anal fissure: the facts (are there any?) tamzin cuming colorectal consultant homerton university...

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Anal Fissure: the Facts

Anal Fissure: the Facts(Are there any?)Tamzin CumingColorectal ConsultantHomerton University HospitalClassic fissure in ano90% posterior

< 6 weeks: acute

> 6 weeks + sentinel pile + visible sphincter= chronic

When is a fissure not a fissure?Be suspicious multiple or lateralCrohns

?fissurePost-childbirth womanlow-pressure fissureAnteriorWeak pelvic floorrectocele

?fissureIn an old personCancer: anal cancer even (esp if HIV+)

?fissureIn someone with bad skinEczema, psoriasis, dermatitisOK some facts90% are the fissures you are thinking ofYoung manHigh pressure anusSplit is posterior Because the blood supply is worst at the backThe pain is from anal spasm7ManagementAcute Lignocaine, Fybogel and sympathy (90% cure)

Chronic

ALL THE TREATMENTS (except one) TREAT THE SPASM and let the body heal the fissure

Anal spasm treatment IGive it nitrous oxideGTN0.4% >0.2% 25% headache (cling film)Cure 60%1 Recurrence 50%2Diltiazem 2% 15% pruritisCure: 75%3 RRecurrence 0.664Why not block the Ca2+ channels?nifedipene top/oral

1 2006 Cochrane Review Nelson 2 DCR 2004;47:422-431 3Steele SR 2006 Aliment Pharm 4Sajid MS Colorectal Dis 2013Anal Spasm treatment IIParalyse it!

At least Botox wears off

Clinical conviction

Less expensive than 5 years ago Cochrane reviewHealing rate variable: 75%Recurrence rate 50% at 4 yrs10% temporary incontinenceNo better than GTN 0.2%More expensive than NO (77/pt)Works for NO-resistant

Nelson 2012; NICE ESUOM14; Lindsey DCR 2004Anal spasm treatmentCUT IT!

Lateral anal (internal) sphincterotomyFINALLY! A CURE!95%

5% up to 47% mild incontinenceforever No longer

Posterior sphincterotomy: key-hole deformityLords anal stretch

If all else failsHistology to exclude odd things plus DOSHAdvancement flap anoplasty48% cure with 0% incontinenceAlso a treatment for low pressure fissuresrecur if pelvic floor dysfunction not addressed

Anoplasty optionsV-Y or rotational island advancement flapMucosal advancement flapCutaneous advancement flap using sentinel pile (SCAFA)

Probably fail due to same high pressure ischaemiaBotox AND anoplasty if high pressuresLAS and anoplasty

ConclusionIf its not at the back in a young man: worry(but you dont need to do a PR)If it is:Diltiazem is goodBotox is goodLAS short term good long term badandAnoplasty can be good if desperate