Ferri – Anal Fissure

Mar 13, 2020 admin TIÊU HÓA 0

Anal Fissure

  • Maria E. Soler, M.D., M.P.H., M.B.A.

 Basic Information

Definition

A fissure is a tear in the epithelial lining of the anal canal (i.e., from the dentate line to the anal verge). Acute anal fissures typically heal with conservative management within 6 weeks. Chronic fissures require a more aggressive, surgical approach.

Synonyms

  1. Anorectal fissure

  2. Anal ulcer

ICD-10CM CODES
K60.0 Acute anal fissure
K60.1 Chronic anal fissure
K60.2 Anal fissure, unspecified

Epidemiology & Demographics

An estimated 235,000 new cases of anal fissure occur annually in the U.S. Although they can occur at any age, they are more common in infants and middle-aged adults. They occur more in men than women. Women are more likely to have anterior fissure than men (10% vs. 1%, respectively).

Physical Findings & Clinical Presentation

With separation of the buttocks will see a tear in the posterior midline or, less frequently, in the anterior midline

  1. •

    Acute anal fissure:

    1. 1.

      Sharp burning or tearing pain accompanying the passage of stool

    2. 2.

      Bright-red blood on toilet paper, a streak of blood on the stool or in the water

    3. 3.

      Appear as a fresh laceration (Fig. E1)

      FIG.E1 

      A, Schematic depiction of acute and chronic anal fissures. An acute fissure is simply a split in the anoderm (inset). A chronic fissure can show signs of chronicity with rolled edges, fibrosis, a hypertrophied anal papilla proximally, a tender distal skin tag, and exposed internal anal musculature. B, Inspection of an acute anal fissure with a cotton-tipped swab. Once an acute fissure is identified, no internal examination is needed until the fissure is healed.
      From Feldman M, Friedman LS, Brandt LJ: Sleisenger and Fordtran’s gastrointestinal and liver disease, ed 10, Philadelphia, 2016, Elsevier.
  2. •

    Chronic anal fissure:

    1. 1.

      Perianal pruritus or skin irritation

    2. 2.

      Pain less intense or not present

    3. 3.

      Intermittent bleeding

    4. 4.

      Sentinel tag at the caudal aspect of the fissure, hypertrophied anal papilla at the proximal end (Fig. E2)

      FIG.E2 

      Chronic fissures are characterized by fibrosis, a skin tag at the distal extent of the fissure, and/or a hypertrophied papilla at the proximal end. The internal sphincter muscle may be visible at the base of the fissure.
      From Cameron JL, Cameron AM: Current surgical therapy, ed 12, Philadelphia, 2017, Elsevier.
    5. 5.

      Have raised edges exposing the horizontally oriented fibers of the internal anal sphincter; appearance due to chronic infection and fibrosis

  3. •

    Atypical fissure can be acute or chronic:

    1. 1.

      More likely to occur at locations other than the midline

    2. 2.

      Extends proximal to the dentate line

    3. 3.

      Unusually wide or deep; multiple, recurring, or nonhealing

    4. 4.

      Associated with perianal tag that is edematous and tender

    5. 5.

      More commonly associated with an underlying disease process

Etiology

  1. •

    Most initiated after passage of a large, hard stool

  2. •

    May result from frequent defecation and diarrhea

  3. •

    Bacterial infections: tuberculosis (TB), syphilis, gonorrhea, chancroid, lymphogranuloma venereum

  4. •

    Viral infections: herpes simplex virus, cytomegalovirus, human immunodeficiency virus

  5. •

    Inflammatory bowel disease (IBD): Crohn’s disease, ulcerative colitis

  6. •

    Trauma: surgery (hemorrhoidectomy), foreign bodies, anal intercourse

  7. •

    Malignancy: carcinoma, lymphoma, Kaposi sarcoma

Diagnosis

Differential Diagnosis

  1. •

    Proctalgia fugax

  2. •

    Thrombosed hemorrhoid

  3. •

    Carcinoma

  4. •

    Anal fistula

Workup

  1. •

    Digital rectal examination after lubricating the entire anus with anesthetic jelly (i.e., 2% lidocaine) and waiting 5 to 10 min

  2. •

    Anoscopy

  3. •

    Proctosigmoidoscopy to exclude inflammatory or neoplastic disease

  4. •

    Biopsy if doubt exists about the etiology of the condition

  5. •

    All studies done under adequate anesthesia

Imaging Studies

  1. •

    Colonoscopy if diagnosis of IBD or malignancy is suspected

  2. •

    Small-bowel series occasionally obtained for similar reasons

Treatment

Nonpharmacologic Therapy

  1. •

    Sitz baths

  2. •

    High-fiber diet and increased oral fluid intake

Acute General Rx

  1. •

    Bulk-producing agent (e.g., Metamucil) and/or stool softener.

  2. •

    Local anesthetic jelly (may exacerbate pruritus ani).

