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home - Colon - Anal Diseases - Anal Fissures Written by Dr Sebastian Zeki

Understands the clinical anatomy of the rectum and anus
Knows the causes of rectal bleeding and the methods of investigation
to determine the cause

Has awareness of the range of perianal conditions (which includes
abscesses and fistula), their clinical presentation and their

Knows the techniques of investigation and the possible medical and
surgical treatments

Is aware of the treatment options for radiation proctitis
Take a history and appropriately examines the anus and rectum
Refers the patient for the appropriate endoscopic and radiological

Manages patients with anorectal disease in a sympathetic manner,
recognising and addressing the concerns caused by such conditions

Anal Fissures

Definition and PathogenesisIt is defined as a tear in the lining of the anal canal distal to dentate line, usually in posterior midline; second most common is anterior midline. Mucosa tearsInternal anal sphincter goes into spasm Spasm pulls the edges of the fissure apart, causing further tearing Reduced blood flow posteriorly may reduce healing (hence why topical GTN used) Clinical Presentation: Tearing pain with the passage of bowel movements.Small volume bright red rectal bleeding.Pruritis ani occasionally. Acute fissure appears as a fresh lacerationChronic fissure:Raised edges exposing the white, horizontally oriented fibers of the internal anal sphincter at its base.Often accompanied by external skin tags distally, and hypertrophied anal papillae at their proximal extent. Causes:Hard stool passage (most common).Crohn's.TB.Leukemia. Lateral sphincterotomy (if above fails)Division of the internal anal sphincter from its distal most end for a distance equal to that of the fissure, or up to the dentate line.Fissure itself doesn’t need therapyComplications: Fecal incontinence- in 45% immediately post-op.After 5 years, 1% faecal soilingOverall, only 3% reported that incontinence had ever affected the quality of their life.DilationLord's or four finger dilatationAssociated with a high incidence of sphincter tears and fecal incontinence.Pneumatic balloon dilation -Only limited experience Typical fissure (not lateral): Treat for 1-2mnths Topical nitroglycerin:Side effects: Headache-10 to 15 mi-utes after application and lasts < 30 mins- decrease after 2 wks Bulking fibreStool softeners GTN topically Warm sitz baths to relax the sphincter Endoscopy to rule out Crohn’s If persistent Treatments for refractory fisssures:Botox injection.Topical diltiazem (2% bd for 2 months).Oral diltiazem (60mg bd for 2 months).Topical bethanecol (0.1% tds for 2 months).Nifedipine gel 0.2% bd for 3 weeks. Initial Treatment Further Treatment Anal fissures Written by Dr Sebastian Zeki

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