3. Acute Anal Fissure is a longitudinal tear in the anoderm
distal to the dentate line, exposing the internal anal
sphincter with possible contraction/spasm.
This causes pain, further tearing and decreased blood
supply to the anoderm.
This cycle of pain, spasm, ischemia contributes to the
development of poorly healing wound that becomes a
Chronic Anal Fissure.
4.
5. Posterior midline(m/c)
Strained evacuation of a hard stool (constipation) - (m/c)
Repeated passage of watery stool (diarrhoea)
Anterior midline
Seen in women following vaginal delivery
Lateral
Crohn’s disease
Tuberculosis
STD/HIV related ulcers
Syphilis, chlamydia, chancroid, HSV, CMV, Kaposi sarcoma, B-cell
lymphoma
Squamous cell carcinoma
6. Tearing pain with defecation f/b sensation of intense and
painful anal spasm lasting for several hours
Hematochezia (blood in stools)
Characteristic features of acute/chronic fissures can be seen
in anoderm by gently separating the buttocks
It is too tender to do digital rectal examination, anoscopy or
proctoscopy
If suspecting atypical fissures/other causes of anal pain,
patient can be taken for examination under anaesthesia.
7. Diet modifications and bulking agents
Stimulant purgatives
Sodium picosulfate
Bisacodyl
Osmotic purgatives
Lactulose
MgSO4, Mg(OH)2
Stool softeners (surfactants)
Liquid paraffin, Mineral oil
Bulk forming agents
Dietary fibre, bran, methylcellulose
Syp. Duphalac – Lactulose
Syp. Cremaffin – liquid paraffin and milk of magnesia
Syp. Cremaffin Plus – contents of cremaffin with sodium picosulfate
8. Topical therapy
Nitrates (GTN)
0.2% or 0.4%
Headache is the m/c side effect
Calcium channel blockers (CCBs)
0.2% nifedipine or 2% Diltiazem
Side effects are lesser compared to GTNs
Temporary chemodenervation
Botox injection
Causes relaxation of the internal anal sphincter & increased blood
supply to affected anoderm
20 units of botox is injected into the internal anal sphincter on each
side of the fissure.
9. Indications
Severe/Chronic Anal fissures
Acute Anal fissures who have failed to respond to medical
therapy
Various surgeries
Lateral Internal Sphincterotomy (Gold standard procedure)
Open or Closed technique
Fissurectomy with Endoanal advancement flap
Anal dilatation (Lord’s procedure)