7/16/2015

AnalFissures

AnalFissures

AnalFissures

Etiology

Ananalfissureisatearinthesquamous
epithelialmucosaoftheanalcanal.They
occurbetweentheanocutaneousjunctionand
thedentateline.Thegenerallyaccepted
etiologyofanalfissuresisthemechanical
tearingfromthepassageofahardstool,
howeverthepathophysiologyislikelytobe
multifactorialandmayinvolveanodermal
ischemia,infection,chronicconstipation,
and/orhypertonicityofthesmoothmuscleof
theinternalanalsphincteranditselevated
restingpressure.
Fissuresmostoftenoccurintheposterior
midline,andthereasonsforthisareboth
anatomicandfunctionalinnature.The
posteriorcommissureoftheanodermislesswellperfusedthanotherregions.Furthermore,before
thebranchesoftheinferiorarteryreachtheanoderm,theycourseperpendicularlythroughthesepta
oftheinternalanalsphincter.Thus,flowthroughthesearteriesisthreatenedbyelevated
intramuscularpressureoftheinternalanalsphincter,andinfact,studieshavedemonstratedthat
patientswithanalfissurestendtohaveelevatedanalcanalpressures.
Additionally,womenoccasionallyhaveanteriorfissures,andlateralfissurestypicallysuggestan
unusualdiagnosis(Crohn'sdisease,STD,malignancy).
ClinicalPresentation
Acarefulhistoryandphysicalexamwillusuallysuggestthediagnosis.Patientsoftencomplainofa
historyofconstipationorexcessivediarrhea.Painiscommon,particularlywithdefecationandmay
bedisproportionatetothesizeofthelesion.Ifbleedingispresent,itisusuallybrightred,andinfact,
isthemostcommoncauseofbrightredbloodperrectum(BRBPR)atanyage.
Thediagnosisismadebyinspectingtheanalregion.Gentleretractionofthebuttockswillrevealthe
tear.Havingthepatientbeardownwillaidinseeingafissureifitispresent.Incaseswherea
fissurecannotbyseen,adigitalexamshouldbedonetoruleoutotherpathology.Likewise,ifpain
limitsthediagnosis,anexaminationunderanesthesiawouldbeappropriate.
Ifthefissureischronic,asmall,external,skintag(sentineltag)maybeidentifiedatthebaseofthe
laceration.Additionally,ifthefissureexposesinternalsphincterfibersandtherearehypertrophied
analpapillaatthelevelofthedentateline,thenthistriadoffeaturesisgenerallyconsidered
pathognomonicforchronicfissures.
Treatment
Acuteanalfissuresrarelyrequiresurgery.Conservativetreatmentofadietarymodification,stool
softeners,andSitzbathsusuallysuffice.Symptomsfromanacutefissureusuallyresolveover1014
dayswithconservativetreatment,howeveritmaytake68weeksforafissuretoactuallyheal.
Ifafter68weeks,thetearhasnothealed,thefissureisconsideredchronicandmoreactivemeasures
canbeemployed.
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7/16/2015

AnalFissures

Chemicalsphincterotomyemployingnitro
glycerinointment(NTG)canbeattempted,
wheretheointmentisappliedtopicallytohelp
healthewound,however,headacheand
diarrheaarecommoncomplications.Topical
diltiazemcanalsobeused,withlessreported
sideeffects.Lastly,botulinumtoxincanbe
injectedtoreduceinternalsphinctertoneand
promotehealing,howeverthisapproachismore
invasiveandcostlythanthetopicaltreatments.
Asmentionedabove,surgeryisrarelyneeded
foranacutefissure,asconservative
managementusuallysuffices.Ifafissurepersistsdespitemedicalmanagement,thenalateral,
internalsphincterotomycanbeperformed.Thepurposeoftheprocedureistocutthehypertrophied
internalsphincter,therebyreleasingtension,andallowingthefissuretoheal.

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