Management of Fissure-in-ano

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Fissure in ano is a linear crack or ulcer in the anoderm. It is caused by hard stool trauma on anal valves, that rupture and gives rise to formation of fissure in ano.
In the presentation, various aspects of etiology and management have been described.

Published in: Health & Medicine

Management of Fissure-in-ano

  1. 1. Fissure in Ano & it’s management Dr. Lakshman Singh B.A.M.S.(Delhi University),M.S.(Ay), BTMAS(SGRH),M.R.A.V (Su.S), Ph.D, Associate Professor Faculty of Ayurveda Department of Shalya Tantra Institute of Medical Sciences Banaras Hindu University Varanasi
  2. 2. Introduction • Anal fissure is the most common cause of severe anal pain. • It is equally one of the most common reasons of bleeding per anus in infants and young children. • The pain of anal ulcer is intolerable and always disproportionate to the severity of the physical lesion. • It may be so severe that patients may avoid defecation for days together until it becomes inevitable. • This leads to hardening of the stools, which further tear the anoderm during defecation, setting a vicious cycle.
  3. 3. FISSURE IN ANO • Fissure – This term has been derived from the Latin root “Fissura” that means a cleft, sulks, or groove, normal or otherwise. • Fissure-in-Ano is a true ulcer in the anoderm. It is longitudinal in shape. Synonyms • Anal ulcer • Anal fissure • Ulcer-in-ano • Chronic ulcer • Faecal ulcer • Parikartika
  4. 4. FISSURE IN ANO • An anal fissure is a linear ulcer in the lower half of the anal canal and extends from just below the dentate line to the margin of the anus (anal verge). The ulcer may be acute, recurrent or chronic and may occur alone or with other rectal disease, most commonly haemorrhoids.
  5. 5. EPIDEMIOLOGY Age  Young or middle aged adults 30– 50 years specially; women suffer from fissure the most. Occasionally – infancy or early child hood resulting in acquired mega colon.  Uncommon in aged groups. The cause may be laxity of muscles.
  6. 6. Sex • Fissure is more common in women than men. Site • Most common site is midline posteriorly. Next frequent site is midline anterior. • Other sites also are not very uncommon. But when anal ulcers are more in number, one can suspect associated diseases like tuberculosis, syphilis or colitis. Gender Ant. Post. Male 10% 90% Female 40% 60%
  7. 7. The predominantly posterior midline location of fissures has been explained by a) Posterior angulation of the anal canal, b) Relative fixation of the anal canal posteriorly, c) Divergence of the fibers of the external sphincter muscle posteriorly d) The elliptical shape of the anal canal An anterior mid line location of fissure is much more common in women, particularly in those who have borne children.
  8. 8. Etiology  Primary causes 1. Constipation 2. Spasm of internal sphincter 3. When too much skin has been removed during operation for haemorrhoids, anal stenosis may result, in which anal fissure may develop when hard motion passes through such stricture.  Secondary causes i) Ulcerative colitis ii) Crohn’s disease, iii) Syphilis iv) Tuberculosis
  9. 9. Frontal Section of Anal Canal The Lining Membrane of Anal Canal
  10. 10. Pathogenesis In constipation ,during defecation passing of hard faecal mass , mainly on the posterior ano rectal angle in which the overlying epithelium is greatly stretched and torn leading to fissure in ano.  The healing of this fissure is hampered by increased internal sphincter tone.  Faecal matter infection and poor blood supply posteriorly . If left untreated hypertophied anal papilla above the fissure and skin tag below the fissure are formed.
