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ANAL FISSURE

DR.MAHAR NAVEED SARWAR RESIDENT SURGEON WARD # 26, JPMC

 An anal fissure is an elongated ulcer in the

long axis of lower anal canal.

LOCATION
Midline posteriorly 90%. Midline anteriorly

ETIOLOGY
Hard fecal mass Ischemia Incorrectly performed operations for

haemorrhoids in which too much skin is removed. Inflammatory bowel disease (crohns disease). Sexually transmitted diseases.

PATHOLOGY
Anal fissure occurs in the stratified sensitive
epithelium of lower half of anal canal so pain is the most prominent symptom.

ACUTE ANAL FISSURE

A deep tear through the skin of anal margin
extending into anal canal. Little inflammatory induration or edema of its edges. Spasm of anal sphincter muscles.

CHRONIC ANAL FISSURE

Inflamed indurated margins Ulcer is canoe shaped & at the inferior extremity

there is a tag of skin known as a SENTINEL PILE (it guards the fissure). Spasm of internal sphincter. Infection, abscess & fistula formation may result. Common cause is crohns disease.

CLINICAL FEATURES
PAIN
Sharp agonizing pain on defecation in lower half of anal canal lasting for an hour.

BLEEDING

DISCHARGE

Bright streaks on stool.

Slight discharge in chronic cases. CONSTIPATION

EXAMINATION
Sentinel skin tag can usually be displayed. Tightly closed puckered anus. By gently parting the margins of anus, the lower
end of fissure can be seen. Digital examination should be avoided because of intense pain but if fissure is not seen then 5 % xylocaine is applied & necessary examination should be done. Characteristic crater feels like a vertical buttonhole can be palpated.

DIFFERENTIAL DIAGNOSIS
Carcinoma of anus. Multiple fissures as a complication of skin
disease e.g. scratching, herpes, HIV. Tuberculous ulcer. Proctalgia fugax.

TREATMENT
The object of all treatment is to obtain complete relaxation of internal sphincter.

CONSERVATIVE TREATMENT Chemical sphincterotomy

GTN (0.2% by weight) is applied to the anal

canal. Diltiazem, calcium channel blocker. Botulinum toxin. Laxative to ensure stool softner. Anal dilators with xylocaine are rarely effective.

SURGICAL TREATMENT
Under general anesthesia the index & middle finger of each hand are inserted into anus & carefully pulled apart .Care should be taken to prevent the over stretching of anal sphincter.

LATERAL ANAL SPHINCTEROTOMY

The internal sphincter is divided away from the fissure itself either in right or left lateral position. The procedure can be done by an open or close method. Success rate is 75%.

 ANAL ADVANCEMENT FLAP

Recently introduce technique. Little risk of damage to internal sphincter. Incontinence is unlikely. The operation consist of excision of edges of fissure & mobilization of square, full thickness & skin flap so that it can slid over the fissure & sutured in place.

Follow-up
Sitz baths, analgesics, and stool bulking
agents are used in follow-up care. Frequent follow up visits within the first few weeks help ensure proper healing and wound care. Digital examination findings can help distinguish early fibrosis. Wound healing usually occurs within 6 weeks

Complications
Early postoperative

Urinary retention Bleeding Fecal impaction Thrombosed hemorrhoids

Delayed postoperative

Recurrence Incontinence (stool) Anal stenosis: The healing process causes fibrosis of
the anal canal. Delayed wound healing: Complete healing occurs by 12 weeks unless an underlying disease process is

HAEMORRHOIDS

PREPARED BY DR.AKRAM M ALIUDDIN PG WD 26 UNITIII JPMC

Dilated or enlarged veins in the lower portion of the rectum or anus.

TYPES
INTERNAL HEMORRHOIDS It is the dilatation of internal venous plexus with displaced anal cushion lie above dentate line covered by anal mucosa. EXTERNAL HEMORRHOIDS It lies below the dentate line, external to anal orifice covered by skin. INTEROEXTERNAL HEMORRHOIDS Both varieties are present.

INTERNAL HEMORRHOIDS
ETIOLOGY

Congenital weakness of wall of veins Unsupported collecting radicles of superior

hemorrhoidal veins. Constriction of superior hemorrhoidal tributaries during defecation. Absence of valves in superior rectal veins. Straining during constipation. Straining at micturition. Pregnancy.

Internal hemorrhoids are arranged in three groups at 3,7 &11 Oclock position with patient in lithotomy position. Each hemorrhoid is divided into 3 parts 1.Pedicle 2.Internal hemorrhoid 3.External hemorrhoid

Classification of Internal Hemorrhoids

I- Bleed, but do not prolapse. II- Spontaneous prolapsing and reducing
with or without bleeding. III- Prolapsing, that require manual reduction. IV- Permanently Prolapsed, cannot reduce

CLINICAL FEATURES
Symptom

Bleeding Prolapse Discharge Pain

Sign
Inspection Digital rectal examination Proctoscopy Sigmoidoscopy

PROLAPSED INTERNAL Prolapsed Internal Hemorrhoids HEMORRHOID

COMPLICATIONS

Profuse hemorrhage Strangulation Thrombosis Ulceration Gangrene Fibrosis Suppuration Pyle phlebitis

TREATMENT
Medical Treatment
90% can be treated with conservative medical and conservative non-surgical measures. Fiber, avoid constipation, diarrhea if causative. Lidocaine jelly, NTG cream

Active Treatment
INJECTION This is ideal for 1st degree hemorrhoids. Through a proctoscope 3-5ml of 5% phenol in almond oil is injected.

BARRON BANDING Useful in 2nd degree hemorrhoid. Slipping of tight elastic band on base of pedicle. Only 2 hemorrhoids should be banded at each session.

CRYOSURGERY Liquid nitrogen is applied at -196C which causes coagulation necrosis of piles. PHOTOCOAGULATION Local application of infrared coagulation.

OPERATION

INDICATION Third degree hemorrhoid. Second degree not cured by bandig Fibrosed hemorrhoid Interoexternal hemorrhoid

PREOPERATIVE PREPARATION

Rectum should be evacuated Anal region should be shaved

OPEN TECHNIQUE
Lithotomy position

CLOSED TECHNIQUE
Prone jack-knife position HILL-FURGUSON retractor is used.

ENDOSTAPLING TECHNIQUE
It is a new technique using stapling gun. Excision of strip of mucosa & submucosa above
dentate line. Veins are incorporated in excision. Activation of gun repair the cut mucosa & submucosa by stapling edges together. This is a quick, less painful & less traumatic procedure.

POST OPERATIVE CARE

Twice daily hot sitz bath Bulk laxative to take twice daily Analgesics Application of dry dressing DRE should be performed in follow up after 3- 4 weeks. If there is evidence of stenosis, pt is encouraged to use dilator.

POST OPERATIVE COMPLICATION

EARLY Pain Retention of urine Reactionary hemorrhage LATE Secondary hemorrhage Anal fissure Anal stricture Incontinence

EXTERNAL HEMORRHOIDS
THROMBOSED EXTERNAL HEMORRHOIDS

It is a small clot occurring in perianal subcutaneous

connective tissue Sudden appearance of very painful anal lump also called as perianal hematoma It is situated in the lateral region of anal margin If untreated it suppurate, fibrosed & may resolve give rise to a cutaneous tag.