaneous Spincterotomy is performed by placing a No. 15 scalpel blade into the groove between the internal and external sphincters and turns the scalpel medially and divide the internal sphincter

All these surgical procedures resulting incontinence of flatus or feces or may resulting haematoma or perineal abscess. Anal Dilatation: Although the surgical treatment of lateral internal Spincterotomy is the current treatment of choice for chronic anal fissures in most of the centers, since it is associated with significant risk of anal incontinence in 30 % of patients sphincter preserving techniques may be important to avoid the anal incontinence.


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