  11. 11. • At any stage frank suppuration may occur and extend into the surrounding tissues to from a perianal abscess, which may discharge through the fissure into the anal canal or may burst externally to produce low anal fistula. • Usually the external opening of this fistula lies in or close to the midline a short distance behind the anus, and an anal fissure should always be thought of as the commonest cause of such a median low anal or posterior horse shoe type fistula in untreated cases.
  12. 12. CLASSIFICATION: 1. Primary or Idiopathic • In this idiopathic type of fissure there is no pre- existing disease or any other cause except constipation. 2. Secondary or such fissures • anal operation, such as haemorrhoidectomy or laying open of a low anal fistula, where the resulting wound is situated anteriolry or posteriorly. • Other condition to which fissures may be secondary are non-specific protocolitis and Crohn’s disease.
  13. 13. Types Acute fissure- in-ano Acute fissure in ano is a tear of the skin of the lower half of the anal canal. There is hardly any inflammatory induration or oedema of the edges. Anal sphincter muscle spasm is always present. Chronic fissure-in-ano • If the acute fissure fails to heal it will gradually develop into a deep undermined ulcer; termed now as chronic fissure. It is a deep canoe shaped ulcer with thick edematous margins. At the upper end of the ulcer there is hypertrophied papilla. At the lower end of the ulcer there is a skin tag known as “Sentinel pile”. • Spasm of internal sphincter is always present.
  14. 14. CLINICAL FEATURES • Pain on defecation-sharp,cutting & tearing, discomfort 2-3 hrs • Bleeding -slight • Swelling –large sentinel tag • Discharge and pruritis-soiling of underclothes • Urinary symptoms -sometimes
  15. 15. COMPLICATIONS i) Infections: Infection in a fissure may lead to fissure abscess formation. It may also give rise to a fistula-in-ano ii)Sentinel tag iii)Enlarged papilla iv) Anal contracture
  16. 16. DIFFERENTIAL DIAGNOSIS 1) Pruritus ani 2) Ulcerative colitis 3) Crohn’s Disease 4) Squamous cell carcinoma or Adenocarcinoma of rectum 5) Syphilitic fissures-same on opp. wall, discharge-D.G.I. for spirochaetes, wassermann reaction 6) Tubercular ulcer 7) Idiopathic stenosis of internal sphincter- elderly women addict to purgatives
  17. 17. FISSURE IN AYURVEDA Not a separate disease . Charak- C/F of grahni ,Complication of Vamana & Virechana • vk/ekua ifjdÆrdkÜp lzkoks âx~nk=;ksxzZg%A thounkua lfoHkza'k% LrEHk% lksiæo% de%A v;ksxknfr;ksxkÜp n'kSrk O;kinks erk%A çs";Hk"kT;oS|kukaoSxq.;knkrqjL; pAA p- fl-6@30 Sushruta –Samshodhana Vyapada oS|krqjfufeŸka oeua fojspua p iapn'k/kk O;ki|rsA lkekU;eqHk;ks% lko'ks"kkS"k/kRoa] th.kkSZ"k/kRoa] ghunks"kkiârRoa okr'kwye] v;ksxks] vfr;ksxks] thoknkue~] vk/ekua] ifjdÆrdk] ifjlzko%]çokfgdk]ân;ksxilj.ka]focU/k%bfrA ¼lq-fp- 34@3½
  18. 18. • {kkes.kkfre`nqdks"Bsu enkfXuuk:{ks.k ck·frrh{.kks".kkfryo.kefr:{kaok ihrekS"k/kafiŸkkfuykS çnw";ifjdÆrdkekikn;frA • r= xqnukfHkes<ªcfLrf'kj%lqlnkgaifjdrZuefuylaxks ok;qfo"VEHkks Hkäk:fpÜp HkofrA ¼lq- fp- 34@16½ Etiopathogenesis
  19. 19. Management of Fissure in Ano I) Conservative treatment i) Avoidance of constipation ii) Anesthetic ointment iii) Anal Dilator iv) Long acting local Anesthetics v) Analgesics / Muscle relaxant vi) Application of glyceryltrinitrate vii) Botulinum neurotoxin viii) Hyperbaric oxygen
  20. 20. Sr. No. Condition for conservative treatment Condition for surgical treatment 1. Short and single history of pain Long and continues or intermittent history of pain. 2. No sentinel tag Sentinel tag. 3. No induration in the edges of fissure Indurations in the edges of fissure present. 4. Scar is superficial Scar is deep. 5. Fibers of int. sphincter not exposed Fibers of int. sphincter exposed. 6. Mild to moderate pain Severe pain, in acute or chronic cases of fissure-in-ano. Criteria for management
