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Fissure in-ano- lower gi hemorrhage


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FISSURE-IN-ANO – Lower GI Hemorrhage

Dear Viewers,
Greetings from “Surgical Educator”
Today in this episode, I have talked about yet another cause for lower GI haemorrhage- “Fissure-in-Ano”. Unlike other causes of lower GI haemorrhage, fissure-in-ano present with painful bleeding per rectum. I am talking on etiology, types, clinical features and treatment of fissure-in-ano. I have also included a mind map, a diagnostic algorithm and a treatment algorithm. You can watch this video in the following links:

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Fissure in-ano- lower gi hemorrhage

  2. 2. FISSURE-IN-ANO Causes of Lower GI Hemorrhage Etiopathogenesis Types of Fissre-In-Ano Clinical features Treatment Mindmap Diagnostic algorithm Management Algorithm
  3. 3. Causes for Lower GI Hemorrhage Diverticular disease Angiodysplasia- AV Malformation Colorectal carcinoma Hemorrhoids Fissure-in-ano Ischemic colitis Inflammatory bowel disease Meckel’s diverticulum Upper GI hemorrhage
  4. 4. CLASSICAL CLINICAL VIGNETTE A 23 year old lady describes excruciating pain with defecation and blood streaks on the outside of the hard stools. Because of the pain she avoids having bowel movements and when she finally does, the stools are hard and even more painful. Physical examination can not be done, as she refuses to allow anyone to even “spread her perianal area” to look at the anus for fear of precipitating the pain. Diagnosis: Fissure-in-ano EUA should be done to R/O other pathologies like Anal Carcinoma, Crohn’s disease, Tuberculosis, HIV and Leukemia
  5. 5. ETIOPATHOGENESIS  An anal fissure is an ulcer in the lower portion of the anal canal Most tears of the anal canal are due to the passage of large, hard stool or explosive diarrhea, trauma to the anus, or a tear during vaginal delivery. Patients have increased resting anal pressure caused by the increased tone of the internal sphincter muscle. This results in ischemia and ulceration to the overlying anal skin. In men, almost all fissures are located in the posterior midline, whereas in women, 10% are in the anterior midline.
  6. 6. Types of Fissure-in-Ano  Acute Fissure-in-Ano: Symptoms within one month Chronic Fissure-in-Ano: Symptoms 2 to 3 months duration  The primary fissure occurs without association with other local or systemic diseases The secondary fissure occurs in association with Crohn’s disease, leukemia or aplastic anemia.
  7. 7. Clinical Features Bleeding per rectum: Bleeding is painful associated with defecation. It is bright red blood and blood usally streaks on the hard fecal matter Painful defecation: Anal pain during and after defecation is the most prominent symptom.The pain is described as burning, throbbing, or dull aching. Physical examination confirms the diagnosis. Chronic fissures have a triad of a fissure, sentinel skin tag, and hypertrophied anal papilla  In acute Fissure-in-Ano you shouldn’t do DRE or Proctoscopy for fear of aggravating the pain.
  8. 8. TREATMENT Nonoperative for all Acute and some chronic Fissure-in-Ano a. Sitz bath—The patient is asked to sit in warm water with the anal region and buttocks dipped in water for about 20 minutes,2 to 3 times a day. This reduces pain, edema and promotes healing. b. Antibiotics, laxatives (stool softener) and antiinflammatory drugs are beneficial. c. Regulation of bowel habit with a high fiber diet. d. Local application of nitroglycerin or calcium channel blockers like diltiazam lowers the resting anal sphincter tone. e. Injection of Botulinium toxin lowers the resting internal sphincter tone.
  9. 9. TREATMENT Operative Treatment:  Anal fissures usually heals in six weeks. Surgery is not usually required unless the conservative therapy fails.  Lateral internal Sphincterotomy is the surgical procedure of choice if the anal sphincter tone is normal. This can be done as open or blind subcutaneous lateral internal Sphincterotomy. If anal sphincter tone is low- do endoanal v-y skin flap Fissures or ulcers in Crohn’s disease are larger and deeper than primary anal fissures. The surrounding skin is macerated and edematous. Treatment consists of proper anal hygiene and treatment of the underlying inflammatory disease.
  10. 10. TREATMENT Notaras Closed blind subcutaneous lateral internal sphincterotomy Open subcutaneous lateral internal sphincterotomy
  11. 11. MINDMAP
  12. 12. Diagnostic Algorithm
  13. 13. Treatment Algorithm