anal fissure

1. Presented
Dr. Y R Lamture
Professor in surgery
DMIMS DU

2. Introduction
Etiology
Clinical features
Management

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.

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)