FISSURE IN ANO/ANAL FISSURE A case presentation of chronic anal fissures and a brief discussion and management. Suitable for all in the health care provision business.

1. 1
BIODATA
E.A.O 27 year old female
Residence: kenya
Chief complaint.
Pain in the anal region during defecation- 3years
History of presenting illness.
Patient was well until 3 years ago when she developed the above. The pain was of acute
onset, and was burning in nature. On a scale of 1-10 the patient graded the pain as 4. It
would persist for some few minutes after defecation after which it would resolve
spontaneously. However it would recur during subsequent bowel movements. She also
noticed specks of blood on her used tissue paper. One year ago she noticed a swelling
around the anus. It was not painful to touch, however it was associated with intense an
intense itch. Apart from pain patients reports she can pass stool and flatus though the
intense pain discourages her from passing stool. Over the past two months the pain has
increased in intensity a grade of 9. She has also noted another swelling on the anal region.
No loss of appetite, no abdominal pains, no diarrhea or constipation, no changes in stool
color.
OBS/GYNE History.
Patient is a para 1+0
Last menstrual period was on 1st
September 2018.
She has a regular period every 30 days lasting 3-5 days. Uses 2 partially soaked pads
daily.
Past medical surgical history.
She has never been admitted.
Has undergone no surgical procedures
Has no history of chronic illnesses diabetes mellitus, sickle cell anaemia or malignancy.
Has no known drug or food allergies.
Is sero-negative as at last month – however no evidence was seen.
Family, social, economic history.
She is married and lives in Obunga with her husband and one child. She is a small scale
trader dealing with second hand clothes. Her husband is a carpenter. Lives in a semi-
permanent house well ventilated. Water is chlorinated.
Her typical diet is expounded on in the table below.

2. 2
Breakfast Lunch. Supper. Others.
White tea with
mandazi
Occasional sweet
potatoes(ones in
two weeks)
French fries on
most days.(4 days a
week)
Ugali, omena,
cabbage
sukumawiki
Occasional fruits
eg. Pinapple,
watermelon in
small poportions
(once a week)
Water intake is only during meals.
She is covered by NHIF.
REVIEW OF SYSTEMS
Cardiovascular system
No chest pain, no difficulty in breathing on assuming the recumbent position or lying
straight in bed, no awareness of the heart beat no swelling of the lower limbs.
Respiratory system
There is no difficulty breathing, no cough, no sputum production.
Central nervous system
There is no headaches, no visual defects, no hearing problems, no dizziness, no gait
disturbances
Musculoskeletal system
No joint or back pains, no easy fatigability, no difficulty walking no paresthesia,
numbness or weakness of the limbs.
Summary.
E.A.O 27 year old female from Obunga presenting with a 3 year history of pain around
the anus during defecation with associated blood stains on tissue paper. She has also
developed 2 swellings around the anus. Her diet is of low fiber content.
On examination.
Patient in good general condition sitted upright on chair. Not wasted. Not in any
respiratory distress.
Not pale, not jaundiced, had no lymphadenopathy, not cyanosed. No limb or sacral
edema.
Vital signs were as follows
Blood pressure 126
84
Pulse rate(beats/min) 75
Respiratory rate(cycles per min) 12
Temperature. Degrees celcius 37

3. 3
RESPIRATORY EXAMINATION
Inspection- The patient was not in obvious respiratory distress respiratory rate of 12
breaths per minute and had no scars. The chest was moving with respiration.
Palpation there was equal chest expansion, equal tactile fremitus bilaterally.
Percussion- there was normal chest resonance
Auscultation -vesicular breath sounds heard equally on both sides with no crackles,
crepitations or rhonchi.
CARDIOVASCULAR EXAMINATION
The Inspection- no hyperactivity noted in the precordium area, no scars, No distended
neck veins.
Palpation- apex beat palpated at the 5th
intercostals space, midclavicular line, no heaves.
Auscultation- S1 and S2 heard. No additional heart sounds (no murmurs)
No bruit heard over the abdominal aorta.
ABDOMEN EXAMINATION
Inspection- The abdomen of normal fullness and contour and is moving with respiration.
There were no visible scars or dilated veins or visible masses.
Palpation -there were no areas of tenderness, no palpable masses or organomegaly.
Percussion- There was normal resonance with no shifting dullness or fluid thrill.
Auscultation -bowel sounds were heard 2 in one minute.
CNS EXAMINATION
The patient was oriented in time place and person with a
GCS of 15/15. M-6, v-5, e-4
MUSCULOSKELETAL EXAMINATION
Muscle tone, bulk, power and reflexes were normal with a score of 5/5 on all four limbs.
Local exam.
On inspection there were two masses projecting from the anal canal. They were of the
same color as the surrounding skin. They were located at 3 oclock and 6 oclock.
On palpation the anal wink was present. The masses were non tender and each measured
approximately 0.5cm by 0.5cm by 2cm. A linear ulcer could be visualized at the base of
each mass.
Impression.
Chronic anal fissure with skin tag
Ddx

4. 4
External hemorrhoidal disease.
Investigations.
Full haemogram.
Management plan.
1. Advice on modification of diet to a high fiber diet was given.
2. Sitz baths- the patient was advised on this
3. Booked for lateral internal sphincterectomy with fissurectomy.
Discussion.
Anal fissures.
Fissure in ano is a superficial linear tear in the squamous epithelium of the anal canal
distal to the dentate line. In the short-term, it usually involves only the epithelium but in
the long-term, involves the full thickness of the anal mucosa.
Epidemiology.
Anal fissures affect males and females equally; however an anterior fissure is more likely
to occur in women (25%) than in men (8%). Although an anal fissure is the most
common cause of anal bleeds in infants it is more common seen in young adults. 87% of
people with anal fissures are between the ages of 20 and 60. Anal fissures in children
may indicate sexual abuse.
Data on the prevalence and incidence of anal fissures is scares in Kenya

