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: surgicaleducator.blogspot.com youtube.com/c/surgicaleducator Thank you for watching the video.

1. LOWER GI
HEMORRHAGE
FISSURE-IN-
ANO
Dr.B.SELVARAJ MS;Mch;FICS:
PROFESSOR OF SURGERY
MELAKA MANIPAL MEDICAL COLLEGE
MELAKA 75150 MALAYSIA

2. FISSURE-IN-ANO
Causes of Lower GI Hemorrhage
Etiopathogenesis
Types of Fissre-In-Ano
Clinical features
Treatment
Mindmap
Diagnostic algorithm
Management Algorithm

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. 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. 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. 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. 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. 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. 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. TREATMENT
Notaras Closed blind subcutaneous lateral internal
sphincterotomy
Open subcutaneous lateral internal
sphincterotomy

11. MINDMAP

12. Diagnostic Algorithm

13. Treatment Algorithm

14. THANK YOU
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