Lecture notes for medical students

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2. Introduction

3. Introduction
• Anal fissure is a linear or oval shaped ulcer
in the squamous epithelium of the anal
canal distal to the dentate line.
• Occurs equally in both sexes
• Tend to occur in younger age groups .

4. Aetioloty

5. Aetioloty
• Multifactorial
• Initiating factors
– Posterior perineal descent coupled with
excessive stretching of the anoderm: velnerable
to tearing
– Relatively fixed anococcygeal ligament
posteriorly.
– Extreme bowel pattern: Hard stool/explosive
diarrhoea.
– Excessive straining at defication.
• Perpetuating factors

6. Aetioloty (Perpetuating factors)
• Intrinsic anal sphincter hypertonia
– Reduced production of NO
• Relative tissue ischaemia
– Paucity of branches of inferior rectal artery
– Less dense capillaries in both subanodermal
space and within the IAS in the posterior
midline
• Posterior perineal descent

7. Classification

8. Classification
• Historically according to duration of
symptoms
– Acute: symptoms < 6 weeks
– Chronic: ≥ 6 weeks
– < 6 weeks but examination shows features of
chronicity

9. Classification
• Based on morphology of the fissure
– Superficial fissure:
• severe pain ± bleeding
• superficial separation of the anoderm with sharp
edges
• base of the fissure does not reach the internal anal
sphincter
• vast majority heal spontaneously within days or
within weeks of appropriate conservative treatment.
– Deep fissure

10. Classification
• Deep fissure
– Deep, often with visible fibres of the internal anal
sphincter
– Minimal granulation tissue at the base
– Wide pear shaped ulcer
– Triad of indurated ulcer edges, a distal skin tag
(sentinel pile) and a proximal hypertrophic anal
papilla. Later is not universal.
– Often persist and either tend not to heal without
intervention or recur regularly.
– May result chronically from prolongation or
repetition of the causes of superficial anal fissures
or they may arise de novo as a result of a deep
tearing right from the start.

11. Location

12. Location
• Posterior midline: 75%
• Anterior midline: 25%
• Both anterior and posterior: 3%
• Atypical locations or multiple
– Crohn’s disease
– Trauma
– Tuberculosis
– Syphilis
– AIDS
– Anal carcinoma

13. Symptoms

14. Symptoms
• Anal pain
– Predominant symptom
– During defecation, may last for several minutes
to hours or the entire day.
– Like knife cutting
• Rectal bleeding
– Minimal, bright red
• Pruritus ani

15. Physical examination

16. Physical examination
• Visualised by gentle parting of the buttocks
with eversion of anal verge.
• Position of fissure
• Features of acute/ chronic fissure
• DRE, proctoscopy and sigmoidoscopy is of
little value.
• In acute setting when there is a strong
suspicion of secondary pathology these
procedures can be done under anaesthesia or
when surgery is being undertaken.

17. Physical examination
•

18. Diagnosis

19. Diagnosis
• Characteristic description of symptoms
• Generally easily confirmed by physical
examination (inspection only).

20. Diagnosis
• Characteristic description of symptoms
• Generally easily confirmed by physical
examination (inspection only).

21. Concomitant presence

22. Concomitant presence
• When the patient complains of anal pain
– Perianal abscess
– Anal fistula
– Inflammatory bowel disease
– Sexually transmitted disease
– Anal carcinoma
• In older, particularly female
– Obstructed defecation

23. • Atypical fissures, painless, nonhealing:
– further evaluation via examination
– Possible biopsy and cultures.

24. Treatment

25. Treatment
• Nonoperative:
– First line management both in acute and chronic
anal fissure. Half of all patients of acute and
chronic anal fissure will heal with nonoperative
measures.
– Not as effective as surgery. Late recurrence is
higher (about 50%) with nonoperative Rx.
– Associated pain and bleeding from trauma to
sentinel piles
– Persistent tenesmus or soilage due to the presence
of fibrous polyp.
– Side effects and non compliance.