  3. •

    Nitroglycerin ointment (0.4%): apply 1 inch of ointment (equivalent to 1.5 mg of nitroglycerin) intraanally every 12 hours for up to 3 weeks. This medication (Rectiv) is expensive. Topical diltiazem (compounded by pharmacist) is also effective and much less expensive.

  4. •

    Suppositories not recommended.

  5. •

    Surgery, if failed medical management after 2 months.

  6. •

    An algorithm for the management of acute, chronic, and recurrent fissures is illustrated in Fig. E3.

FIG.E3 

Algorithm: management of acute, chronic, and recurrent fissures. TRUS, Transrectal ultrasound.
From Cameron JL, Cameron AM: Current surgical therapy, ed 12, Philadelphia, 2017, Elsevier.

Chronic Rx

  1. •

    Although less effective, medical treatment should be offered, as it is better tolerated and does not incur the risk of fecal incontinence.

  2. •

    Surgery: lateral internal anal sphincterotomy (Fig. E4, Fig. E5). It is a more durable treatment for chronic anal fissure compared with topical nitroglycerin therapy and does not compromise long-term fecal continence.

    FIG.E4 

    Open lateral internal sphincterotomy. A, First the overlying anoderm is incised. The internal sphincter muscle is then dissected free (B) and divided (C).
    Reprinted with permission from Wexner SW, Beck DE, eds: Fundamentals of anorectal surgery, ed 2, London, 1998, Saunders; pp. 214–215. In Cameron JL, Cameron AM: Current surgical therapy, ed 12, Philadelphia, 2017, Elsevier.
    FIG.E5 

    Closed lateral internal sphincterotomy. A, After anesthetizing the perianal area, the finger is inserted into the anal canal, a #11 blade scalpel is inserted in the intersphincteric groove, and the muscle is cut toward the finger. B, After cutting the muscle, a wedge defect should be felt in the internal sphincter muscle.
    Reprinted with permission from Wexner SW, Beck DE, eds: Fundamentals of anorectal surgery, ed 2, London, 1998, Saunders; pp. 214–215. In Cameron JL, Cameron AM: Current surgical therapy, ed 12, Philadelphia, 2017, Elsevier.
  3. •

    Topical glyceryl trinitrate ointment.

  4. •

    Injection of botulinum toxin (Fig. E6) (an injection into each side of the internal anal sphincter) is effective in healing chronic anal fissures in more than 90% of patients.

  5. •

    Table E1 summarizes treatment of anal fissures.

FIG.E6 

Botox injection is performed by injection of Botox at 10 and 2 o’clock anteriorly in the intersphincteric groove. First, the index finger palpates the intersphincteric groove (A), and the needle is then placed within the groove (B) to inject the Botox.
Reprinted with permission from Braasch C, Sedgwick K, Veidenheimer M, Ellis H, eds: Atlas of abdominal surgery, Philadelphia, 1991, Saunders; p. 199. In Cameron JL, Cameron AM: Current surgical therapy, ed 12, Philadelphia, 2017, Elsevier.
TABLEE1 Treatment of Acute and Chronic Anal FissuresFrom Feldman M, Friedman LS, Brandt LJ: Sleisenger and Fordtran’s gastrointestinal and liver disease, ed 10, Philadelphia, 2016, Elsevier.
Treatment Comments
Acute
Increase oral fluids, high-fiber diet, fiber supplements, sitz baths, and stool softeners if needed Avoid digital rectal examination until the fissure is healed unless the diagnosis is in doubt (then perform the examination in the operating room)
Usually responds to these measures
Chronic
As for acute, usually with the addition of one of the following: Avoid digital examination unless the diagnosis is in doubt
   0.2%-0.4% nitroglycerin ointment applied to the anal area Headache is a common side effect
Long-term success has been questioned
Calcium channel blockers (topical nifedipine or topical 2% diltiazem cream) applied to the anal area Seem promising, but long-term success has been questioned
Side effects (especially headache) may be less common than with nitroglycerin ointment
    Botulinum toxin A injected into the anal muscle Dose and optimal injection site are not clear
Expensive
Long-term success is unknown
Lateral internal sphincterotomy Standard treatment
Best results, with >90% long-term healing rate
Durable
Can lead to fecal incontinence

Disposition

Outpatient surgery

Referral

  1. •

    If fissure does not resolve with conservative therapy in 4 to 6 wk

  2. •

    If patient prefers surgery for acute fissure

  3. •

    If patient has chronic fissure

Pearls & Considerations

Comments

HIV-positive patients should be referred to clinicians who are well versed in the myriad infectious and neoplastic conditions that masquerade as anal ulcers in these patients.

Related Content

  1. Anal Fissure (Patient Information)

  2. Anorectal Fistula (Related Key Topic)

  3. Hemorrhoids (Related Key Topic)

 

 

 

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