ANAL FISSUREANAL FISSURE

INTRODUCTIONINTRODUCTION

Fissure is a tear in the anal canal extending from Fissure is a tear in the anal canal extending from just below the dentate line to the anal verge. just below the dentate line to the anal verge.

Most commonly in young and middle age adults. Most commonly in young and middle age adults.

The cardinal symptom is pain during and for The cardinal symptom is pain during and for minutes to hours following defecation. minutes to hours following defecation.

Bright red blood is common Bright red blood is common

INTRODUCTIONINTRODUCTION

Over 90% of anal fissures are located in the Over 90% of anal fissures are located in the posterior midline.posterior midline.

Almost all the rest located in the anterior midline. Almost all the rest located in the anterior midline.

The acute fissure is a "mere crack" in the The acute fissure is a "mere crack" in the anoderm. anoderm.

Distal sentinel tag, a proximal hypertrophied anal Distal sentinel tag, a proximal hypertrophied anal papilla, fibrotic edges, and exposed internal papilla, fibrotic edges, and exposed internal sphincter fibres are features of chronicity sphincter fibres are features of chronicity

Etiology and PathogenesisEtiology and Pathogenesis

The initiating factor is trauma, typically overstretching of the The initiating factor is trauma, typically overstretching of the anoderm by a large hard stool. anoderm by a large hard stool.

The proposed explanation for the posterior midline The proposed explanation for the posterior midline predominance is a lack of tissue support and maximal predominance is a lack of tissue support and maximal stretching at this site. stretching at this site.

Failure to heal is secondary to poor perfusion of the Failure to heal is secondary to poor perfusion of the anoderm in the posterior midline. anoderm in the posterior midline.

Posterior midline ischaemia is the result of arterial anatomy Posterior midline ischaemia is the result of arterial anatomy and internal anal sphincter hypertonicity. and internal anal sphincter hypertonicity.

Treatment Treatment

Warm baths and a diet sufficiently high in fibre to Warm baths and a diet sufficiently high in fibre to achieve soft bulky stools allows approximately achieve soft bulky stools allows approximately 50% of acute anal fissures to heal within three 50% of acute anal fissures to heal within three weeks. weeks.

Stool softeners and fibre supplements are Stool softeners and fibre supplements are reasonable additions. reasonable additions.

Recurrence is common, in the range of 30 - 70%, Recurrence is common, in the range of 30 - 70%, but can be reduced to 15 - 20% by maintaining a but can be reduced to 15 - 20% by maintaining a high fibre diet high fibre diet

Acute FissureAcute Fissure Topical Application Topical Application

Nitric oxide has been identified as the chemical messenger Nitric oxide has been identified as the chemical messenger of the intrinsic non-adrenergic, non-cholinergic pathway of the intrinsic non-adrenergic, non-cholinergic pathway mediating relaxation of the internal anal sphincter. mediating relaxation of the internal anal sphincter.

Topical application of nitroglycerin, a nitric oxide donor, Topical application of nitroglycerin, a nitric oxide donor, causes a transient lowering of resting anal pressure and an causes a transient lowering of resting anal pressure and an increase in anodermal blood flow. increase in anodermal blood flow.

A 92% healing rate within two weeks for acute fissures A 92% healing rate within two weeks for acute fissures treated with application of 0.2% glyceryl trinitrate ointment treated with application of 0.2% glyceryl trinitrate ointment t.i.d. t.i.d.

Acute FissureAcute Fissure Topical Application Topical Application

Topical calcium channel blockers (2% Topical calcium channel blockers (2% diltiazem, 0.3% nifedipine) .diltiazem, 0.3% nifedipine) .

Heal 65-95% of fissures .Heal 65-95% of fissures .

The most common side effects are The most common side effects are headache, flushing, and symptomaticheadache, flushing, and symptomatic hypotension. hypotension.

TreatmentTreatmentChronic FissureChronic Fissure

Topical Nitroglycerin: At eight weeks healing Topical Nitroglycerin: At eight weeks healing was observed in 68% of the GTN was observed in 68% of the GTN

Botulinum Toxin: Botulinum toxin has been Botulinum Toxin: Botulinum toxin has been injected into the external and internal injected into the external and internal sphincters and, with short term follow up, sphincters and, with short term follow up, healing rates of 80% have been achieved. healing rates of 80% have been achieved.

TreatmentTreatmentChronic FissureChronic Fissure

Are unlikely to heal with warm baths and a Are unlikely to heal with warm baths and a high fibre diet. high fibre diet.

Internal Sphincterotomy : Lateral internal Internal Sphincterotomy : Lateral internal sphincterotomy (LIS) achieves healing in sphincterotomy (LIS) achieves healing in over 95% within several weeks over 95% within several weeks

Anal DilatationAnal Dilatation