  21. 21. Aims and objectives of treatment  Complete relaxation of internal sphincter.  Oral pain medication before any anticipated bowel movement.  Stool softener, weak bulk laxative.  Soothing ointments with anaesthetizing properties may be applied  Injection of long-acting anesthetic agent.  Application of long Glyceryltrinitrate.
  22. 22. Anal Dilatation • Intracanal packing is given to avoid soiling during operation. • Digital anal dilatation (stretching of the anal sphincters) - A procedure similar to that described by Recamier (1829), is done instead of Lord’s procedure. Technique • With the patient in lithotomy position, the anus is forcibly stretched by introducing first both index figures and then index and middle fingers of both hands, which maintain a firm distraction for three or four minutes. • During this manoeuvre the forearms are fully pronated so as to stretch particularly the posterior wall of the anal canal.
  23. 23. Anal dilatation
  24. 24. ANAL SPHINTER STRETCHING
  25. 25. Incision over fissure Revelation of anterior fibres of internal sphincter Incision of anterior fibres of internal sphincter dorsal internal sphincterotomy
  26. 26. Lat. sphincterotomy
  27. 27. Excision of Anal Fiss. By Gabriel’s method
  28. 28. Holding of the Sentinel tag • After stretching the anal sphincters and dorsal internal sphincterotomy, the sentinel tag is boldly held with the help of Allis tissue forceps. Thereafter, a semicircular groove is made with blunt scissor at the base of sentinel tag, to excise the tag.
  29. 29. • excison of sentinel tag is done at the demarcation made by semi circular groove, • After achieving the secured ligation, the excision of ligated sentinel tag is carried out about 5 mm digtal to ligature to minimise the necrosed tissue and subsequent debris in turn to reduction of post operative infections. • Gauze soaked with Jatyadi Taila is placed inside the canal One end of the anal packing given initially is withdrawn out for facillating easy removal.
  30. 30. • T-bandage is given to hold the lay on dressing in position. Insertion of flatus tube
  31. 31. postoperative • Simple non narcotic analgesics for 24hrs • Orally allowed after an hour of operation. • Regular monitoring for haemorrhage is done without disturbing anal dressing.
  32. 32. Post operative care and prescription • Dressing is removed next morning after that avaghana with is given. ushnodaka • Frequent ushnodaka avaghana every 12 hourly • Instilation of Ropan sashang / jatayadi taila into the anal canal with the help of No. 8 rubber catheter attached with a 10ml of syringe. • Triphala gugulu - 2 tablets x BD • Sigru gugulu - 4 gm x BD • Triphala powder - 2 TSF x HS SOS
  33. 33. Samshodhana Snehan- Narayan Taila, Panchaguna Taila Swedana-Warm water Virechana-mridu Vasti - Samshaman Langhana Pachana
  34. 34. • nsonk:frykuka ok dYdeq".kkEcquk ficsr~A vÜoR;ksnqEcjIy{kdnEcSokZ J`ra i;%A • d"kk;e/kqja 'khra fiPNkofLreFkkfi okA ;"Vhe/kqdfl)a ok LusgofLra çnki;srAA ¼p- fl- 6@64&66½ • r= fiPNkcfLr;Z"Vhe/kqdd`".kfrydYde/kqÄ`r;qä%] 'khrEcqifjf"käa pSua i;lk HkqäoUra Ä`re.Msu ;"Vhe/kqdkfl)su rSysu ok·uqokl;sr~A ¼lq- fp- 34@16½
  35. 35. Conclusion • conservative treatments with Ayurvedic method- Samshodhan, samshaman, are all effective methods that may reduce the need for anesthesia and surgery in many of the patients. • These could always be offered to the patients who are not willing for operative procedure. • Surgical manipulation should be sought in case of recurrence or failure of conservative treatment. • While all the available options are explained to the patient with complete information about the method, cure rates, complications, and reversibility of the disease, the surgeon should analyze the optimum treatment for the particular patient in order to make a good and safe choice and then offer to the patient the result of the best of judgment of his own.
  36. 36. THANK YOU

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