FISSURE IN ANO

Definition

Longitudinal tear in the lower end of anal canal results in fissure in ano. It is the most painful condition affecting the anal region. Commonly seen in young patients.

Aetiopathogenesis 

• 90% of anal fissures occur in the posterior part of anal canal and 10% anteriorly. It is initiated by hard stool causing a crack. As a result of this, defaecation results in pain. Anal fissure is more common posteriorly in the midline because of relative ischaemia.

• Due to pain, internal sphincter spasm takes place which makes constipation worse resulting in a chronic fissure.

• Anterior fissures occur in elderly women secondary to repeated pregnancies. This is due to damaged pelvic floor and lack of support to anal mucous membrane. Acute fissure in females may occur after vaginal delivery.

PEARLS OF WISDOM

Fissure away from midline should raise the possibility of Crohn 's disease, sexually transmitted diseases, etc.

VARIOUS FACTORS WHICH PRECIPITATE ANAL FISSURE

• Faeces-hard

• lschaemia

• Surgical procedures-haemorrhoidectomy

• Sphincter hypertonia

• Underlying diseases-Crohn's, sexually transmitted diseases, etc.

• Repeated childbirth

• Enthusiastic usage of ointments and abuse of laxatives

Remember as FISSURE

Clinical features

• Severe pain during and after defaecation, burning in nature, lasting for about 1/2 to 1 hour because of which defaecation is postponed.

• Severe constipation is present.

• Stools are hard, pellet like and there is a drop of blood or streaks of fresh blood.

• Sentinel pile refers to tag of skin at the outer end of the fissure.

• In some cases, fissure may be associated with a small perianal abscess resulting in worsening of pain.

PEARLS OF WISDOM

Drop of blood is due to anal fissure. Splash of blood is due to haemorrhoids, bloody slime

Is due to carcinoma.

Diagnosis

1. When the buttocks are spread apart, a longitudinal tear and a hypertrophied, thickened skin is seen near the lower end of fissure-sentinel pile.

2. Per rectal examination can be done (with lignocaine jelly application) and sphincter spasm can be appreciated.

3. Proctoscopy is contraindicated because the condition is very painful.

Difference between acute fissure in ano and chronic fissure in ano

Acute	Chronic
•Sudden onset-example after vaginal delivery or following hard stools • Acute pain in the anal canal, severe burning after defaecation with bleeding • No itching around anal opening • Severe sphincter spasm, small crack in the lower anal canal • No sentinel pile-tag of skin • PR very painful • Proctoscopes-better not try insertion • Usually responds to conservative treatment	•A few months duration of symptoms • Chronic pain in the anal canal, burning after defaecation with bleeding-few exacerbations • Itching is usually present due to ulcer or hypertrophied skin sentinel pile • Sphincter spasm, chronic canoe shaped ulcer in the lower anal canal • Sentinel pile tag of skin • PR painful • Proctoscope-can be done with proper ligonocaine application to the anal canal • Responds to conservative treatment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Management

• Conservative Avoid constipation-encourage fibre diet, mild laxatives and not to postpone defaecation.

• Surface anaesthetic creams: Lignocaine jelly.

• Sitz bath.

 

 

 

TREATMENT AT DR. SOHAN LAL CLINIC

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