FISSURE IN ANO It is an ulcer in the longitudinal axis of the lower anal canal. It is superficial, small but distressing lesion. Fissure ends above at the dentate line.

1. en love da Homoeopathy
FISSURE IN
ANO

2. FISSURE IN
ANO

3. FISSURE IN ANO
• It is an ulcer in the
longitudinal axis of the
lower anal canal.
• It is superficial, small but
distressing lesion.
• Fissure ends above at the
dentate line.

4. LOCATION
• Commonly it occurs in
• midline,
• posteriorly (more
commonin males),
• but can also occur in
the midline anteriorly
(more commonin
females).
INCIDENCE
• 95%- men
• 80% - females
• Anterior anal fissure is
commonin females.
Internal Sphincter
The internal sphincter is formed
froma thickening of the smooth
muscle of circular coat of upper
end of anal canal.
↓
Circular muscle is the
continuation of the inner coat of
therectum.
↓
This involuntary muscle
commences where the rectum
passes throughthe pelvic
diaphragm

5. ↓
ends just within the anal
orifice, where its lower border
can be felt.
↓
The internal anal sphincter is
2.5 cm long and 2 to 4 mm
thick.
↓
The internal sphincter is closed
by a sheathof striped muscle.
↓
Spasmand contracture of this
muscle play a major part in
fissure and several other anal
infections
External Sphincter
• It can be dividedinto
three parts
• Deep
• superficial
• subcutaneous
portion.
• It is considered to
be one muscle.

6. Deep part - encircles the upper
end of anal canal and has no
bony attachment.
Superficial part - is attached
posteriorly to the coccyx,
anteriorly insertedinto the mid-
perineal point in the male, in
female it fuses withthe sphincter
vagina.
Subcutaneous part - encircles the
lower end of the anal canal and
has no bony attachment.
AETIOLOGY
• Because of the curvature
of the sacrumand
rectum, hardfaecal
matter while passing
down causes a tear in the
anal valveleading to
posterior anal fissure.
• Anterior anal fissure is
commonin females due
to lack of support to
pelvicfloor.

7. • Hard stool
• Diarrhoea
• increasedsphincter tone
• local ischaemia
• Trauma
• sexuallytransmitteddiseases.
• Other causes
• Haemorrhoidectomy
• Crohn’s disease
• venereal disease
• ulcerative colitis
• tuberculosis.
TYPES
• Acute
• Chronic.
Acute Anal Fissure
• It is a deep tear in the lower
anal skinwithsevere
sphincter spasmwithout
oedema or inflammation.
• It presents withsevere pain
and constipation.

8. ChronicAnal Fissure
• It has got inflamed,
indurated marginwith scar
tissue.
• Ulcer at its inferior margin
is having a skin tag which
is oedematous, acts like a
guard—sentinel pile.
• Proximally hypertrophied
anal papilla is observed.
• It can causerepeated
infection—fibrosis—
abscessformation—
fistula formation
CLINICALFEATURES
• Chronicfissureis less
painful than acuteone.
• Multiple fissures are seenin
inflammatorybowel disease,
homosexuals and venereal
diseases.
• Chronic fissure can cause
complications like—
abscess, fistula formation

9. • Common in middle aged
women, not in elderly.
• Pain is severe in nature in
acutetype, whereas less
severe in chronic.
• Constipation, bleeding and
discharge
INVESTIGATION
• P/Rexaminationand
proctoscopy is not possible
in acute fissure in-ano.
• General anaesthesia is
required for examination.
• In chronic fissure, ulcer is
felt withbutton like
depression, indurationand
often sentinel pile

10. DIFFERENTIAL DIAGNOSIS
• Carcinoma anal canal.
• Inflammatory bowel disease.
• Venereal diseases.
• Anal chancre (painful).
• Tuberculousulcer.
• Proctalgia fugax
TREATMENT
GENERALMANAGEMENT
• Adequate fluidintake (6–8
glasses of liquids) ™
• Fiber rich diet (vegetables,
fruits, brown rice)™
• Bulk forming agents
(psylliumhusk, bran)™
• Stool softeners (lactulose) ™
• Local anaesthetic agents
(lignocaine 5%) ™
• Sitzbath ™
• ™
Once recovers,
regular anal dilatation

11. In an acute case
• Stretching of the anal
sphincter using two fingers
of eachhand (4 fingers)
under anaesthesia is also
an alternative one.
• It is better than Lord’s
dilatationas complications
are less
• Lord’s dilatationis done
under G/Ato relaxthe
sphincter.
• It is the manual dilatation
of the anus under general
anaesthesia with
relaxationusing four
fingers of eachhand (8
fingers)to causevigorous
stretching of the anal
canal to breakthe circular
constricting band in the
wall of theanorectum.

12. • Later, use of laxatives,
xylocaine surface anaes
theticapplication, and anal
dilatation with finger can be
carried out for certain
period.
• Bed rest;2%nifedepine
ointment
For chronic fissure
• Dorsal fissurectomy with
sphincterotomyis done
under anaesthesia.
• Lateral anal sphincterotomy
SENTINEL PILE
DEFINITION
• SENTINEL PILE (‘sentinel’
means guard)
• It is commonly associated
with Fissure-in-ano of
chronic typewherein, in the
lower part of fissure, skin
enlarges and appears like
guarding thefissure.

13. CLINICALFEATURES
• It cancauseperianal
haematoma
• abscessformation,
• discomfort.
TREATMENT
• The chronic fissure is
treated along with excision
of thesentinel pile.
• There may be low grade
infectionand lymphatic
oedema.
• Haematoma/abscess
can develop in it.

14. REFERENCE
1. SRB's Manual of Surgery
by SriramBhat M
2. A Manual on Clinical
Surgeryby Das
3. A Concise textbookof
Surgeryby Das

15. A
Special Thanks
To A Very
Special Doctor