26. Treatment
• Operative
– For treatment failure
– Sentinel piles
– Surgical excision of SP and fibrous polyp
relieves symptoms and offers good healing for
fissure
– Has been described as initial modes of
treatment. Causes lack of behavioral changes.

27. Nonoperative management

28. Nonoperative management
• Treat both initiating and perpetuating
factors concurrently
– Dietary advice, medication, biofeedback
– Perineal support
• Manual
• Modified toilet seat
• Sitz baths
• Topical preparations

29. Topical preparation

30. Topical preparation
• Combination of
– Anaesthetics
– Antiinflammatory
– Antibiotic
• Erian:
– Cinchocaine HCI (local anaesthetics)
– Hydrocortisone
– Framycetin Sulphate (aminoglycoside
antibiotic)
– Esculin (coumarin glucoside)

31. Sphincter relaxants

32. Sphincter relaxants
• 0.2% GTN ointment: two to three times
daily for 4-8 weeks.
– 77% headache, 6% orthostatic hypotension,
anal irritation 67% lack of compliance.
– 6 weeks:90% healing rate Vs 85% in LIS
– 8 weeks:67% healing rate Vs 92% in LIS
– 2 years : 46% ,, ,, Vs 91% in LIS

33. Sphincter relaxants
• 2% diltiazem.
– Equally effective in chronic anal fissure. Less
side effects.
• These are first line treatment in chronic anal
fissures.
• Who are already on these drugs for HTN
and ISD may be unsuitable for these
treatment

34. Sphincter relaxants
• Parasympathomimatic: 0.1% bethanechol
gel tds
• Adrenergoc antagonists: lack of efficacy.
• Phosphodiesterase inhibitors (sildenafil):
significantly reduces anal sphincter tone

35. Sphincter relaxants
• Botulinum A toxin: exotoxin
– Binds with presynaptic nerve terminal at the
neuromuscular junction. Prevent release of
acetylcholine. Temporary muscle paralysis
– Injection of 20 U on each side of anterior
midline in the intersphincteric groove. Repeat
for persistence
– Over all healing rate significantly lower than
LIS

36. Botox (contd…)
• Second line agent in the treatment of CAF.
• Side effects:
• Mild incontinence to flatus (or stool) that
is short lived and resolve spontaneously
• Perianal haematoma
• Pain
• Sepsis

37. Surgical treatment
• LIS with excision of SP and fibrous anal
polyp.
– LIS: open/ closed method
– Tailored
– ASCRS recommends LIS as the surgical treatment
of choice for refractory anal fissure.
– External anal sphincter deficits are recognized
preoperatively.
– Healing rate >90%. Incontinence to flatus in about
15% of patients.
– Recurrence : in 70% of patient lack of adequate
IAS division founds. LIS on the opposite side is the
option.

38. Surgical treatment
• Controlled anal dilatation
– Parks retractor opened to 4.8 cm
– Pneumatic balloon inflated to 40 mm
– Healing upto 94%. Healing rate and
incontinence is similar to LIS.
– Symptomatic improvement 93% after dilatation
Vs 72% after LIS at 4 months in one study.
– Still practiced in some centres. Not in North
America.

39. Flap
• Indicated in absence of sphincter
hypertonia.
• Anal cutaneous advancement flap along
with fissurectomy
• Island/sliding advancement flap .

40. Recurrence after LIS
• Anal manometry and endoanal ultrasound
are essential.
• Separate patients with low and high resting
anal pressure
• High pressure: repeat LIS on opposite side.

41. Atypical anal fissure

42. Atypical anal fissure
• Address the primary disease
• Otherwise the management is same.
• Among crohn’s patients, anal pathology
leading to symptoms identified in 42% of
patients. Commonest is the perianal abscess
(29.5%), anal fissure (27.6%), anal fistula
(26.7%)
• AIDS: atypical, deep, broad base fissure.

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