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Anal fissures

  • Most acute fissure heal spontaneously
  • Chronic fissures (more than 6 weeks) duration associated with increased intra-anal pressure
  • Treatment aimed at reducing anal sphincter pressure

Aetiology

  • Probably due to mucosal ischaemia secondary to muscle spasm
  • Probably not a 'tear' due to the passage of a hard stool (Pecten band theory)
  • 5% associated with chronic intersphinteric abscess
  • Usually seen between 30 and 50 years
    • 90% posterior midline
    • 10% anterior midline
  • Anterior fissure more common in women specially post partum
  • If multiple fissure or at unusual site consider 
    • Crohn's Disease
    • Syphilis
    • Tuberculosis

Clinical features

  • Present with pain on defecation, bright red bleeding and pruritus ani
  • Fissure often visible on parting of buttocks and or a 'sentinel pile'
  • Features of chronicity:
    • Symptoms for more than 6 weeks
    • Papilla
    • Undermined edges
    • Visible internal sphincter

Treatment

  • Bulking agent and topical local anaesthesia produces symptomatic improvement
  • 50% of acute fissures heal with this treatment
  • Recent interest in the use of 0.2% GTN ointment for treatment of chronic fissures
  • GTN is nitric oxide donor that relaxes internal anal sphincter
  • Induces a 'reversible chemical sphincterotomy'
  • Reduces anal resting pressure by 30 40 %
  • Heals more than 70% fissures by 6 weeks with about a 10% risk of early recurrence
  • Most common side effect is headache
  • Similar results to GTN achieved with diltiazem
  • Botulinum toxin also produces a chemical sphincterotomy

Surgery

  • 95% achieve prolonged symptomatic improvement
  • 20% some degree of incontinence (faecal soiling or incontinent of flatus)
  • Anal dilatation or internal sphincterotomy are the two most common procedures
  • Sphincterotomy more effective and has a reduced risk of incontinence
  • Lateral sphincterotomy preferred
  • Posterior sphincterotomy or fissurectomy should be avoided.

Bibliography

Bacher H,  Mischinger H-J,  Werkgartner G et al.  Local nitroglycerin for treatment of anal fissures:  an alternative to lateral sphincterotomy?  Dis Colon Rectum 1997;  40:  840-845.

Farouk R,  Duthie G S,  Gunn J.  Changing patterns of treatment for chronic anal fissure.  Ann R Coll Surg Eng 1998;  80:  194-196.

Lindsey I,  Jones O M,  Cunningham C et al.  Chronic anal fissure.  Br J Surg 2004;  91:  270-279.

Lund J N,  Scholefield J H.  A randomised prospective, double-blind, placebo-controlled trial of glyceryl trinitrate in the treatment of anal fissure.  Lancet 1997;  349:  11-14. 

 

 
 

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