5. 5
Aetiology
1. Trauma -passage of hard stool (constipation)
-anal intercourse
- Rectal examination speculum
2. Low-fiber diets- lacking in raw fruits and vegetables
3. Prior anal surgery -scarring from the surgery may cause either stenosis or tethering of
the anal canal
4. Chronic diarrhea
5. Habitual use of cathartics
6. Abnormalities in internal sphincter tone - hypertonicity and hypertrophy of the internal
anal sphincter, leading to elevated anal canal and sphincter resting pressures.
Pathophysiology of anal fissures.
The pathophysiology of anal fissure is thought to be related to trauma from either the
passage of hard stool or prolonged diarrhea. A tear in the anoderm causes spasm of the
internal anal sphincter, which results in pain, increased tearing, and decreased blood
supply to the anoderm. This cycle of pain, spasm, and ischemia contributes to
development of a poorly healing wound that becomes a chronic fissure. The vast majority
of anal fissures occur in the posterior midline. A chronic fissure may subsequently
develop a sentinel tag as a ‘protective’ feature
Diagnosis.
The diagnosis of anal fissures is a clinical one.
History. Physical exam
1-Severe pain during a bowel
movement, with the pain lasting minutes
- hours afterward.
-The pain leading to a cycle of
worsening constipation, harder stools,
and more anal pain.
2- Bright red blood on the toilet paper or
stool but no significant bleeding
1.Visual examination may disclose a posterior
oedematous tag and, on parting the buttocks, an
associated fissure may be seen.
2. Majority of tears are found in the posterior
midline. Fissures occurring off the midline should
raise the possibility of other etiologies.
Acute fissures are erythematous and bleed easily.
-With chronic fissures, classic fissure triad may be
seen.

6. 6
3- Mucous anal discharge and pruritus
ani are also common.
History of chronic anal fissure is
typically cyclical; periods of acute pain
are followed by temporary healing, only
to be succeeded by further acute pain.
A. Deep ulcer
B. Sentinel pile-skin tag
C. Enlarged anal papillae
Investigations.
Sigmoidoscopy should be undertaken, under anaesthesia if the fissures are located in a
peculiar location to exclude specific causes of fissure, IBD (esp. Crohn's disease), anal
syphilis, anal herpes, anal carcinoma, lymphoma, anoreceptive intercourse (with or
without HIV infection), and, in children, sexual abuse.
Treatment.
Therapy focuses on breaking the cycle of pain, spasm, and ischemia thought to be
responsible for development of fissure in ano.
1st
line medical therapy
1. Diet modification increase -water and fibres-fruits and vegetables.
2. Stool-bulking agents/Stool softeners -such as fiber supplementation and stool
softeners-polyethylene glycol
3. Laxatives are used as needed to maintain regular bowel movements.-Lactulose
4. Mineral oil may be added to facilitate passage of stool without as much stretching or
abrasion of the anal not used for long.
5. Sitz baths after bowel movements - symptomatic relief as they relieve painful internal
sphincter muscle spasm
2nd
line medical therapy
Topical application of 0.2% nitroglycerin (NTG) ointment directly to the internal
sphincter.
NTG ointment is thought to relax the internal sphincter and to help relieve some of the
pain associated with sphincter spasm; it also is thought to increase blood flow to the anal
mucosa. Main adverse effects are headache and dizziness; could be used directly before
bedtime.
Others -hydrocortisone cream, lignocaine gels, Proctosedyl ointment (cinchocaine
anaesthetic 0.5 per cent and hydrocortisone 0.5 per cent).
Newer therapy for acute and chronic anal fissures is botulinum toxin.

7. 7
The toxin is injected directly into the internal anal sphincter and, in effect, performs a
chemical sphincterotomy.
The effect lasts approximately 3 months, until the nerve endings regenerate. This 3-
month period may allow acute fissures (and sometimes chronic fissures) to heal and
symptoms to resolve. Recurrence indicates need for surgery.
Surgical therapy:
Surgical therapy is usually reserved for acute anal fissures that remain symptomatic after
3-4 weeks of medical therapy and for chronic anal fissures. Few chronic fissures heal
spontaneously or from medical therapy and is indication for surgery
1.Sphincter dilatation
Controlled anal stretch or dilatation under general anesthetic. This is performed because
one of the causative factors for anal fissure is thought to be a tight internal anal sphincter;
stretching it helps correct the underlying abnormality, thus allowing the fissure to heal..
2.Lateral internal sphincterotomy
Current surgical procedure of choice. Done under general or spinal anesthesia.
The purpose of an internal sphincterotomy is to cut the hypertrophied internal sphincter,
thereby releasing tension and allowing the fissure to heal.
Sphincterotomies are normally performed in the lateral quadrants as most fissures are
posterior or anterior and cuts would not heal due to impaired blood supply.Only the
internal sphincter is cut; the external sphincter is not cut and must not be injured. In
chronic anal fissures, excision of the fissure in conjunction with the lateral
sphincterotomy may be done. An advancement flap may be performed to cover the defect
in the mucosa.
Follow-up care-stool softeners and fiber supplementation after the surgery
Complications from surgery
Infection
Bleeding
Anal abscess
Fistula development,
Incontinence.(14% incidence)
Recurrence of fissure
Prognosis

8. 8
Approximately half of uncomplicated fissures heal in 2-4 weeks after institution of
correct therapy. Fissures healed on conservative therapy may recur(50%) chronic fissures
inevitably require surgical intervention.
REFERENCES.
1.Bailey and love 26th edition
2.Oxford textbook of surgery
3.UON online repository.